COVID-19: Current state of affairs, Omicron, and a search for the end game | Peter Attia, M.D.

1. 0:00 – 4:15

   Intro

   1. PAPeter Attia0:01

      [upbeat music] Hey, everyone. Welcome to The Drive podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in-depth content if you wanna take your knowledge of this space to the next level. At the end of this episode, I'll explain what those benefits are, or if you wanna learn more now, head over to peterattiamd.com/subscribe. Now, without further delay, here's today's episode. [upbeat music] Welcome to this week's episode of The Drive. This week we have two guests simultaneously being interviewed, something I don't do often. My guests this week are Dr. Marty Makary and Dr. Zubin Damania, AKA ZDoggMD. Both of these are close friends of mine who have also both been previous guests. Now, I wanted to have Marty and ZDogg back on to talk about COVID, which is not something I've done a podcast on in some time. In fact, when I did my last podcast on COVID, I really thought that was kind of the end of it and I was sort of done talking about COVID publicly. I would obviously continue to stay as up to speed as necessary on all things relevant to my patients, but I really was kind of done with talking about COVID policy and things like that. But, you know, truthfully, in the past, I would say month, I've become a little bit frustrated with what I've seen around kinda shoddy science and even worse messaging around COVID, so I thought it was time to revisit this. So this episode, we talk about a bunch of things. We talk obviously about Omicron and what's known, and understand that these podcasts are always dated, right? So the date of the recording of this podcast was Monday, December 27th, and by the time this podcast is out, that's already been a week. Three months from now, we'll know things we don't know today. That's just the nature of things. But nevertheless, we talk about what is known today about Omicron. We talk about what we understand about vaccine, both benefits and risk, focusing on the mRNA vaccines here, and specifically looking at the differences between Pfizer and Moderna, especially in the subset of young people, and further stratifying that by gender. We also talk about natural immunity, something that seems to be a very taboo subject matter, but it's a very important thing to discuss. I also spend a lot of time trying to explore the what is the end game here? What is it that we're hoping to achieve from a policy perspective to get to living in a world that looks more like it did in 2019? Is that even going to be possible? What is the difference between a pandemic and an endemic? So this is a very conversational interaction. It's partly an interview, but really in the end, it kind of is just a discussion between the, the three of us. Just by brief way of background, Marty is a Johns Hopkins professor and public health researcher. He's served on the faculty of Hopkins at the School of Public Health for the past 16 years and served in leadership at the WHO. He's a member of the National Academy of Medicine and serves as the editor-in-chief of the second-largest trade publication in medicine called MedPage Today. He also writes for The Washington Post, The New York Times, and The Wall Street Journal. ZDogg is a UCSF Stanford-trained internist and the founder of Turntable Health. He's also the host of a very popular podcast, ZDoggMD podcast, as well as the co-host of an excellent podcast called The VPZD Show, and that's with Vinay Prasad, who, by the way, has also been a guest on this podcast, and we reference Vinay here. In fact, I would have loved to have had Vinay on this podcast as well, other than the fact that it would have been pretty cumbersome to have four people on a podcast. Final thing to note here is that because we recorded this on December 27th with the aspiration of getting this out as quickly as possible, our video team was not in town, so we did not do this on video, and we don't really have the staff this week to put out show notes. So we're doing this to be as quick as possible and responsive as possible to some of the questions that many of you, I suspect, are asking. So I hope you'll accept our apology that this will be an audio-only podcast and there won't be show notes beyond just a number of references. So without further delay, I hope you enjoy my conversation with Marty Makary and Zubin Damania. [upbeat music] ZDogg, Marty,

2. 4:15 – 13:15

   Comparing omicron to delta and other mutations

   1. PAPeter Attia4:15

      so awesome to be sitting here with both of you. As you know, not a topic I have been spending much time on, certainly publicly. Obviously, anyone who's taking care of patients has to be paying attention to what's relevant to them, so that's permitted me the luxury, I think, of being able to offer my opinions to patients, my interpretations. But I did feel a need to go a little bit deeper in the, in the past few weeks and thought I'd reach out to you guys, and we could do this as a discussion because you guys have been spending a heck of a lot more time on this than I have. And in the last five days, I've been drowning in this substance. Luckily, I have wonderful analysts who have been able to organize information for me. But anyway, let's, uh, let's just start with helping me understand and the listeners understand kinda what we know and don't know. And, and one of the ideas that we had talked about at the outset, which I think you guys agreed was a, was a, a, a good thing that we can try, is for the listeners, helping people differentiate between what we believe is fact or when-- what is knowable, and then what is opinion. 'Cause I think we're gonna very easily go back and forth between those two, and I think people expect that, right? On some level, people wanna hear our opinions, but I think they also wanna know when that's separated from fact. So hopefully between the three of us, we can always kind of remember which of those pillars we're, we're playing in. But what I'd like to do is kind of start with some basic questions for you guys. So we're recording this on, uh, what is it? The 27th, right? And obviously, a lot of what we're talking about is in flux. Part of what's prompting this is Omicron being a new surge. What do we know about this virus, this particular mutation, and how it differs from Delta and do we wanna call the original one Alpha or OG or what, what, what do you gu- what do you guys call that?

   2. MMDr. Marty Makary6:00

      First of all, great to be with you, Peter, and great to see you again here, Zubin. So I think we can compare Omicron to Delta because Delta represents sort of the worst of the previous strains, and now we've got some pretty good laboratory data that tells us that Omicron is not infecting lung cells, neither lung individual cells or what we call organoids in a, in a lab, which is a cluster of similar tissue types, at the same efficiency. It's about 90% less efficient in replicating in those lung cells. So we've got laboratory data now confirmed by three independent labs that it's not infecting those cells as well. That's why we're not seeing the cough and the severe disease and the systemic illness like fever as frequently with Omicron. We're seeing more of the upper respiratory stuff, the nares, the bronchus symptoms, and by virtue of that, you're gonna blow it off more, and maybe that's one of the drivers of it be- it being more contagious. But we've got the laboratory data. We've got epidemiological data looking at South Africa, looking at the numbers down now over 35% off their peaks. We've got a shorter length of stay there observed, about two and a half days versus eight days. Hospitals were not overrun in a country with, you could argue, semi-limited resources, and we've got bedside observation. So we've got epidemiological data, laboratory data, and bedside data that all fits that it is, in fact, no longer an open question. This is a more mild virus.

   3. ZDDr. Zubin Damania7:26

      And I guess one of the questions that I have around the mildness of the virus, 'cause there is also the, I think it's that Hong Kong data that you're pointing at, that you have a lot of upper airway replication, you know, some multifold over the, the OG strain and Delta. But this idea that it's a milder clinical syndrome is a little complicated by the fact that in South Africa you have a lot of, a high seroprevalence of previous infection, and so the question is, how much of this is we have now a degree of natural immunity and some vaccine immunity in South Africa, and what you're seeing is a virus that's more replicatable, maybe a little less pathogenic, maybe a l- a little less disease, but in the setting of a much more immune population. Because if you're looking at the, kinda the three precepts of a pandemic, it's a very transmissible virus that causes a lot of disease that we don't have great immunity for, so those three things. And it looks like with Omicron we have a very transmissible virus that may cause milder disease that we have quite a bit of immunity to already. And, and so all those things may collude to make this less of a problem than Delta in terms of what we care about, which are actual outcomes.

   4. PAPeter Attia8:33

      I mean, at the risk of asking maybe a naive question, is it still reasonable to say that this is absolutely a COVID variant, or at some point will mutations of the OG strain, a la the Delta lineage, get so far away from those strains, presumably in terms of virulence as one metric, that we really oughta be thinking of them more as coronaviruses and not necessarily COVID-19? Where would that line be?

   5. MMDr. Marty Makary9:02

      [laughs] Look, I think that is the ultimate question. Is COVID going to be the fifth seasonal coronavirus, as, uh, I know you and Amisha Dalal had postulated early in this pandemic. There, uh, you know, as a reminder to those listening, four coronaviruses that circulate year to year that account for about 25% of the cases of the common cold. This may be the fifth, and it may be in this version. Now, the Russian flu, which was 1889 to n- 18, uh, 1891, many are now postulating that that was a horrible pandemic of a flu season preceding the Spanish flu, and that may have very well been a coronavirus that turned into one of those four seasonal coronaviruses that we live with today. So we may have essentially a fossil of a previous pandemic that mutated to a seasonal mild coronavirus, and it may be in fact one of those four existing viruses.

   6. ZDDr. Zubin Damania9:55

      Yeah, I, I think this dividing line is interesting, right? Because it, it really is at what point do we decide that's the case? Because, you know, a seasonal cold can actually kill somebody who's medically fragile with comorbidities. We see it every winter. As hospitalists, we, [laughs] we admit it's an impending sense of doom. It's like winter is coming. Every time in October we know that just standard flu, standard seasonal cold, the coronavirus stuff that we already have, the adenoviruses, even RSV in adults can cause a very nasty syndrome if you have a lot of comorbidities, and it fills up our hospitals 'cause the hospitals operate at capacity. So at what point is where we are now considered very different from that? And that's a really operative question.

   7. PAPeter Attia10:39

      Another interesting question, and again, we're clearly now in the editorial phase, but we'll, again, we'll, we'll come back to some data later, but if you were thinking about this through the lens of evolution, Omicron would be by far the best of the three so far. Like, if you're putting your virus hat on and you're saying, "What's in the virus's best interest?" You have the perfect virus. It is highly communicative and not lethal, and in fact, like, the worst viruses are the ones that are a little harder to spread and kill their hosts. So is there any evolutionary argument to suggest that it's, we would expect this to be the evolution of the virus, that it's, as it gets more evolutionarily fit, it should be killing people less and it should be spreading more?

   8. ZDDr. Zubin Damania11:26

      It seems that that makes evolutionary sense on many levels, and actually if you compare it to SARS, the OG, the SARS-1, SARS-1 seemed to have a little higher case fatality rate, affected a different swatch of people, but it, the way that it spread, you could detect it symptomatically when it was contagious, and when you were asymptomatic, you weren't contagious. So we were able actually to stop that virus through behavior restrictions, testing of, for people with what we consider now to be hygiene theater, pointing a, and this is editorializing, [laughs] pointing a, a temperature gun at somebody's head, back then may actually have worked with that. But if you look at then the success of the virus, that wasn't a very successful evolutionary virus, whereas this one, oh boy, spreads when it's asymptomatic, causes severe disease just in, uh, typically more vulnerable people, but, but there's so many people that are vulnerable that you end up causing a, a, a pandemic level of, of drama. But as you start to evolve it to Omicron, where man, it spreads so fast that everybody pretty much has a date with, you know, Omicron at some point, but it causes less severe disease, we think, based on the data that Marty's citing and emerging information, well, that's a very successful d- virus, and that virus gets rewarded by being part of the pantheon of our seasonal biome that affects us every year. And, uh, I think it, it would be very unsurprising if that's the MO of evolution in this case.

   9. MMDr. Marty Makary12:45

      I like the temperature gun reference. For some reason, those temperature guns scare me as much as a virus. [laughs] But, but, um, you know, it may be that Omicron is nature's vaccine. It is far more mild, and for the 93% of the population living in poor countries in the world, they don't have access to a vaccine right now, and it's gonna be very difficult. So a lotta people out there are going to get vaccinated e- essentially by getting Omicron. And,

3. 13:15 – 18:45

   Measuring immunity and protection from severe disease—circulating antibodies, B cells, and T cells

   1. MMDr. Marty Makary13:15

      like, it's ideal to get the vaccine over getting the infection, but it may be sort of a silver lining of this variant, and it may be how a pandemic ends. We do know from a Johns Hopkins study that's now on the preprint server that your T cell immunity, which is the most under-recognized part of the immune system in the entire COVID discussion, that is still solid against Omicron just as it was against Delta, that the crossover is, uh, very high and that if you get Omicron, you've got T cell immunity to Delta and vice versa. That's now pretty-

   2. PAPeter Attia13:50

      Can I jump in here on something? Because I'm glad you brought this up, Marty, and I, I, I suspect both of you will have a lot to say on this. Everybody's heard the expression, "What gets measured gets managed." What we can measure, we tend to fixate on, and unfortunately, when it comes to measuring immune strength, we really have one tool in the toolkit, which is to measure circulating antibodies, which are not the same as neutralizing antibodies, which are part of the, you know, B cell immunity. And then you have this other thing that you've alluded to, Marty, called T cell immunity. I don't think we need to go into it in great detail. I did a podcast with Steve Rosenberg that was cancer-focused, but we had a totally in-depth discussion on B cell versus T cell immunity. So we'll, we'll, we'll s- we'll send people there if they want the primer on it. But the upshot is we don't have a laboratory test to measure T cell immunity. We, we don't even have a commonly available test to measure neutralizing antibodies. We just measure circulating antibodies, so we can't really even measure what memory B cells are doing. Do you think that's a little part of the problem here, in that we're kind of flying blind and making a lot of assertions about immunity based on arguably the least important thing that you could measure? And again, I'm editorializing in my question a little bit, but, but what do you guys think about it? Push back on that if you think that we're undervaluing circulating antibodies.

   3. MMDr. Marty Makary15:14

      I definitely think that we are undervaluing circulating antibodies and cellular immunity as a broad group, that is, the memory B cells, memory T cells. Listen to our public health officials from day one. They talk about the antibody levels jump up, and then we see them go down, and then initially there was a fear of reinfection. Well, we didn't see it clinically at the bedside. Then when the vaccines came, early on they said, "You know, you really have to get that second dose because look at the antibody levels just go up tenfold of what they go up after the first dose." Well, that's good, but it's good for activating your memory B cells and memory T cells. It's good for the cellular immunity. Antibodies come and go. That's in the textbooks, right? They linger for months in the system, and then they, they wane. And by having this in- intense fixation on only one aspect of the immune system, and that is antibody titers, what we have done is w- we've created a scenario where we're chasing our tail to keep those levels high, because when they're higher, you're less likely to test positive. So what, what we have created th- we've created this expectation that the vaccine is somehow failing now when you test positive, even though that cellular immunity is still strong in preventing severe illness.

   4. ZDDr. Zubin Damania16:25

      And it creates an almost a cascade of surrogate markers that don't really measure what we're directly interested in, right? Because if you have the surrogate marker of, okay, neutralizing antibodies, and then that's trying to treat a surrogate marker of cases, PCR positive cases, but what do we really care about? We care about people in the hospital, filling up the hospital, sick, dying, maybe we can say long COVID is in that question mark of things we care about. And so how do we really look at that? I think what Peter's question really points at is, do we have good measurement criteria to look at are we actually immune against severe disease, which is that sort of innate memory response that as antibodies wane, you still are able to mount this, which means, hey, you're still gonna get cold and flu symptoms. You're still gonna potentially be infectious during that period, but y- it's not gonna settle into cytokine storm ARDS and being proned in a ICU ready to die. And that's what we care about. And I, I agree. I don't... I, you know, we talk about things like T Cell Detect, which I actually don't know much about. It's one of these com- you know, commercially available tests. I don't know if Marty knows more about it. But I really don't think we have good outpatient commercially available tests outside of research that measure these things.

   5. PAPeter Attia17:36

      I mean, in the study that we're... A- and I'm not really that involved. I mean, I was involved in some of the, the planning of it, but there's a, a, a study that's going on at the University of Indiana right now, and it's specifically looking at long-term B cell and T cell immunity. And in speaking with the investigators there, I mean, the assays to measure that degree of function are quite complicated. I mean, these are not things [laughs] that are amenable to commercial testing with any rigor. So I, I do feel pretty confident in saying that we don't really have the tools to measure those things. And, and, and I forget who, who I heard say this, but I'm paraphrasing somebody. They said, "Measuring circulating antibodies and saying you know everything about a person's immunity is sort of like looking in a person's bank account and saying you know everything about their net worth." It's probably correlated, right? But, you know, especially with a wealthy person, like, the, their checking account [laughs] is really not representative of their net worth. You know, their checking account probably doesn't have $0 in it. They're probably not overdrafted, but it's unlikely that a billionaire is going to have hundreds of millions of dollars sitting in a checking account. So I think that's sort of, to your point,

4. 18:45 – 24:00

   Policy questions: what is the end game and how does the world go back to 2019?

   1. PAPeter Attia18:45

      both of you, I think created a series of metrics that are problematic, especially when I haven't heard a clear articulation of what the end game is, right? So this is now a macro question, right, which is I had to go out somewhere today, and it's actually pretty unusual for Austin 'cause Austin really doesn't care about masks or anything like that, but I was surprised. I went in and the woman said, uh, you know, she took my temperature, and so I got the temperature gun in the face, and then she said-

   2. ZDDr. Zubin Damania19:11

      [laughs]

   3. PAPeter Attia19:11

      ... "Oh, you know, we're, we're, we're wearing masks," so she handed me a mask. And, you know, I, I don't, I don't argue with people over that kinda stuff because I feel like it's, th- this is just, that's her pay grade, right? Like, that's her job to tell me that. Fine, I'll wear a mask and whatever. But I keep thinking like, "Well, what's the end game here?" Is the implication... 'Cause if you're making me wear a mask now, ch- shouldn't it be implied that you're gonna make me wear a mask forever? 'Cause I-

   4. ZDDr. Zubin Damania19:33

      [laughs] Yes

   5. PAPeter Attia19:33

      ... how, how do you extract yourself or walk back from this position of temperature gun, mask, y- you know, et cetera? So when it comes to what is the end game, what can we all agree is a reasonable line in the sand beyond which the world goes back to 2019, I, I'm having a hard time understanding that. So, so what do you guys understand with respect to that?

   6. ZDDr. Zubin Damania19:55

      You know, if [laughs] from my end, so much of it, Peter, emer- is an emergent property of how we're measuring stuff. It's actually the question that you asked in the beginning. It's like if we care about cases and neutralizing antibody levels, then it's gonna be an infinite number of boosters and masking into perpetuity, and even though the data is very questionable on all this stuff, we keep doing it. This is a policy question. How do we want to be in the world? How do we wanna live our lives? What's the difference quantitatively and qualitatively between 2019 before we had this pandemic, but we would have severe flus that would overwhelm hospitals in the fall, and certain places would go on divert, and we've all worked, you know, I've worked in those facilities when that happens. It sucks. Every medical person grinds their teeth and gnashes everything, but we get through it, and we don't disrupt society. We certainly don't s- close schools. We don't inflict masking on the public because we would never think to do that as a policy. So this is really a policy question. How do we wanna be in the world? And I think that's where all the division that's been sown on social media, through mainstream media, alternative media, you know, all this disinformation, misinformation, I don't even know what that even means anymore, has created an environment where we're so atomized by tribe that even the policy questions become tribal identifiers. So we need to kind of really see that clearly from a perspective of a more holistic i- you know, integral perspective where we can go, "Okay, this is what's happening. All right, well, what do we really care about? We care about people not dying, not filling up hospitals, and we care about our economy working because health actually is correlated [laughs] to wealth, which is correlated to longevity." I mean, these, these are things that are clear, socioeconomic status. Education matters for that. So these, this is how we have to look at policy, not a reductionist how many cases can we prevent. And I think there's political stuff here that happens and, and it, it just becomes a, a complicated mess.

   7. MMDr. Marty Makary21:48

      Can you imagine, um, guys, if we tested for influenza every flu season when, say, four years ago, we had 41 million flu cases in a matter of a couple months. Can you imagine if we graphed on a daily basis the number of newly diagnosed flu cases? And w- we'd create mass hysteria. Now, it doesn't mean we blow off flu or we don't take it seriously or we don't tell people some reasonable strategies like, "If you're around someone vulnerable, be careful. If you think you've been exposed, wear a mask. If you have symptoms, stay home." I mean, th- that's kind of how we l- live with a respiratory pathogen. F- 10 to 25% of the population will get infected with a respiratory pathogen every year in perpetuity because there's a whole bunch of them. There's rhinovirus and echovirus and influenza and parainfluenza and the four coronaviruses we talked about. If a parent brought their kid in, say, for their newborn evaluation, the first pediatrics visit, and the pediatrician said, "Your child will develop five to seven pediatric respiratory infections during their childhood," I mean, you could, you could blow that up into, you know, a he- he- headline, but the reality [laughs] is this is, we're not going to eradicate pathogens from planet Earth. Real quick, Peter, you mentioned something about, we were talking about the antibody titers and sort of chasing our tail. This just came out a day before Christmas. From Britain, from the UK now, this is from the UK Security Agency. They're pooling the data. They got, they've got great data. So the vaccines, as they have had them with the primary series, are 70% effective against symptomatic COVID. 10 weeks after a booster, it goes down to 35% for Pfizer and 45% for Moderna. So within 10 weeks, you're seeing even the booster wear off against your ability to test positive or have a symptomatic case, but those memory B cells and T cells are still working. The cellular immunity is still protecting against severe illness. So if we keep chasing

5. 24:00 – 39:00

   A policy-minded framework for viewing COVID and the problem of groupthink

   1. MMDr. Marty Makary24:00

      antibody titers, you might be getting a booster every first Monday of every month when you show up at work, and it still won't work.

   2. PAPeter Attia24:08

      I was thinking about something this morning, guys, that I, I thought could help us kind of anchor a little bit into the evolution that we've undoubtedly all experienced. So if I think back to March of 2020, I actually pulled my kids out of school about two weeks before the lockdown. So before two pe- you know, two weeks before this got kind of insane, I was like, "You know what? I don't know anything about this virus. I don't like what I'm seeing outside of the United States. We're gonna keep our kids home." Oh, my daughter was furious, "How could you do this to me?" Ba, ba, ba, bla, bla, bla. So I look back at that and I think, "That was the wrong thing to do because it didn't matter," but I didn't know better, and I think it was a reasonable precaution in the absence of any information, right? Like, if this turned out to be as bad as SARS-1 Meaning it was as, as lethal as SARS-1 but as infectious as SARS-2 would have been a good thing to do. Turned out it was overkill. So I was thinking about, like, how many times has my view of this problem changed, and the answer is many, and I think part of it comes down to a framework around what tools do we have at our exposal-- uh, at our disposal, and what knowledge do we have about how to reduce morbidity and mortality for COVID? And I was thinking about this 'cause the first time I delineated this was in the spring of 2020, and now when I do it today. So, so tell me if you guys would add to or subtract from this. So I break it into three broad categories. The first is preventing infections, the second is treating infections, and the third is providing supportive care for people who end up in hospitals. In the preventing infections, you have two things, basically vaccines and behaviors. In the treating infections, you would have existing drugs versus new drugs, and then supportive care. So back in the spring of 2020, we had no vaccines. We had behaviors, but we didn't know which ones were right versus wrong. Being indoors, being outdoors, wearing this type of mask, that type of mask. You know, we, we didn't know anything. Stand six feet apart, stand sixteen feet apart. I mean, it was just a whole bunch of made-up stuff. On the treating infection side, we obviously had no new drugs, but we had a whole bunch of existing drubs and-- drugs, and there was a whole slew of ideas around, well, would this drug work? What about-- Remember remdesivir? We talked about that so much and, and then of course, you had half these drugs became totally politicized, et cetera. And then in the supportive care side of things, we didn't know anything, right? It was like, is this ARDS? Should you be oxygenating the bejesus out of people? [chuckles] Steroids must be horrible. I mean, we really knew nothing. You have a whole bunch of empirical insights, and when you consider where we are today on that front, I mean, I just kind of jotted out a bunch of ideas. It's kind of amazing that in less than two years, we have multiple vaccines with pretty clear ideas about which behaviors reduce the spread of infection and which don't. On the treatment side, we've a pretty good sense of at least one existing drug that works, which is fluvoxamine. We can discuss if there are others. And we've got at least two new drugs that seem quite promising. Uh, I'm more familiar with the Pfizer data than the Merck data. And, you know, you guys can probably speak much more to the, the therapy side, right, the supportive care side, but it seems to me that ICU doctors and nurses have a way better sense of what to do today than they did a year ago, let alone eighteen months ago. Anything you guys would add to that framework? Because I, I think it's important to differentiate between what the world looked like in the spring of 2020 with respect to those data points or those, you know, those parameters versus what it looks like today. So would you expand or subtract on that?

   3. ZDDr. Zubin Damania27:45

      I can say a couple things here. That's a really good framework. It's interesting because in the prevention framework, you could also throw in, hey, you know, what about things like vitamin D, treating metabolic syndrome, diet, exercise, those kind of things, which are a little softer, but s-

   4. PAPeter Attia27:58

      So ca- call it lifestyle. But no, I like it. I like it.

   5. ZDDr. Zubin Damania28:00

      Yeah, like lifestyle modification, which I remember in the early days you were talking about things that you did. Uh, things I, I did too were, were because I said, "Oh, this is more like OG SARS than wha--," 'cause we didn't know what the IF, the infection fatality rate was. I was sitting there exercising like a lunatic, and I stopped drinking alcohol, and I [chuckles] I did all these personal things to try to improve my metabolic condition. So th-that's a piece of it, and then there's a question of chemoprophylaxis. You know, some have been, uh, these politicized drugs, they've been advocating that they're more prophylactic as well. You could take a, you know, ivermectin once a week and prevent this. Well, I mean, it's worth exploring. I don't think there's data that we have. But your, your comment that this has evolved so quickly is absolutely a beautiful vindication of the scientific process when it's allowed to unfold. People, I think people who've politicized this a lot on both sides say, "Oh, nothing's, you know, doctors aren't really trying to do anything to treat this. We haven't really learned anything." No, the opposite is true. Multiple good vaccines, things like dexamethasone in the hospital that have really improved mortality, and we've actually thrown out things that don't work, which is actually just as important, because those things can actually cause harm. So the question of hydroxychloroquine, for example, you know, Ioann- Ioannidis's, uh, meta-analysis showing that maybe we actually cost lives by giving that much hydroxychloroquine. These are things we need to actually really dive into, and it comes down to this, Peter, like let's say the IFR, this is how I think about it. If infection fatality rate, let's say it's, you know, .2, .3, somewhere in that range, which seems reasonable, although we don't have the exact data, how many people in the US are roughly at risk then of dying based on the population of the US and the IFR of the disease? And I did a back of the napkin calculation a few months ago that was roughly about one point four million Americans. If that thing was the actual IFR of the disease, if we didn't do anything, that's, at the current state of the IFR, that's how many people would die. We're at what, eight hundred thousand? So the qu- the question is, will we get to one point four or will it not reach one point four? And if it doesn't, what of those three buckets, what, I mean, what, what did we do to actually improve that? And I suspect it's a mix of vaccines, therapeutics in hospital, lowering IFR by improving hospital care, and some behavioral stuff, like maybe avoiding big crowds when something's surging, something like that. But I, I, but th-that's kinda my current thinking on it is, you know, the, the goal is get that down from one point four million as much as we can without destroying the fabric of society, which will actually push it back up towards one point four through ancillary damage in terms of substance abuse, overdoses, mental health problems, suicide, that kind of thing.

   6. MMDr. Marty Makary30:39

      Yes, it's amazing what we have in our toolbox, how far we've come, scientific innovation. To me, what's almost equally amazing is how we've not incorporated many of these new therapeutics into common practice, and that is probably a glimpse as to what's broken with our broader healthcare system. The average, uh, seventeen-year lag For new evidence to get broadly adopted into practice, and we're seeing that play out now. Now, maybe it's truncated, maybe it's a three-year lag, but it's too slow for a health emergency. Yes, it's amazing how, how much we've learned, but it's also amazing how we still have doctors telling folks, "Oh, you have COVID? Tough it out, stay at home." You know what? We should be telling them in order, based on evidence, a list of things, and in no specific order, fluvoxamine reduces mortality by 91%. Budesonide, a steroid inhaler, markedly reduces hospitalization. Vitamin D has been found to be correlated with severity of illness in a German study in hospitalized patients. Hypertonic saline is an age-old treatment that's been used to sort of rinse out the navel- nasal cavity, and it's been used by doctors for a long time with many viruses. And you've got all of these things that are not being adopted broadly, and to me, we are still suffering from significant groupthink. We've been burned badly with groupthink in medicine throughout this pandemic, in the failure to warn about it, in the surface transmission idea, in the draconian and barbaric practice that doctors and hospitals were complicit in to ban people from visiting their loved ones to say goodbye, closing public schools w- ironically with a less contagious strain out there, ignoring natural immunity, not talking about fluvoxamine. I just saw another White House briefing. We've never once heard our public health officials talk about it. The groupthink and not spacing out the doses. Maybe we wouldn't be talking about boosters as vigorously if we would've spaced out the first two doses as we should have.

   7. PAPeter Attia32:47

      By the way, I wanna make a comment on that. When the vaccine started rolling out, I spoke with three immunologists, virologists, so... And these are, I won't name who they are just for the sake of protecting their identity, but I mean, I explicitly talked to them about this, and I said, "Why the four weeks between first and second shot? That seems at odds with the little bit that I know about the immune system." And they said, "There's not a single reason to do that other than they probably did the trial that way for the sake of speed," but they said, "If you can drag your feet as much as possible between those doses, do so." And I was like, "Well, do you think it's worth saying that?" And they're like, "No, don't want to say [laughs] like, not gonna say that. Just, just, you know, drag your feet as much as you can, show up three months later saying you forgot to get your second shot kind of thing." So yeah, there's a little bit of, of this going on. By the way, I wanna, I do wanna go back to one thing you said, Marty, that, that I have generally found the evidence to not be favorable, which is vitamin D, at least supplemental vitamin D. So, 'cause my patients ask me about this all the time, I've said, "Look, don't confuse your vitamin D level that you acquired being in the sun playing sports outside with the vitamin D level that you can get by taking 4,000, 5,000 IU of vitamin D. I don't think those are the same. I think vitamin D might be a surrogate for health through other means." Did this study that you're citing specifically look at outcomes being improved with supplemental vitamin D, or did it simply associate or note the association of higher levels of vitamin D and better outcomes?

   8. MMDr. Marty Makary34:27

      The latter. So out of all the things I mentioned, that has the weakest evidence. That was sort of a retrospective review of hospitalized patients just looking at their levels, and they found some correlation, but it doesn't, uh, imply causation necessarily. All the other stuff has randomized controlled trial data behind it. The vitamin D thing was a retrospective review.

   9. PAPeter Attia34:47

      Yeah, so my, my take on that has been, in my practice, has been not to prescribe vitamin D and instead to get outside and exercise in the sun and get it that way. Zubin, do you have a, a take on any of those in-

   10. ZDDr. Zubin Damania35:01

       Yeah, that was my take on the vitamin D piece, too, is there's a correlation causation situation there. There is definitely something going on with naturally acquired vitamin D that seems, at least in a correlative way, protective. One thing that I think is interesting, so fluvoxamine again, I think when you've been through the hydroxychloroquine ivermectin mill, there, the groupthink starts to shift and go, "Therapeutics just simply don't work, especially if they're repurposed drugs." There is a lot of groupthink in medicine, and people are then uninclined to look at these pieces. The other interesting thing about this particular pandemic that makes it tough, Marty, is that, you know, 99.6% or whatever of people are going to get better no matter what. In other words, staying home and doing nothing, they're probably gonna be just fine. And so it becomes this question of how do we... Do we tell the whole world to take, you know, budesonide and fluvoxamine and all of that the minute they get sick? Like Omicron, it's gonna infect everyone. I, and I'm getting tons of emails, "Hey, I have cold symptoms, I'm at home. Should I go get monoclonal antibodies? Should I..." You know, 'cause Peter has his defined patients. I have, like, millions of patients [laughs] who email me, and I keep telling them, "I'm not your doctor." But what I, what I always say is, you know, "Look, you have to look at your risk factors. You have to look at your age. You have to look at were you infected previously. How'd you do with that?" There's so many intricacies, whereas it would be nice to say, "You know what? If you're, if you have these symptoms, here are low-risk, high-yield, uh, things we can do." And I don't know, Marty, do you think some of those things on your list are applicable to, say, anyone who gets COVID, or would you risk stratify?

   11. MMDr. Marty Makary36:31

       Well, w- we've got to risk stratify because, one, it's, it's just overkill. Somebody who's young and healthy, the German data just came out that between the ages of 5 and 17, not a single healthy person died pre-vaccine. So when you've got someone vaccinated, it's probably a, a indicator of overuse if we're d- using some big guns in that population. And, you know, I made a comment about doctors being slow to adopt some of this stuff, and I just wanna be clear. We have put doctors in a terrible situation in the United States. We've put them in a very bad situation By putting them on the front lines of this pandemic without any good data for a long time. When this pandemic ha- happened, it hit this country and every single person, all of our friends and everybody, and everybody who emailed you, Zubin, and by the way, sorry for telling people who email me just to email you. Maybe I'll stop-

   12. ZDDr. Zubin Damania37:26

       Oh, thanks

   13. MMDr. Marty Makary37:27

       ... telling them to, [laughs] to tweet at you.

   14. ZDDr. Zubin Damania37:28

       Yeah, you know, I'll, if, it, just pay me a nickel every time that happens, and then as Peter says, if you do a, if you do a wallet biopsy of my bank account, I'll have, like, at least a dime in there.

   15. MMDr. Marty Makary37:37

       [laughs]

   16. ZDDr. Zubin Damania37:37

       It'll be great.

   17. MMDr. Marty Makary37:38

       But we were all getting the questions. How does it spread? Do masks work? How long are you contagious for? Can you spread it pre-symptomatic? All the basic questions of COVID. We did not have answers because our gigantic $4.2 trillion healthcare system could not do the basic bedside clinical research. I remember Peter was even doing a, a quick video about, "Somebody please do this study." We were all saying the same thing. Labs were mostly closed 'cause there was no PPE. The NIH w- was unable to pivot their $42 billion to answer these questions quickly, so what we did is we had a vacuum of scientific research, and all the doctors were on the front lines without any data to really answer these questions, and that's when the groupthink began. And guess what ended up filling that vacuum? Political opinions. So we just did this study of NIH research funding last year. Less than 5% went to COVID research. Three months into the pandemic, 0.05% of the NIH's budget went to COVID research. The average time for them to give a grant was five months to fund a research team to then start the research. 257 grants on social disparities with COVID, an important topic, but only four on how it spreads, and one on masks, which hasn't even read out

6. 39:00 – 46:00

   The difference between science and advocacy

   1. MMDr. Marty Makary39:00

      yet. So the most basic questions doctors needed evidence for, that was not being conducted.

   2. PAPeter Attia39:07

      I wanna go back to something that you guys have both now alluded to, and I talked about this a little bit on the podcast with Rogan, and I think it's worth mentioning again, 'cause it's a fundamental issue that I think we're going to talk about many times this afternoon. David Allison and I had a discussion a couple months ago, and, and, and he put this very eloquently, and I, it's something we all understand, but I think I like the way he phrased it, right, which was, always know the difference between science and advocacy. And a- as we explain these differences now, I think people will inherently understand it, but, and again, we're now talking in the w- realm of opinion, my opinion is perhaps the greatest disservice that has come out of this has been that that line has been so blurred to be nonexistent. So science is messy. Science is uncertain. Science speaks in probabilities, and science constantly changes in the face of new information, right? So science is a process, not a thing, right? Science says, "This is what we know today with this degree of certainty. As new information becomes available, the new truth will be this." So, so, so truth is not a constant within science, right? Truth, we hopefully converges on greater certainty. And so when scientists speak, it doesn't really sound that reassuring. I mean, y- you know, we know this 'cause we interact with scientists a lot. They never give you a straight answer because if they're doing their jobs honestly, they r- you know, outside of really well-known phenomenon, we, we have to speak in uncertainty. I think for understandable reasons, advocates can't do that. They don't have that luxury, right? If you're, if you're a public health advocate, your job is to communicate something with complete certainty. But if you're observing this as a member of the public and you don't know the difference, how do you know what to make of this? So is it safe to say that Anthony Fauci is an advocate in COVID and not a scientist?

   3. ZDDr. Zubin Damania41:13

      This is the central thing that's going on here, I think, Peter. I think you're absolutely right. Because what it is, is if you look at Fauci, say, or you look at Francis Collins, so recently leaked email, Francis Collins talking about the Great Barrington Declaration, which was a bunch of scientists, including someone who's been on my show, Jay Bhattacharya, saying, "Hey, as a matter of policy, we think the following things should happen that would improve outcomes in this pandemic based on our interpretation of what the best science is right now. There is no the science. This is our policy interpretation," right? And what Francis Collins roughly wrote in this email was, "Hey, did you see these fringe epidemiologists, uh, coming up with this Great Barrington Declaration? Oh, by the way, one of the fringe guys was a, is a Nobel Prize winner at Stanford, Mike Levitt, and, uh, if you haven't seen it, we need to do a devastating and, you know, decisive takedown of this, and I don't see it out there yet." And so basically saying, ultimately what I would interpret this as is, "Hey, I disagree with this as a policy. We need to put out something that takes it down as a policy." And there's not a discussion of, oh, let's have, let's discuss the underlying science. Let's actually have a discussion about policy, like does it make sense to treat healthy people, uh, that are young the same as elderly people at high risk? These are the conversations we ought to have. Instead, they acted as advocates. "Well, our position is do the lockdowns, make people mask, promote whatever it is we're promoting, and that's our policy, so we need to advocate for it in no uncertain terms, which means a devastating and immediate takedown of these quote-unquote 'fringe epidemiologists.'" And that, that's, that is as clear an aspect of the difference between policy, politics, and science, but this is a scientist who represents our, one of our largest scientific public agencies. So th- that was really concerning to me. I'm curious, Marty, what, what you think of that.

   4. MMDr. Marty Makary43:06

      That was chilling when I saw that email from Francis Collins to Fauci, and it called for a devastating takedown of another opinion, basically. I mean, they control the currency of academic medicine, which is NIH funding. When you've got the head of that talking about taking down ideas and taking down people, this is probably the greatest lesson we should learn from the pandemic. In addressing how do we avoid groupthink in the way that it's burned us time and time again, we've got to openly talk about the corruption of science itself, how there has been a shutdown of scientific discussion, how you cannot talk about certain things. It started with Google suppressing any search of Wuhan lab leak, and they admitted this openly. They said, "You know, we, we suppressed any searches 'cause we weren't sure and we didn't want people to get the ideas if they weren't sure." Well, that's not their role. They did the same with the Great Barrington Declaration, took down Dr. Bhattacharya. I was skeptical of the, of the declaration early on, but look at what's happening in Sweden now and tell me if there wasn't some truth in what they were talking about. Martin Kulldorff, very well-known, uh, vaccinologist from Harvard, on the CDC ACIP committee, basically dismissed, openly, he told me this and he said I could say this publicly, I've written about it in the Wall Street Journal, dismissed from the committee for having a different idea. He was upset about the J&J pause being too prolonged and creating vaccine hesitancy, asked to leave the committee. FDA bypassed their own expert advisors, called VRBPAC, on the boosters for young people vote. CDC, with their expert advisors on boosters for young people, told that committee specifically, "You're voting on older folks. We're not holding a vote on boosters in young people." And then they go ahead and author, and recommend it for, for young people. Two senior FDA officials quit, including the head of the vaccine center at the FDA. Academic bullying, how many people have reached out to us and said, "Thank you for talking about natural immunity. I see it in my patients. I can't talk about it. I'm told we have to keep one message, and that is to get everyone vaccinated. And, you know, thank you for speaking up. I can't do so." Why has the NIH not done a study on natural immunity? They keep saying we don't know. They're ignoring the 141 studies that have been documented by the Brownstone Institute. It's not that hard. Go to New York, where people had the infection, interview them, test their blood. I mean, why is my research team doing this without NIH funding? Because the NIH is not only not funding it, they're not doing it, and they're relying on two really flawed studies that the CDC put out. This is the, the distortion of science

7. 46:00 – 57:15

   Natural immunity from COVID after infection

   1. MMDr. Marty Makary46:00

      itself, shutting down scientific discussion, and that should be our greatest lesson.

   2. PAPeter Attia46:04

      I wanna come back to something you said about natural immunity, 'cause now I wanna kinda get into l- let's talk about what we know. So let's start with that. What do we know about naturally acquired immunity?

   3. ZDDr. Zubin Damania46:15

      You know, it's interesting, because there are multiple studies showing that natural immunity is actually a real thing, it's a real phenomenon. It generates really good protection against either reinfection at a lower rate or severe disease at a much higher rate. And then there are a couple of studies [laughs] that are CDC-sponsored studies that Marty has reviewed in depth that say the opposite. And what's interesting is, as a matter, again, as a matter of policy then, the policy makers in the US have chosen to go with that approach, saying, "Listen, it doesn't matter if you've had natural immunity. You still need two vaccines and a booster. And by the way, you cannot space them out beyond a certain point or they will not even count for the mandates that we're talking about." So where policy actually contradicts evidence that we have, it becomes, th- at this point, it's pure advocacy, pure policy, and that distinction between public health and science, where public health says we have to speak with a monolithic voice that simplifies complexity into binaries, otherwise no one's gonna listen because Americans are too stupid. Uh, that's the subtext. Um, versus actual scientists who are like, "Wait, no, wait, wait, wait, wait, wait." And those are the emails we get, right, Marty, the people who can't even talk about this nuance because they'll get censored in their own academic institution. So, uh, back to you.

   4. PAPeter Attia47:27

      Well, I do wanna ask a technical question. Is there a precedent for a respiratory virus to not generate natural immunity? In other words, like, what would be your prior on this if you knew nothing? Like, wouldn't... I don't, I, again, this is so outside of my wheelhouse, guys. I, I'm not an immunologist. I'm not a vi- m- more importantly, I'm not a virologist, right? I think that's the real question, and, and none of us are. So do we know if it's actually the norm that once you have a virus, you tend to develop natural immunity to it? I mean, that was sort of my understanding from medical school, but have things changed significantly? And what would be our expectation here?

   5. ZDDr. Zubin Damania48:05

      Yeah, so just real quick, strep throat, which is a bacteria, that can reinfect you and reinfect you, so you cannot have a viable vaccine. Respiratory pathogens in general, you can get reinfected, but your immunity against severe disease tends to be quite strong.

   6. PAPeter Attia48:22

      Alternatively, when they're just changing, right? So, so of course, like the flu you could get theoretically every year, but that's because you're getting a novel pathogen effectively, correct?

   7. ZDDr. Zubin Damania48:31

      That's right, and even then, even the novelness of the pathogen is actually not as novel as a real phase shift in the antigens you're presented with, like maybe would happen in H1N1 swine flu or a new bird flu. So yes, it's a spectrum all the way up to measles, where it doesn't change that much even though it's an RNA virus and you can get true permanent sterilizing immunity from natural infection for the rest of your life, and that's why we don't even vaccinate people who were born before, say, 1960, because we assume they all got measles and they have immunity. So Marty, I'm curious your thoughts.

   8. MMDr. Marty Makary49:03

      Yeah, no, I... Look, I think one of the, um, little-known secrets is we all have our group of go-to people. We've got our immunologists, our vaccinologists, our infectious diseases experts, and we go to them frequently, and we learn to trust the judgment of many of these, and I even heard Paul Offit on your podcast, uh, Zubin, talk about How there's that spectrum. So let's look at the hot coronaviruses, what I call the hot coronaviruses. The cold ones ca- cause the common cold, and they're seasonal. The ones that cause severe illness, or the hot coronaviruses, there's only been three in history, and that's SARS, MERS, and COVID-19. Now, SARS was studied 17 years out, and the natural immunity was solid. MERS was studied three years out, and the natural immunity was solid. Probably longer, but that's just the time points at which they studied the viruses [laughs] that no longer circulate. Why would you study it much longer if it's no longer in circulation? So the starting hypothesis, in my opinion, should have been natural immunity appears reliable. We don't see people getting reinfected with severe illness on the ventilator in the ICU, and once we start seeing that, we can change the starting hypothesis, but let's use the starting hypothesis that natural immunity works, at least in the time that it's been around. And what you had was a series of studies come out from early on, two months into the pandemic, rhesus monkeys were rechallenged with the virus and they did not get reinfected. The Cleveland Clinic then came out with their big study of hospital workers who were around COVID all the time and found no reinfections, and the vaccine did not add anything to their immune protection. Then you had the Washington University study, which actually did bone marrow biopsies and looked at the T cell, activated T cells in the system, the very difficult experiment that we talked about is not as simple as a blood draw, and they concluded that immunity from COVID is likely lifelong, it's lasting. And study after study kept coming out. Then we got the biggest study ever done out of Israel, a population study showing that n- natural immunity was 27 times more protective, adjusted for age, than vaccinated immunity.

   9. PAPeter Attia51:18

      Tell me a little bit more about that one, Marty. That seems difficult to quantify. Can you, can you tell me a little bit more about what that actually means?

   10. MMDr. Marty Makary51:26

       Sure. So what they did is just they have all the positive testing data, as the CDC does, but they won't release it, of people who test positive and then subsequently testing positive again. They also have all the vaccine records. So if you tested positive and did not get a vaccine, they looked at the rate of testing positive again, and it was, there was something like a 13-fold difference, but adjusted for age, because we know every age group is different, it ended up being an age-adjusted 27-fold difference. Now, when that came out, it was a few weeks before the data came out on boosters reducing hospitalizations by tenfold in people over 65. The tenfold reduction in hospitalizations with a booster in older people, Dr. Fauci immediately described it as, quote-unquote, "dramatic data", and wrote up a lot of policy around that immediately. The data on natural immunity being 27 times more protective, not mentioned once ever by public health officials. There's a general fear I h- I hear in my private conversations with public health leaders that if they talk about natural immunity, people might just go out there and try to get the infection, and we don't want them to do that. And I agree, we don't want them to do that, but we can be honest about the data and encourage vaccination at the same time. Look how many careers we've ruined. Teachers, uh, nurses, soldiers getting dishonorably discharged. They have antibodies that neutralize the virus, but they are antibodies that the government does not recognize. That has been a tragic misstep, and I think it's one of the reasons why the government has lost credibility.

   11. PAPeter Attia53:01

       There's a lot I wanna talk about there, but can you talk about the two studies by the CDC that suggest that natural immunity is not lasting?

   12. MMDr. Marty Makary53:10

       [laughs] Yeah. These studies would not qualify for a seventh-grade science fair, the methodology was so poor.

   13. PAPeter Attia53:18

       Is that fact or opinion, Marty?

   14. MMDr. Marty Makary53:20

       That is my opinion.

   15. PAPeter Attia53:21

       [laughs] Okay, just checking.

   16. MMDr. Marty Makary53:22

       But I think any, [laughs] any honest scientist will tell you that the conclusions cannot be derived from the data. The first study was a study looking at a narrow two-month period in the state of Kentucky, and they looked at reinfection rates, and they didn't say anything about whether or not they had symptoms or were hospitalized or anything, and the rates in both the vaccinated and natural im- naturally immune group were exceedingly low. They were 0.01% over that two-month interview, inter- interval. But because they were both so low and they weren't equal, one happened to be 2.3 times higher than the other in the n- in the naturally immune group. So they concluded those with natural immunity were 2.3 times more likely to get the infection again. It's too small a sample. It's... So what happened was the CDC has data on all 50 states for 15 months of the pandemic at the time. They did something called fishing, and anyone in research knows this technique. You find some small sliver of data in some locale, in some narrow time window that supports a foregone conclusion that you've made before reviewing the da- So they found one state over a two-month period that supported their hypothesis. Why don't they release all of the nation's data on reinfections? They've never done that. In the other study, they surveyed people in the hospital and asked them if they've had the infection in the past, and they, they make conclusions about population-level risk by surveying people in the hospital. You, you simply can't do that. How can you derive a population-level risk without knowing the denominator? So both were highly flawed. No one really defended them, except for a lot of politically appointed physicians were just kind of mum about it, and yet these numbers get quoted all the time, like the Maricopa mask study, highly flawed, wouldn't make its way into any... hasn't been published in any journal that has a review process, just the little MMWR rag that the CDC puts out.

   17. PAPeter Attia55:16

       Now, has there been a meta-analysis, Marty? 'Cause one way to address a body of literature this vast, 'cause as you say, there's always gonna be... I, I mean, you're, you're always going to find a signal, and you're always gonna find noise A good process meta-analysis could sift through that. Has someone done that definitive meta-analysis on this question?

   18. MMDr. Marty Makary55:36

       Yeah, so Martin Kulldorff, who was the Harvard professor, now he's at Brown- Brownstone Institute, has summarized the 141 studies on natural immunity. And so when Fauci gets on the TV and says, "We just don't know about natural immunity," well, do the study. How hard is it? This is not the riddle of the Sphinx. You can figure out how many people have been reinfected from the original days of New York and had severe illness, and as, when this issue was coming up, I reached out to Zubin and I said, "Hey, are you hearing about reinfections after somebody truly was sick, not just an asymptomatic test, but they were truly sick from COVID? Have you heard of anyone coming back to the hospital on a ventilator or dying?" And look, I'm sure there's some rare case out there, but he said, "No, look, I haven't heard about it. It's becoming like Bigfoot. Everyone thinks they've [chuckles] heard about it, but there's no good documentation."

   19. PAPeter Attia56:32

       And anecdotally, I think we see the opposite, right? I mean, I know many people who have been reinfected with COVID, and I can say without exception, every one of them had a much, much milder course the second time. Now, some of that's confounded because some of those people also got vaccinated, right? So they got the first wave, they got their first illness pre-vaccine. That was pretty bad. You know, that was, again, in, in a healthy young person, that could still be, like, a bad case of influenza. Some of them just went on to get another COVID a few months later pre-vaccine. Some got vaccinated and got another COVID. But I think the point here is this is knowable. There are some things that are not knowable. There are some things that are knowable. This falls in the bucket of knowable, and therefore

8. 57:15 – 1:02:30

   The unfortunate erosion of trust in science despite impressive progress

   1. PAPeter Attia57:15

      it's frustrating when we don't have information on things that are knowable, or when we claim we don't have information about things that are knowable.

   2. ZDDr. Zubin Damania57:21

      And I think this points again at Marty's assertations that, uh, as a policy, we haven't chosen to des- devote resources to this, and it is a central question. And, and I think our anecdotal experience, again, speaks to the difficulty of preventing reinfection with a mucosal pathogen like a coronavirus, and that's why, you know, you can get a cold year after year, but you don't die. That long-term immunity, you know, prevents severe disease, and we see that anecdotally. N- Now, speaking of anecdotes, one thing I wanna say about that, everybody has an anecdote of somebody who broke through a vaccine or did this or that and ended up getting sick and died, and h- hospital people are really good at this because they see an enriched sample. So they'll be like, "Well, there was a pregnant mother who was 20 who had no problems, died of COVID, and this and this." And all that, that can happen, but when we now have an internet where these anecdotes can be amplified into larger level distorting sort of data sets, I think it influences a level of fear and policy decisions then that spring from that, and that's something we have to kind of tease out by actually doing science, by actually s- studying the stuff directly and saying, "Okay, no, this is actually a well-designed study that says, actually, no, it, it can happen, but it's a .001% risk," and so do we make policy to prevent that risk? And the answer is probably not, because it has costs.

   3. PAPeter Attia58:39

      Yeah, this gets back to, uh, I'll, I'll just keep harping on this idea of science versus advocacy, science versus advocacy. I mean, again, on the other aside of the spectrum, you have, you have a whole gr- people who are saying, "Hey, vaccines are horrible. They should never be used. Nobody should be vaccinated. Natural immunity is the only way to go. Vaccines don't even prevent illness because look at all these breakthrough cases." And again, I think a very arrogant approach is to say, "Shut up. Vaccines cure everybody. Put your head in the sand, you knuckle dragger." But that would be an advocacy position, right? A scientific position would be like, "No, you're absolutely right. Vaccines, it's a probabilistic game. Vaccines reduce the probability of infection, the severity of infection, but that's all probabilistic." So if you take 100 vaccinated people versus 100 unvaccinated people, on an individual basis, you can't make any assertion. That's what science is. And again, I go back to this thing, which is you look at all of the amazing things that have happened in the last two years that really speak to the scientific method. So, so imagine this pandemic took place in the 16th century, like before we even had the scientific method, so let alone [chuckles] the capacity to generate drugs and all these other things. You know, totally different game, right? And yet, I mean, to think we have monoclonal antibodies, we have novel antivirals, we have vaccines, we've got all of this stuff done in less than 24 months. What bums me out, and I've said it before, opinion not fact, I think that this is a Pyrrhic victory for science. I think it has, what's the expression? Like, we've, we've won the battle and lost the war from a scientific perspective, right? Which is, yeah, you know what? 800,000 people died instead of two million. That's an awesome victory, but it came at such an erosion of trust that the next time one of these things comes around, when you actually do need to take really draconian measures, good luck with that.

   4. ZDDr. Zubin Damania1:00:47

      Hmm. This idea of the Pyrrhic victory of science I think is, is really central here, because one thing you said about advocacy, this advocacy position, maybe it's a good advocacy position to say, "No, vaccines, you're sh- you're dumb if you don't take them. They're, they're absolutely essential to ending the pandemic. The only way through is with vaccines." But even that as an advocacy position is ineffective, because how has that worked? It generates psychological reactance among people who are, have ideological and moral Reasons to be skeptical of these vaccines, whether they're politically aligned with someone who's skeptical, whether they don't like authority telling them what to do, whether they distrust science, whatever it is, that approach to advocacy only serves to shore up people who already agree with you, and it creates reactants in others, which is the problem with mandates, which is the problem with the inflexibility of recognizing natural immunity. So even as a policy standpoint, well, all we've done is serve to ex- do exactly what you said, Peter, which is erode our trust and ability to understand science, and then the next thing that happens is, is potentially a huge disaster. If we had a supercomputer to calculate all the downstream effects of what we've done during this pandemic, so let's say we saved, you know, a million lives, let's say, but how many did we cost in terms of future distrust, in terms of childhood vaccines that now people are reluctant to get because they're so burned by this whole thing with the COVID, in terms of all the whatever screening for cancer we didn't do during the time that COVID was going on, substance abuse, the mental illness, the further fragilization of our children through this culture of safetyism and overprotectiveness and, and f- teaching them that, you know, words and people who disagree with you are

9. 1:02:30 – 1:18:15

   Do the current mandates and policies make sense in light of existing data?

   1. ZDDr. Zubin Damania1:02:30

      evil and violent and so on. So that's something that I think we really, if we don't wake up to that, then it doesn't matter how good our science is, it, it's not gonna actually affect anything in a positive way.

   2. MMDr. Marty Makary1:02:41

      You may have seen the Brown University study that just came out. I'm gonna read the conclusion. "We examined general cognitive childhood scores, 2020 to 2021, versus the preceding decade. We find that children born during the pandemic have significantly reduced verbal, motor, and overall cognitive performance compared to children born pre-pandemic." We are in uncharted territory. We are playing with fire. We're now gonna have a generation now living with this. We've got a mental health crisis declared by the surgeon general in children. We've got a 51% increase in self-harm admissions to a hospital among young women. We have yet to comprehend how significant many of these restrictions have been on the most vulnerable members of our society, and that is children, who don't vote, who have been subject to so many of these policies.

   3. PAPeter Attia1:03:37

      One of the things about this that is odd to me is, again, when you contrast 18 months ago with today is, based on what we know, these proposed policies and mandates don't even make sense. So let's talk a little bit more... Let me, let me get a little more data so I can create a thought experiment, which you know I love. What is the best available evidence we have for how much a vaccinated versus unvaccinated individual reduces the ability to spread an infection to some other person? In other words, how much do vaccines reduce the ability to spread the infection?

   4. MMDr. Marty Makary1:04:20

      I think one of the great mistakes we made as a medical community was to suggest that somehow being vaccinated was going to eliminate that risk of transmission, and we've set that expectation, and now people run around saying they don't work, when in fact the vaccines are very effective in downgrading the severity of illness. But the transmission piece now, it's pretty clear, is not significantly affected by the vaccines, because the virus lands its, lands in the mucosal area of the n- nose and upper airways, replicates, and you blow it off faster than the systemic immunity can kick in. Now, the natural immunity is, is more based in the local area of the mucosa, and so therefore that's why some think it's more effective. But when you look at this Lancet study that just came out about a month ago, the peak viral shedding was equal in those vaccinated and unvaccinated. The difference is the window of contagiousness was more narrow among those vaccinated. So we're talking one day versus about three days on average.

   5. PAPeter Attia1:05:27

      So we could, again, this is a very crude assessment, but we could say there's a 66% reduction in transmission if you believe all things oth- are otherwise equal?

   6. MMDr. Marty Makary1:05:39

      You could, but if you show up to the same daycare center or same workplace every day, you're still [laughs] gonna on, on one of those days be shedding virus at, at a high level.

   7. PAPeter Attia1:05:49

      Okay. Zubin, anything to sharpen that analysis? 'Cause that's, again, to me, that's a very jugular question when I think about a policy decision, right?

   8. ZDDr. Zubin Damania1:05:59

      Yeah, I think it's interesting because there's two ways that I think we can see a reduction in transmission. One is the narrowing of the window, which Marty talked about. The other is that there is, including in current data, and I can't cite the specific studies, I'd have to dig them up, but there is a reduction in, in symptomatic infection overall, which means the operative question becomes, when a vaccinated individual is asymptomatic, and I'm not talking about pre-symptomatic, like they're eventually gonna develop symptoms, and often we found pre-symptomatic people are quite contagious, but they're asymptomatic, but they would test positive by PCR, say, are they infectious? And this is in the realm of speculative now, right? But the, the answer is probably not, and the more people that are vaccinated around them, probably even the less infectious they'll be, because those people have an innate resistance even to infection unless the inoculum is quite high, which is why Delta was kind of a, a real drag if you look at vaccine numbers. With Alpha, vaccine very effective, but then the combination of waning neutralizing antibodies plus a very high R0 virus in the form of Delta made it more likely to break through in terms of infection, mucosal replication. So again, I think there's those two main mechanisms by which, but then you have the emergent phenomenon of a community ... effect, and I'm not using even the term herd immunity anymore because it's, it's just, it's gone by the wayside. It's more that there's this community cocooning effect, and you see it in a place like, say, the Bay Area, where the vaccination rates are 90-plus percent. There really aren't that many cases, and if I talk to my friends here, they're like, "Yeah, you know, there's a few really morbidly obese elderly people that are in ICU, but in general, it's not happening, and kids are doing just fine even prior to being vaccinated, and schools are, you know, opened up and stuff is happening." There, there is this kind of effect. So I think it's more complicated than has currently been measured easily, but that doesn't mean we can't measure it.

   9. PAPeter Attia1:07:58

      If you say it, look at, let's just take the most extreme, like, let's say it's reducing transmission by two-thirds, and it's clearly reducing severity of infection by at least 90%. I mean, I think that would be a fair assessment. In some demographics, probably more than that, but it's a good log reduction in severity. So, and then you, you take on top of that, do we have effective agents to treat it? I think the answer is we have lots. So now imagine a different world. Imagine a world in where you had a vaccine that didn't reduce severity of illness by more than 50%, but it reduced transmission by 99%. Would we want to at least discuss whether there would be a different policy view?

   10. ZDDr. Zubin Damania1:08:51

       Yeah, that makes perfect sense because if you're, if the main goal is dropping transmission, but it's not-- but for the people who do get sick, they still get very sick, then your policy changes to, hey, you know, as many people as we can get vaccinated, the better it is. That's a true herd immunity kind of goal there. We can do that, measles, et cetera. But if it's the opposite, then your calculation of policy changes dramatically, and here's why I think it, it does. At this point, like you said, we have treatments, we have prophylactics in the form of vaccine, we have prophylactics in the form of an N95 or KN95 mask. We have prophylactics in the form of you don't go to that concert or go out to eat if you really are that paranoid, right? So at this point, we've shifted from a community-level decision risk to an individual-level decision. I can get vaccinated if I wanna prevent severe disease in myself. I might have a little cocooning effect on my family. That's fine. So we don't wanna minimize it, but it's, we don't wanna maximize it either because it may not be true, uh, in a maximal sense. If it's true, it's on some continuum. And then if I don't wanna get sick and I'm high risk, I don't have to go to that thing, or I could wear a KN95 or an N95, and then if I do get sick, I'm gonna demand, you know, the right monoclonal that is Omicron, you know, sensitive and fluvoxamine and all the other stuff, right? So at this point, we've turned something from, you know, out of your control entirely to something that becomes a much more individual decision, which is why policies that use the mechanism of the state to actually influence your behavior may be less effective, less relevant, and backfire in a bigger sense. And it goes with colleges too. When you're mandating kids ha- be double vaccinated and boosted, quarantine for 10 days in their room, getting DoorDash if they test positive, well, why? Who exactly are they harming? Their own risk is low. Their professors are vaccinated and can wear masks. So it's kinda like at this point, what are we really doing? So it, the underlying situation matters to what policy you wanna actually instill.

   11. PAPeter Attia1:10:53

       Yeah, and I think what, what I'm struggling with is you could paint two extreme cases. So again, you imagine a, a scenario where the vaccine does not really reduce transmission but really reduces severity of illness versus a vaccine that really reduces transmission but not so much on severity of illness. Well, again, any person with common sense could say you have a totally different set of recommendations, and if you're gonna wave a policy hammer, you're gonna do it totally different in those situations. It seems to me that we're using the wrong policy tool. Again, opinion, not fact. We're using the wrong policy tool for the tools on the ground.

   12. ZDDr. Zubin Damania1:11:32

       Even when you talk about kids, which w- I'm sure you'll talk about, the policy tools we have are, are not concurrent with the situation on the ground in terms of these parameters that Peter discussed.

   13. MMDr. Marty Makary1:11:42

       Look, Peter, I think that's a very reasonable opinion, but here's a fact. That is, the therapeutics we have today have cut COVID deaths to zero in the clinical trials, and once they get distributed, remember, they were just FDA approved, once they get distributed and out there, no one should be dying of COVID right now, with rare exceptions. With all the, you know, state-of-the-art care, with the randomized control trial data behind it, and Paxlovid and molnupiravir, no one has died from COVID in those clinical trials, period.

   14. PAPeter Attia1:12:14

       Now, in, in, in fairness, Marty, still relatively small, right? The Pfizer study only had about 1,000 in each arm. Is that correct?

   15. MMDr. Marty Makary1:12:22

       Yeah, a little over 600 in each arm.

   16. PAPeter Attia1:12:23

       Okay. So we used to have a joke when I was at the NIH at the NCI, whenever a small trial would come out in a phase two that showed an amazing result, the, the patients would say, "Can I get that drug before the results change?" [laughs] You know?

   17. ZDDr. Zubin Damania1:12:37

       [laughs]

   18. PAPeter Attia1:12:37

       And are like, "Once the larger trial comes out." But so, so just to set expectations, right? I mean, people are going to die even still through these drugs, but I think the point is when you look at this protease inhibitor, which is the new Pfizer drug, and this RNA replicating blockade that's the Merck drug, they're kinda remarkable. And presumably, we will come out with another set of monoclonal antibodies that will be reactive to whatever strain is relevant, just as Regeneron was very effective against the OG, reasonably effective against Delta. I think we can talk about how effective it is against Omicron. But yes, I think your point is kind of what we've been saying, like, oh my God, we have tools today we couldn't fathom 12 months ago

   19. MMDr. Marty Makary1:13:24

       So good point. Now 23 people died in the placebo arms collectively of the molnupiravir and Paxlovid trials. Zero died of COVID in the treatment arms. Now, it may not end up being, you know, that dramatic in, in a real population, but whatever it is, it's, it's significant.

   20. PAPeter Attia1:13:42

       It's very impressive. Yeah.

   21. MMDr. Marty Makary1:13:43

       It's very impressive. Then you add to that the GSK Vir monoclonals. The problem is w- we've got the monoclonals out for the delta variant. We just can't sequence quick enough to know what to give people. That's the dilemma, but-

   22. PAPeter Attia1:13:54

       Well, especially by the way, Marty, sorry to interrupt, when you start stacking these things, right, this is where it starts to get very Bayesian. You're vaccinated. You have access to monoclonal antibodies. You have access to a new therapeutic. You have access to existing therapeutics, as in fluvoxamine, and you have ICUs that are ninjas compared to what they were two years ago.

   23. MMDr. Marty Makary1:14:19

       That's right.

   24. PAPeter Attia1:14:20

       That's five pieces of Swiss cheese you can put on top of each other, and you still have to try to get a piece of, you know, a pencil through there is pretty tough.

   25. MMDr. Marty Makary1:14:27

       [laughs] That's right. And you add fluvoxamine, budesonide. I mean, it's ama- so l- we're all in agreement, the therapeutics now are f- matured. Once they're actively available everywhere, it changes the calculus. So if people were jumping out of an airplane and some people chose to use a parachute and other people chose not to, you would say, "You know, people not using a parachute are making a very poor decision." And you might even mandate parachutes of anyone jumping out of the plane. But if the plane is flying at a very low speed, only 15 feet above an inflatable mat, that changes the calculus on the entire necessity of instituting martial law to require parachutes or whatever the mitigation is. And right now it's as if there's this mild illness that people with immunity can develop, and we're bringing all of heaven and earth down to lock up these college students in solitary confinement for 10 days, requiring them to get a booster just so they can go to class despite no evidence that boosters right now help young people, and maybe some evidence that there's harm. Now, that could change, but that's the evidence to date. And look at what we're doing to ourselves. I mean, we've, uh, moved to a second pandemic after COVID-19, which is a pandemic of lunacy, which is this overreaction to mild illness.

   26. ZDDr. Zubin Damania1:16:01

       W- what becomes so frustrating, Marty, is when we talk about this stuff, and you and I are pretty aligned on this, and this isn't, this is a, a opinion based on the best evidence we have, so it's a mix of sort of editorializing and... I will get emails from, say, an ICU doctor who will say, "But I'm still seeing sick people in the ICU." And to which I will reply, "Okay, so what in our societal policies would actually prevent that short of locking everybody up in their house and forcing vaccinations on them and then telling them they can't do anything that they normally do, and what's the cost of that?" And the same ICU doctor will tell me, "Well, my son's actually having a lot of anxiety in high school right now, has to see the counselor because he was kept home and away from his social network, and then the pressure of using Zoom, and he's an introvert, and it didn't really work out." And so I, I, I'm sympathetic to that, and it's like, well, okay, now multiply that by how many millions of kids we've done this to for something that eventually, it seems to me, and I'm editorializing, is going to be fully endemic in the sense that you have a respiratory pathogen to, to which initially we had no immunity or limited immunity. We now have much better immunity against severe disease. We get reinfected every year like the common cold, but people who get very sick have a series of therapeutics at their disposal to prevent them from dying. Some old and frail and comorbid people will die like they do from a common cold, but we don't have to really change society over it because it's another common pathogen that we have. Next, do we really need to vaccinate every single child for this when every single child, every single season after they're born is going to be infected naturally, they're not gonna get severe disease because their parents pass along some degree of immunity even in breast milk, and as it is, we're blessed that the kids don't get very sick typically from this unless they're very sick otherwise. And so they're gonna develop immunity. And so i- in so- in, in less than a few years, we won't even need to vaccinate anybody because all adults will be exposed or vaccinated, all children will be exposed, and we'll have another common circulating endemic coronavirus. So tha- that's what I think is where we're headed, and yet, so why are we destroying our society [laughs] in the process and generating so much division? We're squandering our community to, for this thing that just doesn't

10. 1:18:15 – 1:26:15

    Risks associated with vaccines, and the risk of being labeled an anti-vaxxer when questioning them

    1. ZDDr. Zubin Damania1:18:15

       make sense to me. Now, that's editorializing.

    2. PAPeter Attia1:18:17

       Well, I, I'm gonna keep editorializing for a minute, and then I wanna come back to something you said, Marty, which is let's now look at the data around the risks of vaccine. Because again, I think one of the challenges of the scientists being conflated with the advocates is that no one's allowed to ask that question, right? As though somehow, you know, statins, like let's take a drug that, I mean, just demonstrably reduce the risk of cardiovascular disease. Like, you just, you know, you've gotta look far and wide to figure out over the right time horizon, if you give statins for a year, you might not see a benefit. But demonstrably, the biggest sea change we've had in the reduction of risk for the most prevalent chronic condition in the developed world. Would anybody with a straight face say that there aren't risks of statins? Nobody with a straight face could tell you that statins don't harm some people, and there's nothing bizarre about that, right? There's nothing odd to say that. I mean, like, don't we talk about this every time we give patients a drug? You give somebody a prescription for something, "Hey, let us know if you develop a rash. If you do, it could be really severe, you know? You..." Please call us right away and let's stop it. You might be one of the 4.9% of people that is susceptible to this side effect, right? So somehow it's become impossible to have the discussion, uh, if you're coming at it from the, the sort of the, the advocacy point of view, that there might be a risk associated with a vaccine. Until, you know, something like the J&J thing came along, and then the response seemed the exact opposite, which... Uh, so this is the thing I'm struggling with, okay? So, so this is a long, rambling question 'cause I don't understand something. I don't understand how when the first J&J data came out and said, I believe it was six cases of VTE in 7 million doses, so about a m- one in a million incidents, the drug was pulled, the vaccine was pulled, and in a moment we're gonna talk about myocarditis with Moderna. Nobody wants to talk about that? Why the difference? I'm asking for opinion because, I mean, we can talk about what the facts are, which we'll get to, but the broader question is help me understand the difference, because I'm getting questions from patients of mine saying, "I don't want my 18-year-old son getting a third mRNA booster, which is being mandated by his university. Do you think I'm crazy?" To which I say, "No, you're not. Here's the data that s- tells me you're not crazy."

    3. ZDDr. Zubin Damania1:20:54

       And I'll, I'll let Marty answer this, but I just wanna say this. I think it comes down to the difference between peacetime and wartime vaccine communication, and again, this is advocacy versus science. So in peacetime vaccine communication, you have children who need to get these series of vaccinations in order to prevent common th- what would re-become common diseases like measles, mumps, et cetera, if we didn't get a certain degree of herd immunity that happens, which is above 90-odd percent. And so the v- the messaging has always been, "Hey, listen, there are very rare side effects of these things, and by the way, they can be quite serious, but they're very rare. But as a community benefit, pretty much w- the risk to your child is so small, and the risk of the communicable, communicable disease is small, right? In, in an absolute sense, absolutely small. But if we don't do this as a community, we're gonna have a problem." And you see it when vaccine rates drop below 90%. You see measles outbreaks and that sort of thing. So the public health messaging has always been, "Hey, zero tolerance for anti-vaccine discussions. We don't talk much about the risks of them because we just need to do this, and they're mandated for schools," and so on. Now, risks and... There's, there's merits and demerits to that approach, but that is the peacetime approach to vaccines. The wartime approach, where you have s- un- uncertainty, you have changing data, and you have risks and benefits that are stratified by age and comorbidities, we're applying the same peacetime approach, which is vaccine absolutism with no quarter, and anything you say against the vaccine is taboo. So it becomes almost an unspeakable curse, like in Harry Potter. You can't use them or you're excommunicated from the tribe of medicine, and it has become a tribal thing. Well, now I think it's become this kind of absolutist thing that they've applied in wartime to something that it just doesn't apply to, which is this vaccine, which, as you mentioned, has risks that actually are worse for younger people, and benefits that are much less for younger people. So we ought to be looking at it clear-eyed. So I'm sorry, Marty, over to you. That's just my rant. [laughs]

    4. MMDr. Marty Makary1:23:00

       No, I... Like, you're spot on here, because what we now see in this tribalism of medicine, and we've seen it in the groupthink of so many aspects of COVID that the establishment got wrong. And the reality is we've got a few people making all the decisions on COVID, a very f- small group of non-age diverse, non-ethnically diverse political appointees with political allegiances making all the decisions on COVID for the country. And quite frankly, I think they're detached from the life of a young person in Baltimore City who was barely hanging in to, in school pre-COVID, okay? It's not as easy to hand that person an iPad and say, "We're, you know, we're gonna do remote learning," as it is in the Hamptons or in Santa Barbara County. So what we developed was this sort of tribalism whereby if you would question anything that might result in an answer, even albeit scientific, that could threaten the vaccinate every human being with two feet message, then that needed to be s- suppressed or squashed or ridiculed or labeled an anti-vaxxer. It could, it could be natural immunity. You know, I think that's maybe how I initially got sort of seen as, "Hey, is he one of us?" with the vaccine community. You know, last year I was calling for lockdowns beforehand, warning of this thing, wrote the first piece calling for universal masking to keep society semi-open. And then the vaccine rollout came along and I said, "Hey, wait a minute. It needs to be simply age-based, and h- those who have natural immunity need to step aside in the vaccine line so we can save more lives. And let's just focus on the first doses, because the immunity is pretty good for three months. We can save more lives." Tens of thousands of people could have been saved if we adopted those policies. And some people would suggest, "Hey, wait a minute. If you're saying hold off on the second dose, y- you're kind of anti the vaccine. And if you're telling people with natural immunity they can wait a little bit based on the data, that's kind of anti-vaccine. And if you're asking about the myocarditis complications, trying to understand the rate of them, that could scare some people off, and therefore you might be putting an anti-vaccine message out there." The VAERS data system, which is the self-reported system the FDA set up, is such a shoddy, poor way to track complications that w- it's basically unreliable. It's overloaded And yet at the same time, it's very cumbersome to report into that. Most doctors that tell me about a complication have, say they haven't reported it to VAERS. You really get almost no follow-up. There's been deaths in children in the United States immediately after the second dose from myocarditis, and the CDC says they are gonna investigate one of them. That was several months ago. We never heard anything. So if you ask questions, it's almost as if, you know, how dare you? Now, look, the vaccine still makes sense in a certain context, in a certain way. In young people, it's o- often to present MIS-C and hospitalization more than it is to prevent death in children, but it's nuanced. It's not a one-size-fits-all strategy, especially with those who have

11. 1:26:15 – 1:35:00

    Data on incidence of myocarditis after vaccination with the Pfizer and Moderna vaccines

    1. MMDr. Marty Makary1:26:15

       natural immunity.

    2. PAPeter Attia1:26:16

       So let's talk a little bit about that. ZDogg, Vinay did a great video on this just the other day, but let's talk a little bit about what we know. And now let's just talk in fact for a moment, right? Let's not editorialize anything. What do the data suggest with respect to the Pfizer vaccine and the Moderna vaccine with respect to the incidence of myocarditis in males and females below the age of 40? And stratify that as much as you see fit.

    3. ZDDr. Zubin Damania1:26:45

       So I'll give the high level, and Marty can dive into the details because he's a vastly bigger nerd than I'm capable of being. But I'll s- I'll say this. The party line has been that, and you'll hear pediatricians around the country telling their patients this when asked about vaccine, they're kind of reiterating what CDC says, which is the risk of myocarditis in young people is exceeded, from a vaccine, is exceeded by the risk of natural COVID infection causing myocarditis. In other words, if they were to go out and get natural infection, they're X-fold more likely to get myocarditis than any risk of myocarditis from either of the vaccines, Pfizer or Moderna. Now, this is in the setting of not knowing the denominator of how many people [chuckles] are actually infected with COVID out in the community. They're just looking at kind of hospitalized patients and so on. And of course, those patients are sicker. Of course they have more cardiac side effects and so on when they're infected with COVID.

    4. PAPeter Attia1:27:47

       There's two counting issues there, just to clarify, right, Zubin? The first is you have a negative selection for patients, and then you have a underestimation of the denominator.

    5. ZDDr. Zubin Damania1:27:57

       That's right. So in other words, we don't know how many people got infected with COVID out in the community that did just fine. We're guessing at that, uh, using incomplete tools. And so that's part of the problem in the calculations. Whereas with vaccines, we can say, "Oh, these guys got vaccinated, and there were this many cases of myocarditis, and they were hospitalized for this many days, and they had this kind of cardiac function at discharge, and these were the complications and so on." So you can, you can actually look at that data. Now, looking at all that same data that was available, the European authorities said, "You know what? Actually, we see a bigger risk with Moderna for myocarditis that, uh, especially when we have Pfizer, which seems to have less myocarditis, so we're just not gonna recommend Moderna for men or people under 30." Now, tha- that's a huge difference between US and European policy based on data sets. Now, this is where the newer data comes out that Marty can talk about saying, "Hey, you know, this may not be true, that actually natural infection is more myocardiogenic [chuckles] than the vaccines."

    6. MMDr. Marty Makary1:28:53

       Yeah, so we generally recognized this rate early on to be somewhere in the range of one in 7,000, and that is young boys and young men. So in the age group 15 to 25, the rate was about one in 7,600 according to a New England Journal study after the second dose. The complications, 90% of them were clustered around the second dose, and the myocarditis cases, the vast majority of which were mild, but two were severe in the New England Journal analysis out of Israel, and one person died. That is, a 22-year-old died. I know it, you know, you can barely say that because, you know, of the sort of trigger that it creates. But look, by and large, this is a safe vaccine. But for parents asking these questions about vaccinating their kids aga- against an illness that has an ultra-rare rate of death in healthy children, this is a reasonable conversation to have. Maybe the rate of death from the vaccine parallels the rate of death from COVID in a healthy child. Now, the CDC reports there are 668 deaths over two years, so let's say roughly 300-some deaths a year from COVID in k- everyone under age 18, all children. Who are those kids? We believe, many of us believe that they are nearly all in children with a comorbid medical condition. Now, they're still important members of our society. We need to do everything we can to protect them. But it does change the calculus now for healthy kids when we recognize that the vaccine is not halting transmission. So to subject all healthy children to a vaccine when the risk of myocarditis could be as high as one in 7,000 young males and boys, then all of a sudden you're talking about a very nuanced decision where some pediatricians might say, "You know what? How about we do one dose?" There was a study of kids 5 through 17 in Germany that just went on the preprint server. Of all the deaths in Germany over the 15 months of the pandemic right up until around March, March, April, there were zero deaths in healthy children. No healthy child has died. 100% of the deaths were clustered in kids with a comorbid condition, 100%. So that changes the calculus now to a parent that says, "Hey, my kid's healthy. I'm a little concerned about the rare side effects I'd like to talk about the data. This is a conversation. It is not a one-size-fits-all strategy as we are being told. And especially when you get to boosters, [laughs] I mean, the r- here's n- here's the New E- here's the New England Journal paper from December 8th looking at boosters and no boosters in kids, well, I call them kids 'cause I'm on a college campus, in people under age 30, okay? In people under age 30 who are vaccinated with the primary series, there were zero deaths. This is population data from Israel. Zero deaths after the regular primary vaccine series. You cannot lower that any further. You cannot lower the number zero further with a booster. Well, they looked at those with boosters and, as you would expect, zero deaths in that group. And then in Germany, they looked at people really essentially over a period when there were n- there was no vaccines, and the rate was also zero for healthy kids. That tells me if the kid has a comorbid condition, get the vaccine. Otherwise, for healthy kids, it's a nuanced discussion.

    7. PAPeter Attia1:32:37

       If you look at the circulation paper that came out in July of this year, the knock on this is it doesn't distinguish between Pfizer and Moderna. So we'll talk about that in a second, but I think to me the most interesting table in there is the one that stratifies by age, and then it does risk and benefit male for female, which again, seems to me a very reasonable way to think about this, right? So when you looked at 12 to 17-year-old males and females, and again, this is all mRNA vaccines, we know now, I think, can we say that unequivocally the Moderna vaccine is three to four times more likely to be associated with myocarditis or, uh, myopericarditis?

    8. MMDr. Marty Makary1:33:20

       At least.

    9. ZDDr. Zubin Damania1:33:21

       At least, yeah.

    10. PAPeter Attia1:33:22

        Okay. The supplemental data that came out literally two days ago looks like it's five times worse. But let's be conservative, say three to four times worse. So keeping in mind I'm giving you blended data, 12 to 17-year-old females, eight to 10 cases of myocarditis per million doses, males 56 to 69 cases blended. Benefits, saves 38 ICU admissions, saves one death. So here's where I'm struggling, right? Now if you look at this and you say, "Look, you're gonna give 70 cases of myocarditis to save a death," what's the natural history of those 70 cases of myocarditis? So Zubin, how many of those kids make an unremarkable recovery? How many of those kids are going to have a chronic issue with their heart, they're gonna have a reduced EF for some point of their life, and will any of those kids die?

    11. ZDDr. Zubin Damania1:34:20

        And this is the thing, we don't have enough data to be able to actually answer some of that. I think there's a degree of uncertainty, and when you're talking about the quality life year saved in a kid, if you, if you're gonna in any way impinge on their ejection fraction of their heart in the future or cause any scarring or cause what we may even be under-diagnosing, whether there's arrhythmia happening, it becomes a really open question that this ought to be looked at very carefully. Now, Marty may have his hands on some of the more specific data on the outcomes. You mentioned the 22-year-old that died. It's als- it's also a little difficult to peg causation sometimes because some of these kids had also preexisting cardiac

12. 1:35:00 – 1:40:30

    Outstanding questions about myocarditis as a side effect of mRNA vaccination and the benefit of boosters

    1. ZDDr. Zubin Damania1:35:00

       abnormalities. We always think about sudden cardiac death in athletes and children and, and whether to screen or not, and those kind of things are outstanding questions. But even if, if this were to provoke that to happen, say, if they were to get myocarditis, you're impacting a child and, and tons of live- life years that are affected, as opposed to, say, a 90-year-old who maybe the vaccine gave them a fever that pushed them into cardiac arrest. L- I mean, just speculating, right? It's a very different quality of life, years saved kind of calculation. So I don't have the specific data for, like, how many of these kids go on to have chronic problems or even the hospitalization risk, right? So a certain percentage of these, 86% in one study that I saw, get hospitalized for a, a average of about three days. When you hospitalize anybody, you put their life at risk because th- [laughs] they're in a, the most dangerous place on the planet because medical errors happen, infections in the hospital happen, complications happen. That's why staying out of the hospital is a good idea if you can do it. So you, you have to look at that as well, and I just don't, I haven't seen the data that compellingly says, "Oh, this is the answer to that."

    2. PAPeter Attia1:36:09

       The argument I hear, by the way, 'cause I, you know, a few days ago I saw something that was ranking colleges or something like that, and I made some snarky comment on Twitter like, "Can we start ranking the dumbest colleges?" You know, and I was gonna put my alma mater, you know, gonna put Stanford and Hopkins there, which are two of the idiotic colleges in my view, who... And, and by the way, this is, uh, opinion, not fact. Um, who are mandating, you know, boosters for kids and not letting them back to campus without them. And I couldn't believe the people that were just furious with me. "How could you possibly suggest this? Of course those kids need to have their third shot." And the argument was they're putting so many other people's lives at risk by not having booster shots. And I'm thinking, explain that to me. Like, again, this is, uh, every s- six months I do something stupid, which is I engage on Twitter. And I need to, I, I need to create sort of like a testicular tasing device that is hooked up to the Twitter app, where anytime I look at Twitter, I get like 120 volt tase to my testes, and it just says like, "Don't ever do that again." Like, "Don't ever, don't ever go on Twitter." Like, nothing good comes of it.

    3. ZDDr. Zubin Damania1:37:29

       It's a DEC device, guys, uh, direct epididymal current.

    4. PAPeter Attia1:37:33

       [laughs]

    5. ZDDr. Zubin Damania1:37:33

       And when you apply at least 73 joules to your jewels, it, it will dissuade you from ever clicking on that stupid app. No, no, I, I, actually, just real quick on this because [laughs] this is, this is the thing. This is the tribalization. So what you did is you behaved as an out-group to the in-group of whatever public health doctory types that are on there, and this idea that, that these, uh, vaccinating, triple vaccinating these kids at Stanford, and by the way, closing campus for two weeks because of Omicron, which is what they've done.

    6. PAPeter Attia1:38:03

       How have we got this far in the podcast without, Marty, you referring it to Omicyold? 'Cause-

    7. ZDDr. Zubin Damania1:38:08

       [laughs]

    8. PAPeter Attia1:38:09

       ... this is your term, right? So, so, so for, we're gonna close the campus for two weeks because of Omicyold. Continue, Zubin.

    9. ZDDr. Zubin Damania1:38:17

       O- Omicyold rips through. Marty is, you know, cashing in his royalty money from every time someone says Omicyold, and at this point, the argument is, oh, well, they're protecting professors, they're protecting other people in the community, and this is my take, and I'm editorializing. We have no data that that's actually [laughs] at scale true. We talked earlier in this podcast about the transmission effects with younger people, too. Uh, first of all, who are they exposing? Well, it's professors, and family, and community. Okay, those professors, and family, and community can make the decision to triple vaccinate, to wear a mask, to stay away from big crowds. In fact, a lot of the professors are teaching remotely as it is. So w- who are they really exposing? Other kids their age who are low risk, who also have been vaccinated, and if they don't get a booster or they get a booster, what's the marginal benefit? How many cases of myocarditis will you cause where that kid is out of school for three to six days in the hospital? We don't know the long-term effects of it, although I suspect they are generally mild, but that's, uh, more editorializing. Th- these are the questions you have to ask. So when people behave in that rubber stamp way, now, I'm guilty of it, too, because I editorialize in this way. I think this is crazy. I think these schools are out of their mind. I think we're promoting a culture of safetyism and fragility in children, and we're teaching them that this is okay to do. And who's doing it? People with power, the elderly uber class that can sit at home on Zoom. They're doing it to young people who this is their chance to be in college and engage with other young people in person. That's what college is. It's not [laughs] about learning. That's a side effect. It's about the o- other stuff. So that, that's my take on it.

    10. MMDr. Marty Makary1:39:49

        The WHO has put out an official statement very recently, two weeks ago, saying that universal booster programs w- threaten to prolong the pandemic. They recommend against these booster programs, and they warn that they will increase global inequities because 93% of the population of poor countries has no vaccine, and one dose is better than no dose. So they're taking a global perspective. Now, look, people ask me, "I'm over 65. Should I get a booster?" The answer is, if you haven't had the infection, yes, it's gonna reduce your risk of hospitalization. But if you just bring up what the WHO has already

13. 1:40:30 – 1:43:30

    The risk-reward of boosters and recommendations being ignored by policy makers in the US

    1. MMDr. Marty Makary1:40:30

       concluded, somehow that's considered an outlier idea that you ca- we cannot discuss in the United States. WHO tells people under age six they should not be wearing a mask. The European CDC says that kids in primary school should not be wearing a mask. The, many European countries have restricted or banned Moderna vaccine from anyone under age 30 because of the risk of myocarditis.

    2. PAPeter Attia1:40:57

       So all of that suggests that in many ways the United States is lagging behind in terms of implementing scientifically wise policies, suggesting that we're making errors in our policy that are ill-informed by science.

    3. MMDr. Marty Makary1:41:14

       Certainly the FDA bypassed their technical experts, what we call the VRBPAC, which is their external advisors. So the VRBPAC had to vote on boosters for everybody. They voted against it. They voted 16 to two against it, in part from, because the, the stuff we're talking about, myocarditis and other concerns, and a lack of benefit demonstrated.

    4. PAPeter Attia1:41:35

       And that was in what age group, Marty?

    5. MMDr. Marty Makary1:41:37

       That was for everyone over age 18, so it was boosters across the board.

    6. PAPeter Attia1:41:42

       Oh, yeah, yeah, I see, I see. Yeah, the second wave of boosters, yep.

    7. MMDr. Marty Makary1:41:45

       Yep. So they voted it down. The experts said no. These are smart people. Then the FDA made a second internal push in the agency weeks later, and they chose this time during this process not to convene their experts, to circumvent their own experts because they didn't want the input of people who were opposed to it, and they unilaterally authorized boosters for young people. CDC did the same. And so what we are, now have is this dramatic vigor of enthusiasm around boosting every 16 and 17-year-old in this country with really a lot of experts saying, "Hey, we are not on board with this," and the w- a lot of the world is not on board with it. And so that's where we ended up where we are today. It's groupthink. If you think about it, when Omicron came up, it was almost like, "Here's an opportunity to push boosters in young people." Uh, Pfizer makes a, puts out a press release saying that, "Hey, if you get a booster, it will help with Omicron." Okay, nobody knew anything about Omicron at that point. There was speculation it was mild. Now we have a lot more information. The next day, the next day after Pfizer's press release about a experiment they did in the lab without releasing the underlying scientific data, the next day, the CDC rigorously puts out a strong recommendation to boost every 16 and 17-year-old. Is that what we've come to now? Pharma puts out a press release, and the next day we've bypassed all of our internal experts, and we have this bandwagon effect of colleges and universities, which are supposed to have smart people, requiring boosters in a population that Germany found doesn't have any deaths

14. 1:43:30 – 1:52:15

    Sowing distrust: Lack of honesty and humility from top officials and policy makers ;

    1. MMDr. Marty Makary1:43:30

       in five to 17-year-olds without any vaccine. I'm not s- recommending that, but what are we protecting them from?

    2. ZDDr. Zubin Damania1:43:38

       And again, this is not measles. This is not sterilizing immunity. This is not high-level herd immunity that we're giving them by vaccinating them

    3. PAPeter Attia1:43:45

       Again, I, I just, I'm so troubled by this because of what I think about as the long game, right? The long game is, I mean, how many times has Anthony Fauci said, "An attack on me is an attack on science"?

    4. ZDDr. Zubin Damania1:43:57

       [laughs]

    5. PAPeter Attia1:43:59

       I mean, I, I actually had to go and look some of those things up because I'm like, "No, he didn't really say that. That's just a meme."

    6. ZDDr. Zubin Damania1:44:06

       [laughs]

    7. PAPeter Attia1:44:07

       You know, like, nobody would actually say that.

    8. ZDDr. Zubin Damania1:44:10

       He's had a rough year.

    9. PAPeter Attia1:44:11

       And he didn't say it once, and he didn't say it twice, right? I lost count of how many times he has said that. So, you know, there's a part of me that's very empathetic to Anthony Fauci, right? I, I think that's a horrible position to be in, right? He was sort of thrust into this position as the world's, or at least the nation's expert on infectious disease matters in a moment when nobody knew anything, right? So he's having to sort of wear a mask, don't wear a mask, and... But I think the lack of humility in expressing uncertainty and the doubling down and then the statements around... I mean, I, I have to tell you, I, I didn't wanna get too political today, but I was very disheartened to see how vociferously he denied NIH funding gain-of-function research in the Wuhan lab. I mean, I, I don't really understand how you can deny that.

    10. ZDDr. Zubin Damania1:45:05

        Francis Collins still thinks it's unlikely it came from the Wuhan lab. I mean, the head of the NIH, he just said that last, uh, last week.

    11. PAPeter Attia1:45:13

        How do they not just deny it? I mean, you look at his exchange with, with Senator Rand Paul, like, this is beyond denial, right? This is attacking anybody showing you the evidence [laughs] that your institute has funded gain-of-function research in a particular lab through an intermediary. Like, where's the ambiguity here?

    12. ZDDr. Zubin Damania1:45:33

        Well, where's the humility? People are hungry for honesty right now, and if I were Anthony Fauci or Francis Collins, I would say, "Look, we were out there parading around gain-of-function research, giving grand rounds and lectures around the country, writing op-eds about the importance of doing gain-of-function research. We came, we came at it from a perspective that was a little old-fashioned back in the days when it took months to sequence a, a piece of the gene. Now we can do it in 20 minutes. There's no need to, to Frankenstein up viruses just to study them. We feel terrible. We don't believe the dollars from our research funding went directly to do this type of research, but they went to the lab, and for that, we're sorry. Let's agree now to ban all gain-of-function research in the future, in perpetuity, forever, of all kinds, and let's make that an international treaty." They could show leadership on that, but instead they, it's almost like they're defending it.

    13. PAPeter Attia1:46:32

        Yeah. And what I struggle with, and I think you'll both appreciate this, I know, I know you will 'cause I've heard you both speak on this, is when bad outcomes happen in medicine, the doctors who get sued versus the doctors who don't get sued, it doesn't come down to the grievousness of the error. It comes down to the arrogance and the humility with which the physician interacted with the patient. Every one of us I know have made mistakes with patients, and when you say to that patient, "I really screwed up. I mean, like, I sent you to get a CT scan, and it wasn't even supposed to be your scan. That was a clerical error on my part, and you got exposed to radiation unnecessarily," or even the most extreme examples of, of errors that have happened. You go to that patient and you say what you did and you fess up, and if you want bonus points, maybe even explain what could be done different the next time so that it doesn't happen to somebody else. I don't think there's a scenario under which a physician under that situation has been sued. You start lying and you start posturing and you start denying and you start, in the face of overwhelming evidence, and y- y- you sort of make the person feel like they're crazy, I mean, guess what? Like, there's gonna be a little packet coming your way from a lawyer. This is, like, the highest order example of this, right?

    14. ZDDr. Zubin Damania1:47:54

        That's a really good analogy, actually, because we've all been in those positions, and I tell you, I've thrown, I've thrown myself at the feet of patients' families saying, "This was a mistake I made. Here are the things we're gonna do to make it better. I'm sorry." You know, and again, I have not been sued, knock on wood. But with Fauci, it's interesting because let's l- I'm gonna play Fauci advocate for a second. Here's a guy, 'cause I, I was part of a documentary that hasn't been released prior to COVID. They had interviewed Fauci and, you know, Hotez and some other people about vaccine advocacy and the anti-vaccine movement and things like that prior to COVID and, you know, he has just been kind of filleted by a lot of the sort of more activist conspiracy angles on things and really did feel like science itself was under attack to some degree. Now you throw in, okay, he's under a lot of political attack. He gets all this hate mail and all of this. He's probably doing what humans do, which is entrenching, solidifying his position, and becoming an absolutist, which is not what we need. It's not what we need. If he had insight or a good therapist, they [laughs] could probably tell him, "Dude, bro, this is not good. You need to be honest. Like, if you think masks shouldn't be used because we're really trying to save them for healthcare professionals, just tell the public that." And I think that, that's it, is, y- you know, these are human beings. He's 80 too, and we forget that-

    15. PAPeter Attia1:49:11

        81 now

    16. ZDDr. Zubin Damania1:49:12

        81. Wow. I mean, that's-

    17. PAPeter Attia1:49:14

        Just had a birthday.

    18. ZDDr. Zubin Damania1:49:15

        Nice. Happy birthday, Anthony.

    19. PAPeter Attia1:49:16

        [laughs]

    20. ZDDr. Zubin Damania1:49:17

        You know, and, and I, I was on, I was on a call with Anthony Fauci during Ebola that I was invited to where he was trying to talk to public health people about, "Hey, here's how we can think about Ebola." He was rational, he was calm, he was logical, he was science-based. He diffused a lot of fear. I thought it was brilliant, right? And so to kind of see this transition is, is, is difficult.

    21. PAPeter Attia1:49:37

        And to be clear, and I'm glad you said that, by the way, I'm not saying I would be one bit better. Like, I, I just wanna be clear.

    22. ZDDr. Zubin Damania1:49:43

        [laughs]

    23. PAPeter Attia1:49:43

        Everything I'm saying to be, to be critical of advocacy versus science here I'm sure I would be doing the same thing. I'd probably be worse. He seems to have a much nicer disposition than I do.

    24. MMDr. Marty Makary1:49:53

        I, I agree.

    25. PAPeter Attia1:49:54

        Yeah, yeah, yeah. But it doesn't change the fact, right? What's the aspiration here? And, and maybe this shouldn't be all on one guy's shoulders, 'cause to your point-

    26. MMDr. Marty Makary1:50:01

        [laughs] No

    27. PAPeter Attia1:50:02

        ... how exhausting is this? Like, I'm sick of this and it's not my job.

    28. MMDr. Marty Makary1:50:06

        Yeah, me too. [laughs]

    29. PAPeter Attia1:50:08

        Like, I am sick and tired of this, and I have the luxury of getting to focus on stuff that I actually find interesting. So yeah, maybe this shouldn't be one guy.

    30. MMDr. Marty Makary1:50:19

        It shouldn't be one guy, and we should not be putting our entire faith and trust in one individual. We should be hearing about multiple different medical opinions, and we should from the s- we should have from the start. You know, I called in, as you know, I was very nervous about the pandemic and what it could do beforehand, following what was happening in Wuhan and calling doctors there. And as editor-in-chief of MedPage Today, I wrote some pieces and was t- reading articles coming in, and it was pretty clear to me that our country needed to wake up. So I had some relationships with the White House from my work on price transparency, made a phone call into the White House and said, this was in February before the pandemic, I said, "Look, this is gonna be really bad. We need to drop all kinds of contingency plans as a country, stop non-essential travel, get testing up," and all this stuff, went through the whole gamut. And they were shocked, and they said, "You know what you're saying here is, would be a major shift in how we're approaching this." And I said, "Yes. I, look, I've talked to the experts and I believe firmly in this. This is stuff we need to do." About a week later, I got a call back from them and I, they said, "Well, good news. We got a chance to talk to Dr. Anthony Fauci, and he says we're gonna be okay." Now, look, we all make mistakes, and that's okay, but you've gotta evolve when the data come in, and he had hedged his bet watching SARS 1, that is SARS in 2003. It just petered out in Asia, and he kinda hedged that that's the way it was gonna go, and you had every media outlet going to him saying, "Hey, do I need to worry? Do I need to worry?" And as you know, as a physician, it's much easier to give reassurance than it is to say, "Yes, I'm very concerned." So that's how w- I don't know whether or not to blame him or Meet the Press and Face the Nation and all these that just incessantly ran one opinion and not that of Amesh Adalja and so many other infectious

15. 1:52:15 – 1:58:45

    Thoughts on testing: does it make sense to be pushing widespread testing for COVID?

    1. MMDr. Marty Makary1:52:15

       diseases doctors with the chops to say, "Hey, you know, they've got a different perspective."

    2. PAPeter Attia1:52:20

       Can I ask something heretical at this point, though? At this point in the pandemic where we have Omicron and we have a vaccine, we have therapeutics, does it even make sense to push such widespread testing, whether it's antigen testing or PCR? I wanna throw this at you guys and see what you think, 'cause I, I'm curious the answer to this. I'll share with you my opinion. I don't think so. 'Cause someone's al- one of you has already made this point, which is there really isn't a precedent for tracking rates of infection for respiratory illnesses. What we pay attention to, and as has been noted by many people, what we pay attention to is hospitalizations, severity of illness, death. So morbidity and mortality effectively is the statistic that matters, and somehow infection rate has now become a metric that matters. So you can measure it. What get measures matters. We don't measure influenza infection rates. I've never taken a test for it. I, I remember when I had H1N1 in 2000, what year would that have been, 9?

    3. MMDr. Marty Makary1:53:23

       9.

    4. PAPeter Attia1:53:23

       10?

    5. MMDr. Marty Makary1:53:23

       Mm-hmm.

    6. PAPeter Attia1:53:24

       I had it. I never got tested for it, but we finally put two and two together 'cause my LFTs hit 1,000. I mean, I was sick as a dog. I was literally on the verge of getting a liver biopsy before my doc went, "Wait, I think that illness you had a month ago or two months ago was H1N1. Let's wait another month before we stick a needle in your liver." And sure enough, my LFTs returned to normal. So I mean, I'd fully support, I think, or at least noodle the idea a lot more that what if we never tracked infection rates, and we used it as epidemiologic data, right? So in, we, we did some sampling perhaps so that we could understand movement, new strains, and things like that, maybe even use it to develop predictive models that might tell us when there might be an uptick in hospitalizations. But it no longer became a metric. Like, you didn't, you didn't see it on the news every day, and people didn't talk about it as the thing that needed to go to zero.

    7. MMDr. Marty Makary1:54:20

       Hmm. On top of that, I think there's the personal downside and upside of testing. So I'm a young person, I have a few symptoms, or I'm screened. Let's say I'm screened, asymptomatic, you know, to do whatever I need to do at school or whatever. They screen me with an antigen test and I'm positive. Well, now I'm stressed. I have to quarantine for f- 10 days or five if you're listening to CDC's advice on hospital workers, which apparently is different and has been de- downgraded in terms of time because of need. I'm sitting there freaking out. "Well, oh, let me see. Do I get monoclonal antibodies? Should I take this? Should I do that?" Whereas my pre-test probability of anything happening to me is so low, and in fact, the pre-test probability of this being a false positive is quite high in an, in an antigen test. Is that, isn't that causing a degree of harm and cost? And it might be. Now, the upside is, of course, that person, if it was a true positive, can stay home and doesn't infect other people. But if it's already so widespread, does it really make a dent in something like Omicron that's so transmissible? Now, with an old person who's symptomatic, you're gonna test them anyways because at that point they do need therapies in the forms of monoclonal, fluvoxamine, et cetera. So it, it's, again, it's a stratified by risk, it seems. But a mass population testing-

    8. PAPeter Attia1:55:32

       Another way to think about this is don't order a test unless the outcome would change how you're, you're gonna manage the patient. And in the case of therapeutics, for someone who's symptomatic, the answer is, yeah, might be worth testing. I think the idea of asymptomatically testing athletes is one of the most ridiculous things I've ever seen. Like, we're gonna just Test everybody in the NFL and NBA and NHL and NCAA. I mean, it's like serious? Like, that, what is the logic of this?

    9. ZDDr. Zubin Damania1:55:58

       Mm.

    10. MMDr. Marty Makary1:55:59

        [laughs] If, if you test, if you test athletes or anyone in the population for meningococcus bacteria in their nose, 10% of the population will come back positive because that bacteria lives in a colonized, you know, non-virulent form everywhere.

    11. PAPeter Attia1:56:17

        We have to put these people in a neuro ICU, Marty.

    12. MMDr. Marty Makary1:56:19

        Exactly.

    13. PAPeter Attia1:56:20

        Do you understand how deadly that bacteria can be?

    14. MMDr. Marty Makary1:56:24

        Right.

    15. PAPeter Attia1:56:24

        I mean, this, we, can you imagine what the neuro ICU rate is going to do at this point? This is... But by the way, what if we just checked everybody for, for staph on their skin? Like, how many people are walking around with MRSA on their skin?

    16. ZDDr. Zubin Damania1:56:37

        Quite frankly, guys, you're not invasive enough. I would do urethral swabs on everyone to screen for gonorrhea and chlamydia, because God knows, if you have an asymptomatic case of chlamydia, I mean, your nuts could fall off. So, you know, [laughs] there's all kinds of cr- again, I like Peter's basic medicine, internal medicine idea here. Don't, don't do a test unless it's gonna change your management in a, in some positive way.

    17. MMDr. Marty Makary1:57:03

        Look at what we've done to physicians, and this is what I've, sort of the complaint that I hear from the infectious diseases doctors I respect. We've done a terrible thing to physicians in the United States. We put them on this singular mission to block viral replication, hunt it out, find it, block it at all cost. And what we've lost track of is treating the entire person, and we've lost track of the sustainability of any system to do this. If we start mass testing everybody in the population on a, you could test every child every day when they show up to school in perpetuity, it is gonna create a burden that's unsustainable. It's gonna bankrupt our system. Look at what we're doing right now with the mixed message coming from public health officials/the White House. And look, I don't have a political bone in me, but this is, this has been an endemic problem with government, regardless of any political party, red party, green party, d- it doesn't matter, no party. You've got the government right now saying, "If you wanna gather for New Year's or whatever, you need to do this massive testing of people coming in." And at the same time, they have a very limited supply of about 500 million tests that'll be rolling out over three months, which is about 160 million tests a month. You would need one to two billion a month to do what they're saying. So they're telling you to do something, and then you don't have the tools to do it. It's putting people in a very difficult decision paralysis, and then we've got, we put doctors on this crazy mission of hunt out all viruses, block replication at all cost. We've done a terrible

16. 1:58:45 – 2:05:30

    What is the end point to all of this?

    1. MMDr. Marty Makary1:58:45

       thing to the entire medical community right now.

    2. ZDDr. Zubin Damania1:58:49

       Yeah, with no endpoint.

    3. PAPeter Attia1:58:50

       Has anybody in the driver's seat signaled what the endpoint is? 'Cause I, I do think that is an important question, is, let's use a totally unrelated example, right? So a person who's working their tail off to make more money because they believe that at a certain dollar amount, all their problems are gonna be solved, right? Once I have this amount of money, I don't have to work this hard, I don't have to act this way, I don't have to ignore my family. Like, I'm sort of making something up, right? You always have to ask, "Well, tell me what's going to change." So tell me when you have that many dollars and you retire, what's going to change? So how many dollars do you need and how will it change things? So when you bring that sort of silly analogy back to this, I really haven't heard a clear articulation of that, which is not to say one hasn't been made in defense of those who would make it, but I haven't heard it. Have, have either of you?

    4. ZDDr. Zubin Damania1:59:46

       I haven't heard it recently. It's been an evolving thing. In the beginning, it was a bend the curve until we get better therapeutics and possibly a vaccine, which we don't know if it's gonna, is, is gonna work or not. Then once we had a vaccine, okay, just try to get to the point where we have enough herd immunity from vaccine and natural immunity that we'll get to that point. Well, then it turns out that shifts with new variants. So now the question is, oh, well now with Omicron, the variant's so contagious, well, we don't know. At this point, we have to go back to the same things we were doing before, which is masking and forcing people to vaccinate, including children and so on, to get to I don't know what, so that our hospitals don't get overwhelmed. But no one, I have not heard a public official say, "Oh, this is how we transition to an endemic virus," or, "This is the goal where we're gonna have a virus that lives with us forever and it's gonna be okay, but we just have to get to that point, which means let's not overwhelm our hospitals, so maybe we should shore up our staffing. Maybe we should pay nurses and doctors a little bit of overtime bonus, whatever it is, to get them through this." That's the thing, and we haven't even calculated in, like, well, how many lives were saved, say, from the, and this is kind of irrelevant, but looking at the area under the curve, how many lives were saved from preventing influenza for two years, basically, [laughs] which we've done, and then how many lives were cost by substance abuse, overdose, economic disaster, and in the third world, starvation from economic problems and so on. So w- we don't look at things holistically, and then we don't have an endpoint, so what even, even if we looked at them holistically, we'd have nothing to shoot for. So it's been quite frustrating.

    5. MMDr. Marty Makary2:01:14

       It's so hard because people are conflating two different problems that are happening simultaneous in the United States right now. One is the sort of residual COVID-19 public health threat, which is mostly Delta, but it's the virus infecting the 10 to 20 million American, uh, Americans who are still at s- significant risk. These are adults who have no natural immunity and no vaccinated immunity, and they continue to show up in the hospital and go on ventilators, and that is a problem. That is a real problem, and it's, it's very precise. It's about 10 to 20 million adults with no immunity whatsoever, and they're gonna keep showing up in the hospital, and it's gonna be during the viral seasons, and we can't downplay that. That is still a problem. We still gotta encourage the, them to get vaccinated. But the separate thing going on is that 250 million Americans have some form of, of immunity, and they're at risk of mild illness, and we're waging World War III to transiently beat back a mild infection or one that doesn't result in hospitalizations, and we, we're not putting that in context. And if you say anything to say, "Hey, we've gotta learn to live with this," it's like, "Hey, there are still people dying." But yes, those, that's a very precise group of adults with no immunity and some very older people with, who are unboosted who are coming to the hospital. About 7,000 Am- Americans a day are coming to the hospital, being hospitalized with COVID. About 7,000 of them have no immunity. These are adults, often with a risk factor, like obesity, which we don't talk about, and about 700 or so are unboosted older people. So that is a very precise problem that's addressable. But look at what we're doing to the 250 million American, or everyone else out there. We're holding them hostage right now saying, "You've gotta take this seriously and go and s- you know, make significant sacrifices." Here's what I think the end point is. People are fed up, they're pushing back, and here's what the Australian prime minister just said. Now, if you remember, Aust- Australia had the toughest lockdowns maybe in the world, draconian.

    6. PAPeter Attia2:03:26

       This is where sort of zero COVID was a goal.

    7. MMDr. Marty Makary2:03:29

       That's right [laughs] .

    8. ZDDr. Zubin Damania2:03:29

       Yeah, yeah.

    9. MMDr. Marty Makary2:03:31

       That's right. That's right. So they did a total 180. I mean, they saw people just, you know, protest this and say, "Look, we're not, we're not, we don't wanna live like this." They did a total 180 on their lockdowns, and the Australian prime minister just made this statement very publicly. He said, "We've got to get past the heavy hand of government. We've got to treat people like adults. We have to move from a culture of mandates to a culture of responsibility. That's how we're going to live with this virus in the future." And that could not summarize it better, in my opinion.

    10. ZDDr. Zubin Damania2:04:08

        All of this relates down to the form and function of COVID, so our response, right? So the form takes all kinds of different forms. There's masks and mandates and lockdowns and schools and so on and so forth, but what's the function of it? The function of it is to obtain some outcome that we all agree is reasonable. Well, I think it's reasonable to say we don't want our hospitals to have bodies piling up in the ER parking lot. Well, so when and how did this happen? Well, occasionally it did happen in certain areas, but en masse it has not. Is it happening now? Well, so far we're not seeing it with Omicron. How do we prevent it? Well, targeted, focused protection of the groups that Marty mentioned that are still at risk is the highest yield way to do it. Boosting and triple vaccinating a 16, you know, an 18-year-old college student is not a high [laughs] yield way to do it, especially when the rest of the world is still begging for vaccine. So there are policy solutions to get the function that we want using forms that are less disruptive. And I think, I d- I don't know, Peter, you shared with me, like, what Ontario's hospital numbers look like and their ICU utilization, and yet they're going on lockdown. And I looked at those numbers and I was like, "Man, Peter, like, I've taken calls with more ICU beds full than that. Like, w- [laughs] why, why, why would

17. 2:05:30 – 2:10:30

    Downstream consequences of lockdowns and draconian policy measures

    1. ZDDr. Zubin Damania2:05:30

       they shut down an entire province for this?" I mean, I'm curious what your thoughts are.

    2. PAPeter Attia2:05:35

       Well, again, it comes back to the price that will be paid for this. Uh, do we have data on what the last year has done to the vaccination rates for children, vaccines like MMR and things like that? Have we seen a, a noticeable shift? So, so the kids who should be getting those vaccines now, what's happening? Are we seeing it go up, down?

    3. ZDDr. Zubin Damania2:05:57

       So I don't know if Marty has the specific data, but I've seen articles written about this, and the, at least on an anecdotal level, kids going in for routine vaccinations have dropped dramatically into the more like the 80%-ish range, because again, parents are frightened and there's also a, a backlash against vaccines in general. It's a complex scenario. But what will the outcome of that be, right? That, that's a huge open question.

    4. PAPeter Attia2:06:22

       I've said this now at least twice, but I, I c- I just can't say it enough, which is what is the, what is the long-term consequence of this for a generation? All the people who have been marginalized, all the people who have been dismissed in their concerns, all the people who have been told, "You are a horrible human being for questioning a vaccine. You are a horrible human being for not getting a booster shot. You are..." I mean, I just wonder what the... So let's assume, let, let's come at this from the lens of the people in power wanna stay in power. That's a natural human reaction. I'm sure if I was in power, I'd wanna stay in power. So, so if you're in power, you wanna stay in power, and presumably staying in power has something to do with the people who put you in power, keep you in power. Don't you think there would be some logic that would say, "I want to make sure that if I wanna stay in power as long as possible, I should take the most long-term view of doing what is best"? And yet you just see this doubling down on things that seem less and less logical. So in other words, with a very myopic view of power. Again, totally not the right way one should be thinking about this, but just as, you know, we're trying to think about Omicron through the lens of evolution, I'm just trying to think of the natural history of power and wanting to consolidate it and preserve it as long as possible. This is not even in the best interest of [laughs] those in power.

    5. MMDr. Marty Makary2:07:57

       Peter is just so logical, right? It's, it's just one of these things where it's please don't be so logical, because what you're saying is making so much sense. I think people at very high levels got a taste of what it's like to be king And they've got the keys, and they don't [laughs] they don't wanna hand them back over. It's just a, a theory, but r- I don't think our policymakers are getting good medical advice. Look at what happened. As soon as Omicron cropped up in South Africa, immediately our public health officials retreated to the one blunt tool that they know, which is, "We gotta now give everyone a third dose across the board, including young people." Now, older people, there's data, and young people, there is not data to support it. Masks, half of New York City closed down. What about therapeutics? What about learning to live with it? What about all these other things? And what you saw is this retreat to the same blunt tools that we've had, and not start talking about Paxlovid and fluvoxamine and treatment and learning to live with it.

    6. ZDDr. Zubin Damania2:09:02

       Yeah, you know, Peter, I think, I think you, again, your rational thinking is not exactly how politicians actually tribalize. In our world now, we're, it's tribal identity, and it's a badge of, of identity to say, "Oh, no, no, I believe in this and this and this and this, regardless of what the long-term outcome is. I know it will rally my base. I know it will," you know, it, it's Covidians versus Covidiots, right? It's the people who, uh, on the left feel this way about all these responses because it's been politicized that way, and the right feel this way, and so in a way, they're playing broadly to their base. Like, what did they do when Omicron happened? They s- they stopped travel to South Africa, 'cause that's easy. That's a politically expedient thing except for the South Africans who suffer and the Americans who have family there and others, and of course, Omicron's already everywhere, which we were saying from the beginning. So that blunt tool did absolutely nothing. But it's, uh, it's politically expedient. If you look at what, say, the administration's doing now, well, the key thing is keep case numbers down, because if case numbers are high, then it's gonna be much trickier to get reelected, say. Well, then so what do you do? You, you wanna make sure you get as many people vaccinated and do the kind of blunt instruments that try to reduce cases, which is surprising that they're actually encouraging testing, 'cause that's gonna actually increase the number of cases. Trump was very explicit. He's like, "Don't test. You won't see any cases." You know, "Don't let the Diamond Princess dock because it'll triple our cases." You know, he was at least quite explicit about it, what he was doing. So I think it's quite complicated and, and there's this weird political

18. 2:10:30 – 2:20:00

    The polarized nature of COVID—tribalism, skeptics, and demonization of ideas

    1. ZDDr. Zubin Damania2:10:30

       tribalization that makes it irrational to people who are looking at it from an objective standpoint.

    2. PAPeter Attia2:10:35

       You said, you said earlier something, uh, that I, I think is also interesting, which is like sort of the, what did you call them, the Covidiots and the-

    3. ZDDr. Zubin Damania2:10:42

       Covidians

    4. PAPeter Attia2:10:42

       ... Covidians, right. So I can't describe myself as either. I know the caricature of what both of those represent, 'cause I've interacted stupidly against my better judgment with both of them, and I feel like I'm trying to understand, what's your guess on how many people are in the middle? So on the one hand, it's this is a conspiracy. The whole purpose of this thing is so pharma can make more money, blah, blah, blah, blah, blah. The only thing that works is ivermectin. Like, you've got that whole sort of group, and then you've got the people we've largely been talking about here, sort of everyone needs to have a booster every Monday.

    5. ZDDr. Zubin Damania2:11:22

       [laughs]

    6. PAPeter Attia2:11:23

       And we never, ever want to see the world as it was in 2019 again until this virus goes the way of smallpox.

    7. ZDDr. Zubin Damania2:11:33

       Yes.

    8. PAPeter Attia2:11:33

       This virus will one day be in a museum, and until that time, it is a zero COVID policy world. So you've got, so, so how many people are not at one of those poles?

    9. ZDDr. Zubin Damania2:11:44

       That's the operative question, and I'll tell you my experience with my platform is we have created what we call this alt-middle, and it's not a politically central position. It is the synthesis position. So if you consider Covidians to be the thesis position, Peter Limburg of The Stoa talks about this, the thesis position that lockdown, zero COVID, vaccines for everyone, mandates, closed schools, that position is thesis. Antithesis position is the other position you described, the ivermectin, therapeutics, this is all about control, the thing is not as serious as we think, et cetera. What is the synthesis of those positions? Where do you find truth? There's, everything is a little bit partial. So this alt-middle perspective is, you can call it the center, but it's really a synthesis position, an integral, holistic position. I would say, and every single political group says this, that there's a silent majority of people [laughs] who actually, if you really ask them, and you tell them, "Well, let's think a- about it this way. Forget about all the sound bites. Forget about Twitter. Let's just talk," they will espouse an alt-middle synthesis position or will resonate with it in a way that is really quite profound, which means common sense is there. I think critical thinking is there if you walk people through it a little bit. And to a one, I've never talked to a thesis or antithesis person in person that hasn't ultimately settled on a more synthesis position. So it makes me think there's hope, but the way we're doing it publicly is we're rewarded for polarizing into one of the extremes, Covidian, Covidiot, thesis, antithesis. And what we need to do is change our, uh, basic structure so that we reward a more alt-middle kind of perspective. I don't know how to do that, honestly.

    10. PAPeter Attia2:13:27

        It's very similar, by the way, with kinda woke ideology. On the one hand, you have the people that, in theory, the woke ideologues are there to rally against, right? The true racists, the true sexists, the, the true people who are, you know, think trans people should be killed or something like that. So you, you have those people, and then you have kind of the woke ideologues, and then I think you have most people in the middle that think, "This is crazy. Why can't, why can't there be shades of gray here? Why is this, why is this such a bipolar issue with no," as you say, "no dialectical synthesis?"

    11. ZDDr. Zubin Damania2:14:05

        [laughs] So this is why a podcast like Rogan's is so popular, because he actually very often espouses a synthesis rationalist position, even when he entertains kinda people on the show that are really more antithesis or more synthesis, you know, like a Peter McCullough v- vaccine guy, he is, and when you were on the show too, I was watching and going, "Oh, this is the synthesis position." You're poking fun at all the extremes of this, and there's not very many rational people in the United States who would really want to hurt a trans person or really want to exclude somebody based on their sexual orientation or their race, right? Consciously, they would not want to do that. And I think w- we could, because we've had progress, we've had decades of progress on this, and so what we see, though, is that in order to belong in an atomized world, in a tribe that you can identify with, you take a much more extreme us versus them position, and I think the woke ideologues are in that. And what it does is it di- diminishes real racism, real inequity. The fact that, you know, we talk about COVIDiots, well, are you gonna call a African Amer- you know, like a Black person in Baltimore who's afraid because of Tuskegee and a long history of medical abuse of getting a vaccine, you gonna call them a COVIDiot? W- what is, w- how, how are you gonna reconcile that with your apparent wokeness, right? So there, it just generates a ton of cognitive dissonance until you can see this from a integral perspective, that all the stuff has a bit of truth and partiality to it, and you're always trying to synthesize something that's evolving like an organism towards something that's more true, which means you also have to assume in most people good intent, which we have trouble doing because we are tribal creatures that like to villainize out group. And so getting over that, assuming good intent, I think you might have said this on Rogan, man, if we were able to actually get in people's head, maybe Rogan said that, and assume, "Oh, no, they're actually well intentioned," well, that already levels the playing ground that now you can have a conversation.

    12. PAPeter Attia2:16:00

        I remember that. That was a really great insight from Joe, which was you could totally eliminate racism or at least distill it down to the true racists if you had mind-reading software. Once you had mind-reading software, this issue of intent mattering, you know, 'cause we, we were debating whether or not intent mattered, and which of course it does, right? But yeah, no, that's a, that's a fair point. I, I wanna say something else. This is kind of a mea culpa. I feel my tribalism more than I've ever felt it around this. You know, I remember a few months ago, somebody sent me an image of a woman on Twitter. Uh, I think she was a pediatrician, and she's clearly a we're going to zero COVID philosophy, or at least that's -- I shouldn't even say she's s- you know, that, that was my inference based on what she had just posted, which was a picture of her and her three kids at a grocery store. They were in masks, face shields, PPE f- and this was, this was not in 2020. This was, like, literally this summer. And, you know, her comment, like she was posting this picture very proudly with her and her three kids and, and making a comment like, "This is how we roll. N95, face shield," this, this, this. I mean, you couldn't see her kids. You literally would have seen more of them if they were girls in Riyadh.

    13. ZDDr. Zubin Damania2:17:17

        [laughs]

    14. PAPeter Attia2:17:19

        That's how little you could see these poor little kids that looked like they were none of them over 10. And I c- I can't tell you why, but I got really pissed. I got so pissed at her. I don't know her. I don't know anything about her. I don't know her story. I mean, I replied on Twitter in some snarky response to the effect of, "Please tell me your kids are immunocompromised." Like, why on earth would you do this to them otherwise? But, uh, it's, it's that particular interaction has stayed with me so far because of how much it worries me about what I've become in this. How have I become so angry at both extremes here?

    15. ZDDr. Zubin Damania2:18:07

        First of all, I'm really impressed that you have enough self-awareness to recognize that, because most people don't. I'm with you on this. I think what you're expressing is the righteous indignation of the alt-middle. It is this like, "Wait, this is insane." Just like when you see somebody talking about this whole thing's a hoax and you need to take ivermectin BID for the rest of your life. That's insane, and it generates a kind of a moral outrage, right, based on our own moral palate of what we find valuable. Now, what I, what I'll add one other piece to this is that this has been potentiated by a collective anxiety, a f- a contagion of, Marty calls it the, the pandemic of lunacy. That is, we are social creatures too, so as much as we try to hide from it, we're connected to others, and this general level of anxiety and panic and disruption and social fabric tearing has then, it feeds back on us as individuals 'cause we're also part of a whole, and that gen- that generates that. And that's why things like Twitter really weaponize this. Like, I try to stay away from Twitter now because it, I know, I feel it. And m- you know who's my, who's my, you know, if you think of this as a nuclear reactor and I'm about to blow, I'm gonna go to go Chernobyl and the top's [chuckles] gonna blow out. M- you know, it's gonna be fallout all over the country. The person who is my graphite control rod is my wife, because what'll happen is I'll see something on Twitter, and it'll be like you, Peter. It'll be like a family of people like, "Stay, #stayhome," and it'll, they've got 13 pronouns in their description, and they've got 14 masks [laughs] on their avatar, and they've put somehow, like, bend the curve in their name. And I'm so triggered because I'm just outraged by they don't see the other downstream side effects of their approach. And I'll start ranting and raving to my wife, "These people are idiots. I bet they're all over Stanford where you work," and this and that and the other thing, and she's like, "Could it be possible that," and what she'll do is she'll go, "Could it be that that person is going through this and this and this, and they're seeing it this way, and they've been also paralyzed by fear from this, and you're demonizing them as a bad person, but they're actually a good person?" And, and you can just see, like,

19. 2:20:00 – 2:25:00

    Looking back at past pandemics for perspective and the potential for another pandemic in the future

    1. ZDDr. Zubin Damania2:20:00

       she's lowered the control rod, and suddenly I have empathy for this person, and suddenly [chuckles] I'm like, "Okay. All right. Okay. All right." But we're humans. That's just how we react. The thing is, we've potentiated it on mass now with technology that hacks our dopamine drive to go in group, out group. So I don't know. I don't know. Marty, what do you think?

    2. MMDr. Marty Makary2:20:20

       It's a really good, um, point that you're both raising here, and I think we need to do everything we can to stand against tribalism. I think we, all of us can do that. We can be role models to others, we can listen to others, we can admit when we're wrong. I mean, these are characteristics that are being completely lost in the echo chambers of cable news and hearing what you wanna hear so you're living in an alternate reality because big tech is feeding you news that actually makes the other side look like they're crazy, right? Because that's how the news has framed their position, and you don't, can't see it any other way. So I loved the Rogan interview with Peter, and I, I think that's part of what we're not talking about in society that we need to talk about. And we gotta fix this, because the next pandemic is probably gonna be more severe. You know, we had, we've had a number in our lifetime, I mean, beginning with polio, older patients tell me what it was like going through the polio epidemic, H1N1, SARS, MERS, Ebola, Zika. I mean, we've gotten lucky, we've skimmed the trees on a couple of these, but the next pandemic that's going to be a major serious pandemic, maybe antimicrobial resistance, which is increasing each year, maybe an influenza virus. This COVID-19 virus had an overall global case fatality rate or infection fatality rate somewhere around two-tenths of 1%, somewhere in that ballpark, right? Well, what if it's 2% with a strain of influenza, and we've got this polarized echo chamber of hearing news and the politicalization of the human immune system where the B and T cells have joined the Republican Party and the-

    3. PAPeter Attia2:22:05

       [laughs]

    4. MMDr. Marty Makary2:22:05

       ... antibodies, you know, nu- non-neutralizing antibodies have joined the Democrat Party. We can't do this in the future. We're going to need diverse opinions, an open form of discussion, honesty, humility, and I'm concerned where we are leaving in terms of our situation at the end of this pandemic here.

    5. PAPeter Attia2:22:23

       Yeah, I gotta be honest with you, I'm not optimistic. I mean, I'm gonna probably focus most of my energy on controlling myself, which the easiest step on that is literally not looking at Twitter. That's the, [laughs] that's the first... A- a- and look, I, I don't, I spend very little time on Twitter, like, I mean, less than... I, I mean, I really don't spend much time on it. The problem is, like, any amount of time on it seems to be annoying. It's like you could spend 30 minutes a week on Twitter, and that's, I have to think it's an anti-longevity agent right there. I mean, that's got, there's got to be a study that will demonstrate that, you know, an hour a week on Twitter will shorten your life expectancy by a year, and more importantly, will reduce your happiness all along the way, 'cause it just... I mean, I think there are people who are really good at Twitter who just love to be incendiary, and it doesn't bug them, and nothing bugs them. They just love to carpet bomb for fun.

    6. MMDr. Marty Makary2:23:16

       [laughs]

    7. PAPeter Attia2:23:17

       But, like, if you actually think you're trying to make a point and engage, which, you know, sometimes I do, I, I think there's no upside.

    8. MMDr. Marty Makary2:23:26

       Yeah. I agree. It's, it's a bad format in general for that. Now, you said something that I think is key that I wish more people would say, which is, "I'm gonna focus on me," right? [laughs] Like, so much, especially with guys, you know, we're so bad at dealing with our own internal states, whether it's emotional states, whether it's cognitive states, that we repress, deny, and then project everything out into the world, and we create the world that we hate because it's a reflection of our internal state. And, you know, there, there was a Indian sage, Nisargadatta, who said, uh, you know, some dude asked him, you know, it was, it was, the book was, like, a bunch of, like, Americans come to him and ask him a bunch of questions of this guru in India. And, and this one kid asked him, it's in the '70s or whatever, and he's like, "Man, there's so much war and stuff. We need to, like, reform the world, man. The world's so broken. You're sitting here in this cave meditating. What's wrong with you?" And he's like, "Listen, buddy." He's like, "Don't be talking about, um," [laughs] I don't know why I'm suddenly doing my dad, "Don't be talking about the reforms, okay? Mind the reformer itself. Look inside. You're creating your own situation. Until that internal conflict that's generating this unhappiness is pacified, you're never gonna see the world that you wanna see." And I think there's a lot there, which means we have to be self-aware. Okay, if Twitter is bad for us, if it really hacks our neural circuitry that causes us unco- discomfort and lack of longevity, which I agree with you, Peter, for me it does. That's why I just, I, what I do is I dump and run. I do the Rogan. I'll, like, dump a video there. I'll be like, "Okay, guys, have fun with this," and I'm out. And then every now and again I'll be sitting on the pot and I'll open up Twitter 'cause I'm like, "Hey, what's going on on Twitter?" And I'm like, "Oh, shit,

20. 2:25:00 – 2:28:45

    What parents can do if their kids are subject to unreasonable policies

    1. MMDr. Marty Makary2:25:00

       this went nuts. This is not good."

    2. PAPeter Attia2:25:02

       Another thing I wanna, and maybe this is maybe a better question for you, Marty, but what, what can parents do? 'Cause that, that's the demographic I find myself most concerned with right now is this, this group of, you know, what are we gonna call alt middle folks who absolutely believe in science, uh, certainly understand the benefits of vaccines, understand why we needed to do what we needed to do 18 months ago. But today, I mean, th- these are the calls I get a lot of is, "Hey, you know, my kids still are wearing masks every day in schools. They're not being permitted to play sports if they're not vaccinated." These are healthy 12-year-old kids that are not permitted to play sports unless they get vaccinated. I feel very fortunate, right? I live in a state that doesn't exactly believe in the government controlling you, and therefore, from the minute we've, you know, we've been here for 15 months, school's never been shut down for a day. Our kids are not in masks, or it's, you know, it's masks optional, so my kids are not in masks. No restriction on sports, you know, that kind of stuff. I feel very fortunate. What do the parents do who don't live in these states? I mean, what, y- you said earlier, Marty, this is only gonna change when enough people get pissed about it and the policy makers basically realize, "Oh my God, I'm gonna get voted out of office as a result of this." And by the way, how do you do that with health advocates? 'Cause they're not really on the hook for votes. So the, the, y- you have sort of two layers of this here, which makes it a little more complicated, right?

    3. MMDr. Marty Makary2:26:36

       Yeah. Well, I think a lot of people are getting fed up right now, and, and this country has a democracy, and the democracy does work. It can take time, but elections are already showing polling right now that people want a reasonable approach. And for parents, they should demand an endpoint to restrictions in the schools. If there is a policy that they have no control over, they should demand an endpoint. When we put in so many restrictions in schools, be it the plexiglass, which ironically could reduce ventilation and airflow in a classroom, and kids have to cover their faces with a cloth mask, which the study run out of Stanford and Bangladesh showed had really no impact at all on transmission, uh, just it's such a poor quality mask, or a vaccine mandate, or a booster mandate, which is what, you know, the bandwagon of the lunacy of what colleges are, are jumping into right now. They should demand endpoints to these things. You know, at what point... But, uh, wa- watch the pharma industry change the language, and I, I, I predict this will happen, from a booster to annual boost. "Have you gotten your annual booster?" It may be then, you know, we get a new variant, they pop up a new booster in a six-month interval. The language will change to, "Are you up to date?" Like it's software. And [laughs] people that are chasing this may be getting boosters, you know, they may look back in 20 years and realize, "Hey, I just got 15 boosters. For what?" People should demand an endpoint. They should demand criteria to remove the masks. They were put in place with no criteria to remove them. They should ask their pediatrician about a single dose of the Pfizer vaccine for their child. That's a reasonable option. It c- could depend on a lot of factors, and maybe they have concerns. Maybe their pediatrician sees a risk factor in the child and thinks one dose would be safer. Spacing out the doses. Ask about natural immunity. There's, n- people with natural immunity should feel good about their immune protection. So I think these are the things people need to talk about and, and ask

21. 2:28:45 – 2:32:15

    Voices of reason in this space

    1. MMDr. Marty Makary2:28:45

       about and vote on come election time.

    2. PAPeter Attia2:28:50

       I wanted to ask both you guys this question. Who are the people that you find to be voices of reason in this? Who do you, who do you like to read? Who do you like to listen to? Zubin, you, you, you work pretty closely with Vinay Prasad. I, I find him to be just another amazing example of a thoughtful person in the middle who's rational. Any other folks we can point people in the direction of besides the two of you guys?

    3. ZDDr. Zubin Damania2:29:14

       I'm personally a fan of Dr. Monica Gandhi, UCSF infectious disease doctor. She's been a voice of reason, calm. She also has a really beautiful maternal kind of wisdom about her that she gives off that's a good contrast to a lot of the talking heads that are guys, and, um, she's very smart about it. And actually, if you talk to her offline, she is very much obsessed with getting us back to living instead of living in fear all the time. And part, you know, part of the reason she was such a big advocate of even cloth masks in the early days of the pandemic is she felt that, look, if it lowers inoculum a little bit, it'll prevent some severe disease, but the main thing is it'll get people out there, stop these lockdowns, open up our schools, these kind of things. And, and so she's a pragmatist, a very, very smart and data-driven gal. Marty, who's o- who's on your shortlist?

    4. MMDr. Marty Makary2:30:00

       There's really just one person, and that's Dr. Anthony Fauci.

    5. ZDDr. Zubin Damania2:30:03

       [laughs]

    6. MMDr. Marty Makary2:30:04

       You know, just do... [laughs] No, no, in, in all fairness, he is a true gentleman, uh, if you've ever interacted with him, and he's a very nice guy. Just have had different opinions on how to manage the COVID strategy on almost every single aspect of the pandemic. But to answer your question, Monica Gandhi is terrific. She's got a great sort of feed that she puts out. She's got a, a site and a Twitter feed that's got great information. Amesh Adalja from Johns Hopkins, Peter, you've had him on, I think, early in the, in the pandemic. He's as correct as, I think, any- Well, everyone's been wrong. Every expert's been wrong. Every expert missed India and Delta and so many other things, but he's been as correct, I think. Martin Kulldorff, he's the gentleman from Harvard who's now with Brownstone Institute, puts out great information. And I would say, more importantly, I do not listen to anyone who's a politically appointed physician. Anyone [laughs] current, past, or future. If someone trying to, to become a politically appointed physician or was, I just block them right out, and I go to these go-to people who I trust.

    7. ZDDr. Zubin Damania2:31:17

       Can I add a couple here? Like, so th- this is interesting 'cause I, I agree, Marty, like I actually will even take it a step further and go someone who's very politically angled on, on social media, who's taking very strong political stances, I don't trust them either, just because they aren't able to disambiguate that tribalism from their recommendations. I actually am a big fan of John Mandrola. He's a, uh, EP doc, cardi- cardiologist on Twitter. He's done good work in this space and has been very rational. The other person, and I don't know, Peter, if you know this guy or if you guys have had conflict in the past [laughs] because he's more of a, a vegan dude, who I used to have a little bit of beef with, but now I'm convinced he's been very rational on, on this pandemic, is David Katz, actually, out of Yale, and he's really written extensively, very heterodox, like stuff that would get you booted out of the tribe, basically saying, "Hey, we should look at the big picture here. We need to look at the harms and the benefits to society." And, and he's been very rational and has written very eloquently an alt-middle synthesis

22. 2:32:15 – 2:40:54

    Strong convictions, loosely held: the value in questioning your own beliefs

    1. ZDDr. Zubin Damania2:32:15

       of this pandemic.

    2. PAPeter Attia2:32:17

       The only thing I would add to that, guys, is, by the way, I don't even know everybody on the list that you guys have mentioned. That's how little I'm personally paying attention to this, but I'll, I'll now start paying attention to some of those folks sporadically. I don't wanna-

    3. ZDDr. Zubin Damania2:32:27

       [laughs]

    4. PAPeter Attia2:32:28

       I have no desire to spend too much time on this. As a general principle, I have no trust in people who can't change their opinion So when I encounter a person who says the exact same thing over and over and over and over and over again, and when you ask them, "Do you feel differently about this now versus, you know, six months ago or a year ago or 18 months ago?" The answer is, "Nope. Nope. Double down, double down, double down," no matter what they're talking about, it doesn't guarantee that they're full of shit, but it is, it increases the pretest probability significantly.

    5. ZDDr. Zubin Damania2:33:07

       Yeah.

    6. MMDr. Marty Makary2:33:07

       Yeah, like school closures last year. Um, if anyone who called for school closures has not come out and said, "You know, we got this terribly wrong, and it disproportionately affected poor and minority communities, I feel terrible," then I, you know, I've written them off.

    7. ZDDr. Zubin Damania2:33:23

       Yeah, it's hard to trust them. Yeah, actually, what Peter's pointing at, I think, is something that I talk about when I talk about alt-middle, which is you should be able to question every single one of your beliefs because there's really, you know, if you're sticking to one single view, you, there, you're probably missing something. The only belief that I think is a little bit beyond question is that you should always question [laughs] your beliefs. So it's like a meta belief about belief. I think people who hold that, where they hold their beliefs loosely based on new evidence and persuasion and so on, but they're not wishy-washy, they're not just, uh, going where the wind goes, I think those are the people that are the most trustworthy and who are able to call out their own biases and say when they're wrong and also celebrate when they're correct and go, "Listen, this is, this gives me some credibility. I was right about this and this and this. I was wrong about this for these reasons, and this is how it's changed my thinking."

    8. PAPeter Attia2:34:12

       Yeah, the best investors will tell you they have very strong convictions loosely held.

    9. ZDDr. Zubin Damania2:34:16

       Ah.

    10. PAPeter Attia2:34:17

        And so I've always loved that mantra, right? Strong convictions loosely held. And what's interesting is I assumed we'd be 50% sort of fact, 50% opinion. I, I think-

    11. ZDDr. Zubin Damania2:34:26

        [laughs]

    12. PAPeter Attia2:34:26

        ... we're, we're a little more on the opinion side. But what's really interesting is there's nobody who's successfully running a hedge fund on the mantra of, "I'm always right," because in the hedge fund space, it kinda doesn't matter what you think. It matters how much money you make, and the dollars always decide. So if you just say, "I'm always right, I'm always right, I'm never willing to change my point of view in the presence of new information," you're going to end up losing money eventually.

    13. ZDDr. Zubin Damania2:34:59

        Mm-hmm.

    14. PAPeter Attia2:35:00

        If you can be malleable and say, "This is my point of view based on the available data. Hey, there's new data, I'm gonna change my point of view," there's just no comparison in the long-term success of those two investment strategies. And so it all kind of shakes itself out. It's very interesting that in policy, in medicine even, the system of reward is so uncoupled from the outcome that there's mass confusion around this, and that's why it's very difficult to suss out the really good critical thinkers versus the not so good critical thinkers.

    15. ZDDr. Zubin Damania2:35:36

        Ah. That's a g- that's a great point, great analogy, actually. I think more people would benefit from having some of those endpoints sync with that kind of thinking in medicine 'cause you're right, they're disambiguated. They're completely disengaged. In fact, it's even hard to know what outcomes. Like, if you're talking about improving a healthcare system, okay, so what are the, what are your endpoints? [laughs] What are you trying to do exactly? Well, we want a lower hemoglobin A1C. Okay, but is that really what you want? Or do you want this 62-year-old Hispanic grandfather to be able to see the graduation of their kid in, with decent faculties, decent vision? Okay, that's a different endpoint than a hemoglobin A1C. So how, how are you gonna do that, and how are you gonna measure that? So bec- it's a complex human system. That's where it becomes so, so interesting and difficult, but how is it that different than the financial system? The financial system's exceedingly complex. It's just the measurement outcome is dollars. It's much simpler in that sense.

    16. PAPeter Attia2:36:28

        The measurement outcome is unambiguous.

    17. ZDDr. Zubin Damania2:36:30

        Yeah.

    18. PAPeter Attia2:36:31

        That's right. Yep. It's very binary, and it's very unambiguous.

    19. MMDr. Marty Makary2:36:34

        And you see it in the style of patient management among physicians in the hospital. I mean, think about being on rounds in the ICU, um, Peter [laughs] when, you know, when we were doing that together.

    20. ZDDr. Zubin Damania2:36:47

        [laughs]

    21. MMDr. Marty Makary2:36:47

        The doctors who say, "You know, I thought this patient was not going to benefit from steroids, but now it looks like they have a nice response. Let's go ahead and continue this therapy," the people who constantly pivoted, reevaluated, evolved their position based on information, they were the best doctors. The, the ones who shut down suggestions by a student on the team who says, "You know, I, I read this," and they said, "Ah, it's a dumb idea. That's not gonna work," those were early predictors of not just who was gonna be a great physician, but who was gonna be a great person down the road. And the, the one criticism that irks me that gets thrown at the government, a- and I've got plenty of criticisms [laughs] for the government, but the one criticism that I hear that I'm not on board with is when they say, "Oh, they're flip-flopping." Well, they should. This is, you know, this is not-

    22. ZDDr. Zubin Damania2:37:37

        Yeah

    23. MMDr. Marty Makary2:37:37

        ... some political philosophy you gotta dig in on. They should, [laughs] they should constantly be changing.

    24. PAPeter Attia2:37:43

        I'm glad you said that, Marty, because I completely agree with that, and I, and I think it's a very important distinction to make. To me, it is not a problem when an advocate or a policy maker says, "This is the way we're gonna do things. Actually, this is not the way we're gonna do things. We're gonna change." Situations change, right? No new taxes. Guess what? When George H.W. Bush said no new taxes, [laughs] there wasn't, wasn't, there wasn't a recession going on. There was a recession going on. It wasn't a popular thing to do. It got him outvoted, but politicians get hammered when they change their mind, which is why I would never wish being a politician on my worst enemy. But it is a bit of an unfair criticism when we say, in defense of the criticism now, I will say this, it's because it's typically done with a lack of transparency

    25. ZDDr. Zubin Damania2:38:31

        Yeah. You, you know, relating to that is an interesting piece of this is this idea of persuasion. So how are you gonna persuade somebody of something you think is important based on the data that you have if you do not show them that you're flexible in your thinking, but firm in your convictions loosely held, and that new data would change your mind? And I get a lot of emails saying, "You're the only person who convinced me to vaccinate. I was so angry with Biden or whoever for mandating this, and they talk to me like I'm stupid, and it seems like they don't recognize myocarditis and all these other things. But you guys talk about it, and yet you still say, 'Okay, I think this is important for people like yourself,' and so on." And so I get email after email saying, "You have convinced me," but then in the same breath, I get the dogmatists saying, "Hey, you're like some kind of anti-vaxxer. You know? You're, you're, you're holding back the cause." And it's like, well, I wish you could look at my inbox then, right? You do need that flexibility. Now, I'm not saying I'm perfect at that. I'm very, uh, there's things I, I need a lot of work on, but at least it's on the radar, right? And I think, um, Peter thinks this way. That's why we all kinda gravitate to each other, right? Peter and Marty and me, we were like, "Oh, no, no. There's something about you get the vibe this is someone who thinks independently and is able to change their mind and is curious and so on." And I think that sets an example for other people that you're mentoring or teaching or whatever, and we see it in the hospital all the time. You know those attendings, right?

    26. PAPeter Attia2:39:51

        Gentlemen, I, I feel like we could keep talking, but I feel like we've also sort of provided, I think, ho- hopefully some, A, some information for folks with respect to Omicron, a little bit of clarity around what we do and don't know about the, the utility of vaccines, the potential risks of vaccines. I think we've also shared our biases, right? I think, I guess we haven't explicitly stated it, but I, I think we're, we're all pretty anti-mandate, at least given the current facts. I lo- I don't know. One of you made this, I think it was you, Marty. It might be a reasonable idea to mandate parachutes if people are jumping at 10,000 feet. It might be entirely another thing to not mandate parachutes when people are jumping from 15 feet into the water.

    27. MMDr. Marty Makary2:40:34

        [laughs]

    28. PAPeter Attia2:40:35

        So you have to know the situation. You can't just say, "We must do this. We must never do that." So I, I love that analogy, and I think given where we are now, I realize the amount of criticism I face for being against mandates, but I think you gotta let your, you gotta, your conscience has to speak on this, and I, I think it's wrong.

Episode duration: 2:45:29