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Peter Attia MDCOVID Part 2: Masks, long COVID, boosters, mandates, treatments, and more
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CHAPTERS
- 0:11 – 5:16
Intro and Episode Overview
Peter Attia introduces this follow-up to the earlier COVID episode, adds Dr. Monica Gandhi, and previews the topics. He frames the discussion as fact versus fear and says the situation is now endemic.
- •Follow-up to the January 3rd episode with Marty Makary and Zubin Damania
- •Monica Gandhi joins as an infectious disease specialist at UCSF
- •Recorded January 17th, 2022, with a mix of fact and opinion
- •Previewed topics: Omicron, immunity, boosters, mandates, masks, Sweden, Malone, exit strategy
- •Attia says we are in an endemic and strategies should reflect that
- 5:16 – 13:58
New Omicron Data: Severity, Immunity and Incidental Admissions
Marty Makary reviews a Kaiser Southern California preprint showing very few severe Omicron outcomes, and the group discusses how many hospitalized patients are incidental COVID positives. Monica Gandhi cites South African and US pediatric studies suggesting both population immunity and lower inherent virulence explain the milder Omicron picture.
- •Kaiser study of 52,000 Omicron cases: none needed mechanical ventilation, and 83% of those hospitalized stayed under 48 hours
- •Roughly 50–60% of hospitalized COVID-positive patients at some hospitals were incidental, and Gandhi cited 67% for LA County
- •South African analysis estimated Omicron about 25% less virulent than Delta beyond immunity
- •Gandhi cited a US study in unvaccinated children under five showing about two-thirds less ER visits or hospitalization with Omicron versus Delta
- 13:58 – 22:06
Will the Virus Get Milder? Broad Immunity and Mucosal Defense
Attia asks whether endemic viruses become milder, and Gandhi explains why immunity across the whole virus guards against future variants. The group compares spike-only mRNA vaccines with whole-virus exposure, including Covaxin and mucosal antibodies.
- •Gandhi says milder evolution matches historical patterns but stresses immunity across the whole virus protects against any future variant
- •Natural Omicron infection on top of vaccination produces broadly neutralizing antibodies and broad T and B cells
- •US vaccines expose people only to the spike protein
- •Gandhi wishes the FDA would approve Covaxin, a whole inactivated virus vaccine
- •IgA antibodies in the nose fall with time, and mucosal nasal vaccines are of interest to reduce transmission
- 22:06 – 29:32
B Cells, T Cells and Vaccine Platforms and Side Effects
Gandhi explains how T cells and B cells provide durable adaptive immunity while antibodies wane. The group then covers vaccine approval status and why rare clotting events halted J&J while myocarditis from mRNA vaccines drew less restriction.
- •T cells are the main long-lasting antiviral arm; B cells make adapted antibodies on re-exposure
- •Antibodies come down over time, and B cells can last decades
- •Pfizer is fully approved while Moderna and J&J were described as still under emergency use authorization
- •J&J and AstraZeneca share a rare vaccine-induced thrombotic thrombocytopenia effect
- •Myocarditis is higher with Moderna, whose dose is 100 micrograms versus Pfizer's 30, and risk is higher with shorter dose spacing
- 29:32 – 41:06
Boosters, Dose Spacing and Immune Questions
The group discusses the timing and rationale for boosters, spacing of doses, and concerns about repeated boosting. Gandhi and Makary argue boosters should be judged by benefit to the patient, not transmission, and that natural infection acts as a powerful booster.
- •mRNA doses were spaced three or four weeks apart out of expediency, while longer spacing gave better responses
- •Gandhi says boosters are usually decided by patient benefit, and the UK study showed antibodies rising then falling within 10 weeks
- •Attia argues that boosting healthy college students to curb transmission would logically require boosters every 10 weeks
- •Makary cited a Birmingham study showing a 3.5 times greater immune response with three-month spacing in people over 80
- •Gandhi calls a breakthrough infection the best booster, and Damania describes how re-triggered B cells diversify
- 41:06 – 50:03
The Case For and Against Vaccine Mandates
Attia asks for the best argument for mandates. Gandhi explains why she favored them for hospital protection, Damania and Attia raise concerns about reactance and shame, and Makary describes mandates that ignored natural immunity.
- •Gandhi's argument rested on keeping hospitals from filling with unvaccinated adults, though she says the transmission argument has weakened
- •Attia's anecdote: a father estimated 50% risk of hospitalization or death for his healthy unvaccinated son in his late 30s
- •Damania worries that mandates backfire given low trust in government, and contrasts the Swedes' trust-based approach
- •Makary describes a Washington State hospital system and snowplow workers hit by mandates that ignored natural immunity
- •Gandhi says natural recovery must always be taken into account
- 50:03 – 1:00:46
Risk in Context: Young People and Other Causes of Death
Attia shares an analysis comparing US mortality in people under 35 from motor vehicle accidents, suicide, homicide and overdose against COVID mortality. Makary adds context about broader public health blind spots and stratifying risk.
- •Other causes of death were many times COVID mortality in each age group under 35
- •Attia argues for logical consistency in how upset we get about unvaccinated young people
- •Makary says people die of depression, poverty, deferred care and drug abuse as well as COVID
- •Makary cites CDC data of 65.9 hospitalizations per 100,000 per week among the unvaccinated at the Delta peak
- 1:00:46 – 1:06:38
Natural Immunity, Stigma and the Religion Analogy
The group asks why natural immunity was treated as irrelevant in the US. Damania offers a religion-like purity framework, and Gandhi says Omicron may be destigmatizing infection.
- •Gandhi says Europe counts natural immunity in passports, so this is a US phenomenon
- •Damania compares polarization to religion, with sanctity and purity dynamics on both sides
- •Attia jokes about his brother having COVID in early 2020 being treated as a moral failing
- •Gandhi argues the virus can't be eradicated but can be made endemic, and shame over infection is lifting
- 1:06:38 – 1:21:52
Masks: Which Types Work and the Case for One-Way Masking
Gandhi lays out her current position that mandates no longer make sense, but individuals who want protection should wear high-quality masks. Makary cites a PNAS study on transmission risk by mask type and the group criticizes cloth masks in schools.
- •Gandhi says cloth and surgical masks did little for population-level transmission in a reanalyzed Bangladesh RCT
- •She lists the masks she recommends: N95, KN95, FFP2, KF94, double masks, or a cloth mask with a polypropylene filter
- •Attia explains his own choice not to wear a mask, and anecdotes show logical inconsistencies in current rules
- •Makary cites a PNAS study with transmission risk of 10.4% for surgical, 4.2% for N95 without nose piece and 0.14% with one
- •Makary says the majority of US schoolchildren are still masked, often in cloth masks
- 1:21:52 – 1:31:20
Long COVID and Schools
Gandhi discusses the proposed mechanisms of long COVID and studies suggesting vaccination protects against it and may help treat it. The conversation turns to school disruption and children's low risk.
- •Two proposed mechanisms: spread of virus to many places and lingering innate inflammation when there is no immunity
- •An Israeli study reported vaccinated people with mild breakthroughs had long COVID symptoms at the same rate as people who never had COVID
- •Gandhi cited about 30% persistent symptoms after severe disease in a Nature study, and very low rates after mild disease
- •Attia sees long COVID risk as a possible reason for young healthy people to get vaccinated
- •Gandhi lists harms of school closures and notes Harvard planned normal spring classes
- 1:31:20 – 1:47:32
Sweden, Canada and Proportionate Responses
After Gandhi leaves, Damania and Makary review Sweden's approach and outcomes, while Attia describes harsh Canadian restrictions. The discussion then contrasts COVID policy with how other respiratory viruses such as influenza are treated.
- •Sweden kept schools open and had a higher early death rate from failing to protect nursing homes, but did well by 2021 per Damania
- •Makary cites cumulative deaths per capita of 1 in 663 for Sweden versus 1 in 387 for the US
- •Attia describes Canadian rules barring unvaccinated people from travel and the Quebec plan to tax the unvaccinated
- •The group compares COVID restrictions to the lack of such measures for influenza
- •Makary argues for a pan-viral approach: stay home if sick, be careful around the vulnerable
- 1:47:32 – 2:01:53
Agendas, Tribalism and Hive Minds
The hosts state their own agendas, and Damania explains his view of social media driven group think. They also discuss the hate mail they receive and the value of non-judgmental conversations.
- •Attia says his agenda is concern for the integrity of science and medicine
- •Damania describes himself as 'alt-middle', wanting to bridge divides
- •Makary says his aim is to end tribalism and dismissal of people over early positions
- •Damania describes social media networks as hive minds that punish perceived outsiders
- •Attia reports that some listeners said the podcast moved them toward vaccination, and the group compares this to non-shaming approaches in medicine and HIV care
- 2:01:53 – 2:11:12
Treatments: Monoclonals, Fluvoxamine and Convalescent Plasma
Makary reviews which monoclonal antibodies work against Omicron and argues for selective use of treatments. He discusses fluvoxamine and the history and new data on convalescent plasma.
- •Only sotrovimab was described as working well on Omicron
- •Makary argues high-powered treatments should be used selectively based on individual risk
- •Makary criticizes the NIH summary of fluvoxamine, citing a 91% mortality reduction among compliant high-risk patients
- •Convalescent plasma contains diverse antibodies, and concentrated plasma reduced hospitalization by 50% in a recent study
- •Makary describes politics and calls for an RCT as having dampened interest in plasma
- 2:11:12 – 2:30:36
Evaluating Robert Malone's Claims
Damania gives a point-by-point critique of claims Robert Malone made on Joe Rogan's podcast, noting where he considers Malone right and wrong. The group also discusses excess mortality and the idea of a debate format based on shared data.
- •Damania says Malone is right about not giving infinite boosters and about questioning financial incentives, but wrong on PCR accuracy, spike protein safety testing and animal studies
- •Damania says menstrual changes after vaccination are real but appear temporary, while the ovarian accumulation claim rests on a rat study
- •Malone's citation of Peter Duesberg and his Infowars appearance are discussed as credibility issues
- •Makary gives 477,000 excess US deaths from March to December 2020, with 385,000 attributed to COVID
- •Damania explains Malone's mass formation psychosis idea and says Malone is also subject to groupthink
- 2:30:36 – 2:53:03
Exit Strategy, Scientific Freedom and NIH Influence
The group considers when mandates and restrictions will end, how future variants might be handled, and the Djokovic case. They also criticize concentrated NIH funding power and the pressure on scientists not to speak out, before closing with remarks on Fauci's finances.
- •Makary expects low Omicron levels within a month or two and a major shift in public sentiment, though he thinks reactions may vary regionally
- •Attia says he can't support vaccine mandates on the current facts, but might for a far deadlier pathogen
- •Makary worries about a future higher-fatality virus given dysfunctional institutions
- •Attia and Makary describe scientists fearing loss of NIH funding if they speak out
- •Makary says NIH funded 254 disparity studies, four on spread and one on masks, and Damania defends Fauci's disclosed finances
