COVID Part 2: Masks, long COVID, boosters, mandates, treatments, and more

1. 0:00 – 0:11

   Intro

   1. PAPeter Attia0:01

      [upbeat music]

2. 0:11 – 5:16

   Intro and Episode Overview

   1. PAPeter Attia0:11

      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 want to 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 want to learn more now, head over to peterattiamd.com/subscribe. Now, without further delay, here's today's episode. [upbeat music] Welcome to another special episode of "The Drive." This is a follow-up to our recent COVID-19 podcast with Doctors Marty Makary and Zubin Damania. That episode was released on January 3rd. It was very popular. We, we received a lot of follow-up questions and requests from listeners to revisit the subject matter. So for this episode, in addition to being joined by Marty and Zubin, we're also joined by Dr. Monica Gandhi. Monica is an infectious disease specialist and Professor of Medicine at the University of California San Francisco. She earned her MD from Harvard Medical School, did her internal medicine residency and ID fellowship at UCSF. She also holds an MPH in epidemiology and biostatistics from UC Berkeley. So before getting into kind of the lay of what we discussed, I want to highlight a couple of things. First, along with the previous podcast on this subject matter, this is kind of different from a traditional podcast. It's more of a discussion between the group of us. That format seemed to resonate quite well based on the feedback, so we thought we'd revisit that. Along those lines, we again tried to call out the distinction between fact and opinion, and I think in this episode, we have a pretty healthy mix of both of those things. My hope is that going into this, you're familiar with at least what we spoke about in the previous episode. If not, it might be worth going back to listen to that. This episode was recorded on January 17th, 2022, in an effort to get it out as soon as possible. It's not going to have the most robust set of show notes, and of course, it will be audio only, not video. Now, with that preamble, let's talk about the episode itself. The things that we get into in some detail are the newest data on Omicron since our initial conversation, and of course, we have a lot more information on Omicron since that discussion. We talk about how viruses evolve and change over time and how that affects antibodies. Monica gives a great explanation of what B cells and T cells do and how antibodies work, and what the implications of that are for different types of immunity, vaccine and natural. Talk about the ideal timing and the number of vaccines for long-term immunity and how natural immunity plays into this, and whether or not you should be boosted depending on those things. We also discuss some of the side effects of current vaccines. We get into the controversial topics of vaccine mandates, masking, Canada's lockdowns, kids in school, Sweden's approach to COVID, Robert Malone's recent podcast on Joe Rogan, where Zubin does a pretty good point-by-point discussion of where he thinks Malone is off the mark and where he's potentially saying something valid. We spend quite a bit of time talking about this sort of fact versus fear approach to discussing COVID, and it's clear that we're still in largely a fear-based approach, although it's not entirely clear to me why that's the case. In fact, this morning, shortly before even recording this intro, it's January 20th today, I just saw an article that talked about how by March, the United States could see an additional 50,000 to 300,000 deaths, and the reality of it is that's simply fear-based thinking. It's very unlikely we're going to see 300,000 deaths in the next 40 days. So it's not clear to me why that type of language is being used, and, and I, I think we try to do a good job here of bringing this back to facts as opposed to wildly extrapolated models and things like that. We end this conversation again talking a little bit about the future and what the exit strategy looks like here. I think it's very clear to anybody who's paying attention that we are in an endemic. This is no longer a pandemic, and therefore, we should have strategies geared towards that. So without further delay, I hope you enjoy my follow-up discussion with Marty, Zubin, and Monica. [upbeat music] Hey, guys. Wonderful to have you all here. Monica, thank you so much for joining the trio and increasing the average IQ of this group by 40 points. We're really looking forward to this. So Monica, as you know, Zubin, Marty, and I sat down a couple of weeks ago, kind of had a relatively informal discussion on the topic. We couched much of what we said as this was opinion, this was fact. The format seemed to resonate a lot with people, and the follow-up was surprising. I thought it would be a one and done. Thought it would be this one discussion we would have, put to rest as many of the misconceptions as we felt we could, but the reality of it is people appreciated it, but said, "Look, we have more questions." And so we decided, I guess, we should do this again, and we're really grateful that you could join us. So where do we want to start here? There's so much to get into. Marty, you probably spend a lot of time in the last couple of days looking at some of the questions. Is there, is there anything you want to just jump into right out of the gate?

3. 5:16 – 13:58

   New Omicron Data: Severity, Immunity and Incidental Admissions

   1. MMMarty Makary5:16

      Sure. Well, I think it might be worth talking about the new data on Omicron that came out since our last conversation. It is great having Monica here. I deleted my UpToDate app when I got to know Monica, because I just call her now, and she answers all my questions.

   2. PAPeter Attia5:30

      That's so funny you say that, Marty. I literally just canceled my UpToDate subscription last week as well. [laughs] So that's fantastic.

   3. MMMarty Makary5:37

      [laughs] The app a lot of doctors use to look things up quickly. Now I just call Monica. Big study came out on the preprint server from Kaiser Southern California that looked at Omicron specific cases, and they found 52,000 cases of Omicron. None required mechanical ventilation. And remember, 52,000 documented means there's four or five cases out there in the community for every one that we're picking up with testing. About, you know, roughly half may be asymptomatic, and a lot of people have tough getting access to testing. So we're really looking at a population of, say, a quarter million people with Omicron, and nobody required a ventilator. Now, there was one death in that group, not through the ICU and intubated, but remember, the test they use, which is the S gene deletion, is not a perfect test for Omicron, and it can pick up an occasional rare Delta virus. Plus, they didn't have absolute confirmation that anyone hospitalized was hospitalized for the virus as opposed to with the virus. They looked at the presence of symptoms on their record. But regardless, we're looking at a net total of 154 people who were hospitalized out of, say, a quarter million with Omicron. Now, of those hospitalized, 83% were there in the hospital for less than 48 hours. Now, if you remember way back about two months ago, this is exactly what the South African doctors observed early on. They noticed people were in the hospital about two days instead of eight days, and they proclaimed to the world, "This is a mild infection. There is no need to panic." And we basically did the exact opposite, but this data is pretty compelling right now. Now, the reason it's so important is that 98.3% of new cases of COVID in the United States are Omicron, according to the most recent CDC numbers. On December 10th, it hit 73%. Now we're at 98.3%. So we're dealing with a different virus, and I personally wish it had a different name, because people know it comes from the lineage of COVID, and we've got the raw memories of the destruction of COVID and the loss of life and how our hospitals were overwhelmed. We think of it in terms of COVID, but it's really functioning and behaving like a different virus. Now, you might say, "Well, look, we're in an Omicron wave. People are still in the hospital." The vast majority are people who came in with Delta, who were infected with Delta, who were unvaccinated and got Delta. And remember, people stay in the hospital a long time, especially right now, and it's very difficult to discharge a COVID positive patient to a skilled facility or rehab, so that's inflating the numbers a little bit. But hospitals are truly strained, but it's really those who had Delta. If we look at the future, Omicron promises to be a mild virus based on all of this data.

   4. PAPeter Attia8:29

      Question for anybody, but Marty, it sounds like you might even know the answer already. Do we have a sense of how many people are in the hospital with Omicron because of Omicron or because that's an incidental finding along the way? So somebody's in there for cancer treatment, but they happen to be testing positive, or they are in there because of chest pain that's related to cardiovascular disease, and then of course they're COVID positive along the way.

   5. MMMarty Makary8:53

      So I just actually looked this up. There's a bunch of hospitals in the country that report this number on a daily basis. NYU, for example, reported 53% are not there for COVID, but they're COVID positive. They're incidental COVID admissions. Jackson Memorial in Florida, 65% are incidental COVID positive cases. So think of it in terms of 50 to 60% are incidental.

   6. MGDr. Monica Gandhi9:17

      That latter question also depends on how highly vaccinated the region is. So for example, the numbers are even higher out in California for people with COVID in their noses, 'cause we swab everyone. So LA County reported 67%, which was closest to what we saw in South Africa during the Omicron surge, which was 63%. And it wasn't that South Africa was a highly vaccinated region. It was about a 25% vaccinated region. There was a seroprevalence study in SARS-CoV-2 in South Africa that showed 79% of adults had a SARS-CoV-2 antibody. So meaning, think of South Africa with between natural immunity and vaccines as having the same degree of immunity likely as California. So I think the higher the vaccinated region, the higher the incidental rate is. I'd like to add just to a couple of your Omicron studies, because they just came out yesterday, hot off the press, very verifying of what you just said, Marty. One was from South Africa, which was really well documented. What's the contribution of immunity versus the more milder aspect of Omicron contributing to the better outcomes with Omicron? And they tried to tease this out essentially by looking at the fourth wave in South Africa, hopefully we can post all these links, but in the fourth wave of, in South Africa compared to the prior three waves. And essentially what this study showed that was just this week was that absolutely immunity is contributing to why in December 2021, January 2022, we're having a better outcome with the latest variant. It is absolutely the contribution of immunity, both natural immunity and vaccine induced. Estimated vaccination probably led to a .24 hazards ratio of a severe outcome.

   7. PAPeter Attia11:07

      Monica, can you tell folks what that mean who don't live in the hazard ratio world?

   8. MGDr. Monica Gandhi11:11

      So there's been a great debate since Thanksgiving, which is when the South African scientists, who are amazing scientists, I thought got treated not very well, 'cause they kept on going on TV saying, "This is more mild." And then people would say, "Ugh, let's wait till the UK or the US says this." So it was, I thought, really unfair, and these are my colleagues, because I'm an HIV doctor, so I know them. But they kept on saying this. Fundamental question became, okay, is Omicron more mild because we have so much immunity in the population at this point, January 2022 now, that our T cells and B cells are attacking that SARS-CoV-2 variant. Takes a while for the B cells to make antibodies. You may not have antibodies right away. Maybe if you just got boosted, you may have antibodies right away if you're older. But say you have the vaccines or you've had natural infection, you have your T cells, your B cells, they produce antibodies, they attack that virus, they bring down the viral load quickly, they make it less infectious, and they help you do well with the virus. And so immunity, of course, will help you do well. This is what probably what happened in 1918 when we were transitioning from pandemic to an endemic, had a lot of immunity in the influenza world, in the world. However, in- The next question is also is Omicron less virulent inherently than the other strains that we've had so far, the other variants we've had so far? And yes, it seems to be, not just based on these six laboratory studies, including two in ex vivo lung transplants, so this is human lung tissue, and then also animal studies that show it can't infect lung cells very well, six studies now. But what the South Africa study showed us that I just told you about is that you can distinguish, they did a very good job, it was a very good analysis, distinguishing between immunity making it more mild and also having fewer, less virulence, and they estimated it's 25% less virulent than Delta above and beyond immunity. So it's not just our increasing immunity in the population that's making Omicron more mild, but it's something to do with the virus itself, likely that it can't infect lung cells well. And then another study that would verify what I just said, again over the weekend, was in young children who are less than five, they are all unvaccinated by definition because we can't vaccinate those less than five. We don't have it in this country. This is a US-based study. And also, they didn't have prior COVID infections, so they couldn't have had natural immunity. And severe outcomes in that population is already very low, but severe outcomes with Omicron versus Delta, meaning going to the ER, was about two-thirds less, meaning going to the ER or hospitalized was about two-thirds less. So Delt- Omicron seems a third, at least in young children, as virulent as Delta. So putting all these studies together, you've just really made a very big point, I think, that Omicron by itself, beyond immunity, is less virulent.

4. 13:58 – 22:06

   Will the Virus Get Milder? Broad Immunity and Mucosal Defense

   1. PAPeter Attia13:58

      I want to ask you another question about this, Monica, because you're the expert certainly amongst all of us when it comes to viruses beyond this one. Marty and Zubin and I actually speculated on this, I think, in the last episode, so we kind of came up with a teleologic idea around this. Is it likely that as pandemics become endemics, they become milder? The argument we came up with was, look, it's evolutionarily in the best interest of this virus to become less and less virulent as it goes on, and if it wants to coexist with us indefinitely, it probably shouldn't be killing us. You referenced, obviously, the Spanish flu in 1918 as it went from this deadly pandemic into basically the flu, the thing that we have every year, notwithstanding the genetic drift that comes with it. If you were to look into a crystal ball, do you believe that the SARS-CoV-2 that we will live with indefinitely, which I think there's no question we will be living with SARS-CoV-2 indefinitely, is it going to be a very mild version of this that's gonna be somewhere between all the other coronaviruses and influenza?

   2. MGDr. Monica Gandhi15:02

      It makes sense, and that's been the pattern in history, and it makes sense evolutionarily. It's exactly what you said. Ebola is a really dumb virus because it kills its host, and a virus that makes more copies of itself but doesn't kill its host, that's more evolutionary advantageous, just like organisms want more children. On the other hand, I would say this, and I think this is a very key point because now, because this Omicron is less virulent, there's now been a lot of fear that, well, we're gonna get a more virulent variant later. If you have immunity to the entire virus, then even if you do get a more virulent variant that arises not only in humans but from an animal reservoir, you have a more virulent variant. If you have immunity across the entire virus, like B cells, T cells, antibodies, which will come down with time, that's okay, that's what they do, but B cells and T cells formed across the whole virus, a lot of people have seen Omicron, probably 50% of people in Europe it's estimated, a quarter of Americans, probably more, have seen Omicron, then you have the T cells and B cells to fight that new variant in the future, even if it's more virulent. I think that's a really key point. People are really, they're not taking comfort for Omicron being more, less virulent. There's a lot of anxiety right now. "Well, okay, then what's gonna be the next thing?" But if you have immunity across the whole virus, then you can fight Zeta that comes out later, if you've seen the virus. And what Omicron did is it, it made a lot of us see the virus. I mean, both the FDA chief and the NIH chief, uh, NIA chief have said we're all gonna see Omicron.

   3. PAPeter Attia16:44

      Sorry, Monica, I just want to keep asking you questions befo- and turn this more into an interview of you. [laughs] I apologize, but we'll get back to a discussion. Is the implication then that the immunity acquired naturally by being infected by Omicron, whether you've either been vaccinated or not vaccinated, but you're getting some additional immunity, how would you qualitatively or quantitatively assess that relative to a person who has been vaccinated but has not seen Omicron?

   4. MGDr. Monica Gandhi17:11

      A very important study, and there's been multiple ones of these, shows us that if you get natural Omicron infection on top of your vaccines, you form broadly neutralizing antibodies against all the variants. Totally makes sense. Alpha, Beta, Gamma, Delta. But importantly, you form T cells and B cells a- across all the variants. I mean, again, that totally makes sense. You've just seen the whole virus. It is qualitatively true, I would say, that if you see Omicron on top of your vaccine, that you have a more in-depth and in-breadth immune response against the whole virus, because remember, the vaccines we have in this country only expose us to the spike protein of the virus, so just one piece of the virus, as opposed to the whole virus. Now then people would say, "Hey, I want nothing to do with Omicron. I am gonna stay in my house right now, and I won't see Omicron." One thing I've been really [laughs] thinking about lately is why we don't have Covaxin in this country, but we, I don't want to go off on too much of a tangent, but Covaxin is a whole inactivated virion made in India, and it's a more traditional vaccine. It may have increased our uptake. Covaxin filed for an EUA 73 days ago with the FDA. You get to see the whole virus. So if you never wanted to see the virus Omicron, which again, it's not like people are going out and getting Omicron, but just living right now, a lot of people are exposed. But if you don't see Omicron, I wish the booster could be Covaxin. My new thing is pushing Covaxin and seeing why the FDA isn't approving it, but I don't wanna go into too much of a tangent, but I do think that would've increased our uptake in our country because mRNA vaccine's got a reputation.

   5. ZDZubin Damania18:44

      Can I ask a question, a follow-up on this, that I don't know we know the answer to, but you have the whole virus exposure, Covaxin, vaccinated whole virus exposure, natural infection, Omicron exposure, versus a pure spike protein deltoid exposure from a mRNA vaccine. Is there a difference in mucosal antibody immunity between those mechanisms? Because now we have a mucosal virus that replicates rapidly in the mucosa, and viremia is not a major part of its pathogenesis until later, and so that's why we prevent severe disease with blood-borne antibodies. But we might be able to actually make a dent in transmission and infection in the first place if we had more mucosal defense, so I'm curious your thoughts.

   6. MGDr. Monica Gandhi19:26

      What happens is when we're exposed to the virus, we do develop IGA antibodies in our nose, and then those go down with time, or if even we're exposed to the vaccine, we develop IGA antibodies in our nose and those go with time. So like you just said, there's a great interest in mucosal nasal vaccines to help decrease transmission. But it is true that if you get Covaxin or you get exposure to the actual virus, you develop IGA against multiple parts of the virus. It's just, it's what it is. You're just developing IGA against the spike protein if you get an mRNA vaccine, because by definition, the mRNA vaccines and the adenovirus DNA vaccines only give you exposure to the spike protein of SARS-CoV-2.

   7. PAPeter Attia20:09

      And you know, Monica, this makes me think back to, gosh, early days of vaccine, call it March of a year ago. Was Moderna first out of the gate or Pfizer? I can't remember. They basically came out within weeks of each other, and then J&J-

   8. MGDr. Monica Gandhi20:23

      Pfizer was November 9th, and then Moderna was November 16th. It was literally a week later.

   9. PAPeter Attia20:28

      That's right, and then J&J and AstraZeneca followed shortly thereafter, single dose. One of the things I recall that didn't get enough attention, and it was difficult to figure this out reading headlines and abstracts, you had to go through the raw data, was the absolute risk reduction was greater with J&J than both Pfizer and Moderna. Now again, this was in the original strain, not Delta, and that got easily missed. It makes me wonder if, based on what you're saying, that's not surprising, because the J&J vaccine would have provided a more robust picture to the immune system of the virus than Moderna or Pfizer, correct?

   10. MGDr. Monica Gandhi21:06

       Well, it's interesting, both [laughs] Johnson & Johnson and AstraZeneca are adenovirus DNA vector vaccines. They show you a different part of the spike protein, which is why mixing them give you more of the spike protein antigen. You see antigens across a longer piece of the spike protein. But actually, I think what happened with the DNA adenoviral vectors is they produced a more robust T-cell response than the mRNA vaccines, and T cells are your long-lasting friends [laughs] . Remember those who've got, survived SARS-CoV, the first one, SARS, from 2003, late 2002, uh, early 2003, there are people 17 years later that they have strong T-cell immunity against SARS-CoV. So your T cells are your long-lasting arm of the immune system. Antibodies always come down. If I [laughs] had antibodies for every cold I've ever had in my body, I couldn't move 'cause I'd be so thick. So antibodies will always come down, but T cells are enduring, and AstraZeneca seems to produce, and Johnson & Johnson, a stronger T-cell response.

5. 22:06 – 29:32

   B Cells, T Cells and Vaccine Platforms and Side Effects

   1. PAPeter Attia22:06

      I think it's maybe worth actually spending a minute on this because I think we can easily take for granted here, because of our familiarity with B cells and T cells and how antibodies work, MHC class works. Is there a way that you can maybe explain to folks the difference between a B cell and a T cell and how they work in response to viruses specifically? Because this is going to become interesting. Marty has spoken at length about the idea that if we're gonna get into a mindset where your antibody levels are determining the value of your worth in society, we're in for a [laughs] really rough slog. It's gonna be weekly boosters, maybe monthly boosters if we're being generous. So why is that the wrong metric if you were to exclusively focus on it, as opposed to understanding how the T cells work? What's happening in your bone marrow? Like, there's no reasonable person to my knowledge that doesn't agree that SARS-CoV-2 is never going away, so anything we're talking about should be in the context of eternity here. So why does this matter? What's the difference between these B cells and T cells and how they actually kill viruses?

   2. MGDr. Monica Gandhi23:17

      I'll explain it really fast and simply, I hope, which is T cells are actually the main arm of the immune system that fight viruses. So for example, I'm an HIV doctor, so as T cells go down, people are susceptible to very severe viral infections. They're cells. They last for a long time. They're called cellular memory. And then what B cells do is they become the recipe book or the template to produce more antibodies, but they have to be aided by T cells to do so. And so your antibodies, which are pieces of protein, they will come down with time. They will come down even after a booster, say 10 weeks or so. But what your B cells do, and we know you develop B cells [laughs] to the vaccines because they've biopsied bone marrows from people who've had natural infection, lymph nodes from people who've had the RNA vaccines, and you produce strong B cells in these what are called terminal centers. The B cells will, if they see the virus again, aided by your T cells, will produce antibodies directed against that SARS-CoV-2 when they see it in the future. And not only will they produce antibodies, but they will actually adapt those antibodies to the variant they see They see Delta, they'll make Delta-specific antibodies. Omicron, Omicron-specific antibodies. Zeta, Zeta-specific antibodies, because that's what adaptive immunity is. It's like they vary the recipe based on the conditions. That's what adaptive immunity means. So they, B cells will produce antibodies against the variant they see aided by T cells, and then T cells line the whole virus and directly kill the virus itself. So your T cells and B cells, which are formed by the vaccines, and natural immunity will last a long time and will enable us to have ongoing immunity to the virus in the future, even different variants. If that's lost, if that very simple fact is lost, then we, then we can be very anxious when new variants emerge instead of feeling calm about it and knowing that adaptive immunity works. B cells could last 90 years. There's people who have gotten influenza in [laughs] 1918, and then they found these 90-year-old, 100-year-old people. They looked at their B cells, and they said, "Oh, you actually can produce antibodies directed against the influenza strain from 1918 90 years later." B cells last a long time.

   3. PAPeter Attia25:36

      Marty, just give me a quick approval status on all vaccines at the moment. So the Covaxin is interesting. I wanna also hear a little bit about Novavax, but the exact status of Moderna and Pfizer, they're off EUA, correct? Those are fully approved today, or are they still under emergency use authorization?

   4. MGDr. Monica Gandhi25:53

      Actually, just Pfizer, though, right? I think they're still waiting for the final Moderna [laughs] approval.

   5. PAPeter Attia25:57

      So Pfizer fully approved. Moderna still under emergency use authorization. J&J, what is the status of J&J in the US? It seems to be persona non grata. Is that official or unofficial?

   6. ZDZubin Damania26:08

      Even CDC has sort of given a preferential guidance saying they prefer the mRNA vaccines to J&J, and it, Paul Offit and others have speculated that J&J really always should have been a two-dose vaccine. As a single dose, it had a lot of promise initially, but it's looking more like it w- should have been a double-dose vaccine. And then you have the vaccine-induced thrombotic thrombocytopenia issue, which seems to be a class effect with the adenovirus vector vaccines because AstraZeneca has it as well. And so for those reasons, CDC has given that preferential guidance, and I think it's still under EUA, right, Monica?

   7. MGDr. Monica Gandhi26:40

      Yeah, and you're totally right. Sputnik V, also another adenovirus DNA vector, they all have this rare side effect. So it got did even though... I think that's interesting because it's still really rare.

   8. PAPeter Attia26:50

      Why is it that that side effect, which is incredibly rare, basically led to a complete halting of the use of that vaccine, whereas the myocarditis that's seen in young men specifically, under 25, specifically with Moderna, doesn't seem to warrant the same level of consideration, though by my math, it's more prevalent a concern?

   9. ZDZubin Damania27:16

      I would speculate that it's a question of severity. So the outcomes of people who get vaccine-induced thrombotic thrombocytopenia can be very bad to fatal. It's very rare, but it is catastrophic if it happens, whereas with myocarditis, at least from the early series that we have, generally reversible, although requiring hospitalization, still terrifying for parents and children, but less of a catastrophic issue. And then there's that whole controversy of, which maybe Marty and Monica can speak to, of well, what's worse for generating myocarditis, natural coronavirus infection or the vaccine? And this is where data sets seem to disagree in how you interpret them.

   10. PAPeter Attia27:55

       Who wants to take that one? Maybe I'm just looking at the wrong data, but I'm looking at Nature, I'm looking at Circulation. This doesn't seem ambiguous to me. Can someone explain that?

   11. MMMarty Makary28:04

       That's right. Those studies pretty, um, well did a head-to-head comparison and found that the rates of myocarditis after vaccination were higher, particularly with Moderna. And if you go to Europe, parts of Europe, they've basically restricted Moderna in anyone under age 30, something we haven't really talked about much in the United States. There's also this interesting idea, the myocarditis from vaccination may be different than the myocarditis from the infection itself. There may be more delayed contrast uptake in the heart that they're noticing in the studies of the myocarditis from vaccination. So there's a feeling among cardiologists that it's not the exact same apples to apples myocarditis. Have you guys heard that as well?

   12. MGDr. Monica Gandhi28:50

       Yeah, and I will say, as you know, the Moderna is 100 micrograms. Pfizer is 30 micrograms. So that dose difference probably explains why it could be more seen with the Moderna vaccine. It's just literally a higher dose, which is why, like you said, not used under 30 in so many countries. And the, I think the best study on this is from Canada that showed that the risk of myocarditis after the second dose is more with a higher dose Moderna and also more if you have a shorter period between your two doses, which is why spacing the doses has been such a strategy in Canada of eight weeks or even longer between doses.

6. 29:32 – 41:06

   Boosters, Dose Spacing and Immune Questions

   1. PAPeter Attia29:32

      We speculated on this during the last episode, Monica, but I'm curious if you have an immunologic rationale for why the mRNA vaccines were dosed at four weeks apart. Is there a clear rationale for why that would have been the way to do it?

   2. MGDr. Monica Gandhi29:46

      I think it was just expediency because the trials wanted to hurry. I mean, we're in the middle of a pandemic, so they gave Pfizer three weeks apart, Moderna four weeks apart. But, you know, I think Dr. Stanley Plotkin wrote a clinical infectious disease article in January, and he's our Infectious Disease Society of America, we name our vaccine lecture after him. He really knows vaccines. He was saying we need to space them out longer, for two reasons. One was to save more lives because if you get T cell immunity, you can, if you have limited supply, you wanna save more lives by giving people just one dose while you're, and then give them the second dose later. And then the second was he said that in any field of vaccinology, and now this has been shown in a Cell paper, if you give longer time between doses, you get a better response, not just antibody responses, increased antibody responses, but fundamentally what we are talking about is we want to develop cellular memory, and there's better T cell responses if you space them out, the doses, by eight weeks or so. This was a Cell paper. So Canada has always spaced out doses, especially for the young.

   3. PAPeter Attia30:49

      I knew a doctor, a Hopkins surgeon, a brown-skinned guy, Marty something. I don't remember his last name. But he was, he was making this point about trying to get everybody their first shot before people got their seconds, and boy, he really got hammered for that. I mean, he was... By the way, this is both fact and opinion. Monica, going back to that point, if you were playing the long game, so not the antibody game, I kind of think of antibodies as like a vanity metric. Like, you can brag about how high your antibodies are. It's a cool vanity thing. But if you're playing the really long game, what would be the ideal time to give a booster to somebody who has had two shots of Moderna or Pfizer? And I guess almost nobody would be one year out from their second shot now, because these things only kind of came on board in about January, and healthcare workers and high-risk people were first. So most people listening to this will not even have been fully vaccinated a year ago, and yet many people are boosted, suggesting that giving a booster in less than a year is the optimal way to boost long-term immunity. But is that true based on what we know about the immune system? Would we be better off boosting less frequently? How would we think about that?

   4. MGDr. Monica Gandhi32:03

      We had to extrapolate on the three-dose vaccines from hepatitis B vaccine, human papillomavirus vaccine, and the longer between the second and third doses, the better. I mean, Dr. Plotkin talks about this in the CID article. I think what happened here with the booster is that we had a lot of high transmission with Omicron, and then the idea was, "Oh, if we give the booster, maybe we can bring transmission down." That's actually all I can see is why there were widespread booster recommendations as opposed to more selected booster recommendations for those who were more at risk for severe disease. So I think it was an attempt to increase antibodies to bring transmission down. I'm trying to think of the reason.

   5. PAPeter Attia32:43

      What's the efficacy of that? Do we have data on how the vaccine reduces transmission?

   6. MGDr. Monica Gandhi32:49

      It will increase your antibodies, and it could-- There was an Omicron paper that in households, giving a booster did decrease transmission in the household setting. However, I will say that in any risk versus benefit analysis, and I know you spoke about this last time, what you do is you decide about the boosters based usually on what it does for the patient. If the patient benefits from a booster to reduce severe disease, then that's when you would give a booster in how we usually do infectious disease, not for this purpose of transmission. Because later, say we get a different variant and virus goes up in the community, we probably won't give booster to try to decrease transmission, I don't think.

   7. PAPeter Attia33:31

      How long does that effect last?

   8. MGDr. Monica Gandhi33:33

      The UK study, Marty and Zubin, 10 weeks, the booster made the antibodies go up and then right back down after 10 weeks. It's just never been done that we give boosters to decrease transmission. We usually give boosters in a risk versus benefit analysis for the patients. We want to make sure it's safe for the patient and then also want to make sure that it does something beneficial for the patient, which in this case would be keeping them out of the hospital. So older people, immunocompromised people, people who have medical conditions, maybe everyone over 40, you know, something that's helpful for the patient.

   9. PAPeter Attia34:08

      So if we were to speculate, I won't single out any of my favorite universities, but if we were to speculate based on the policies that are in place of providing boosters to healthy college kids in an effort to prevent transmission, the only logically consistent thing to do would be to make sure college kids get boosters every 10 weeks for the rest of their lives. Because at least that way, we might have some ability to reduce the transmission from college kids who would be unharmed by this virus to potentially anybody in their orbit who could be. And of course, that ignores what you said before, which is this would be a first-in-class episode of putting somebody outside of the patient ahead of the patient or in whom you're putting the booster. Is that a fair assessment? I just like being logically consistent. I mean, I think that's one of my pet peeves in life, right? Is like when we say things that are illogical. If we're going to live in a world where we're going to make college kids get booster shots, they're going to have to get them every 10 weeks.

   10. MGDr. Monica Gandhi35:09

       Of course, that would never happen because we can't do that. We do have to focus in on the patients, so, um-

   11. PAPeter Attia35:14

       But wait, wait. Why can't we do that, Monica? I mean, says who can't we do that? We're doing it now.

   12. MGDr. Monica Gandhi35:19

       Like you said, it wouldn't be logically consistent, and also I think it ignores-- And I think actually everything that's been going on over the last couple of months, especially since Omicron got declared, ignores how well the vaccines work for the individual. So the staff member, the older adult who's teaching the student, I think this is profoundly not recognized is how well the vaccines work for them, even two doses, certainly three doses if they're older. Marty and Zubin, you'll have to tell me if, I think the healthcare worker study in the New England Journal from Israel showed anyone over 50 really benefits from a third dose, even in reducing severe disease. So say you have a staff member, say you have the teacher. What the CDC showed us just in a study two weeks ago is that even the two-dose vaccines, your risk of a severe outcome from COVID with just a two-dose vaccine across the entire swath of the population, your chance of dying from COVID was .00003. Please remember that I said four zeros [laughs] and then three. And then there were specific risk groups that were at risk for severe outcomes. They were older people over 75 with multiple comorbidities, four comorbidities. Not only should those patients be boosted, maybe even get a fourth booster, but they should certainly be one-way masking for themselves to help protect themselves. All of that putting together means that we have underestimated that those college students, if they're around vaccinated staff members and teachers, those vaccinated staff members and teachers are doing great. These vaccines work so well for them against what we're so scared of, which was COVID severe disease. So I think we are underplaying the vaccines when you just put that to the logical conclusion for everyone around those college students.

   13. ZDZubin Damania37:06

       Can I ask a question? Because I think relating to this, this, Peter's proposing is this hypothetical Q 10-week booster that bumps up our antibodies, and WHO and EMA, the European Medicines Agency, just recently said this is probably a bad idea from an immune system standpoint, but they did not elaborate. So are we talking about immune tolerance from giving the same antigen again and again and again? Like, what's the rationale against doing that?

   14. MGDr. Monica Gandhi37:30

       They term it original antigenic sin [laughs] . But it, it just means that you see, you keep on seeing the same piece of protein, that you make the same spike protein to the ancestral strain again and again. But what adaptive immunity does is allow you to produce trained immunity, adapted immunity to whatever virus you see in front of them, and they don't wanna train the immune system to respond to the ancestral strain.

   15. MMMarty Makary37:55

       Well, it is interesting what you said, Zubin, that the European CDC basically said specifically that repeated boosters could cause, quote-unquote, "problems with the immune system." And they clearly have some concerns there, right? Even if they're not... Well, how can you study something that we have not yet done? I mean, we're in uncharted territory. We have anecdotally, colleagues of mine and I seen cases that are just raise questions, like new onset autoimmune diseases either immediately after the second dose or after a mild, very mild infection in somebody fully vaccinated. So maybe that immune system was revved up, caused juvenile diabetes in an adult. How often do you see that on day two of a very mild infection? Well, maybe that immune system was all revved up. Now, the risk benefit still favors vaccination. This is not an argument to say hold off on vaccines because there's concern. This is an argument to say only give boosters if there's a clinical benefit. And the frustrating thing is, as you alluded to, Peter, if we would've spaced out these doses, we might not even be talking about boosters. To put a number behind what Monica is referring to, this University of Birmingham study, Birmingham, UK, not Alabama, found that the immune response was 3.5 times greater when the doses were spaced out three months versus three weeks, and that was in 175 patients over age 80, so they develop a weak immune response in general to vaccines. So it's gonna be even further magnified in young people. That's why I got my two Pfizer doses three months apart. And the most frustrating question I get is, "I'm fully vaccinated, I just got COVID. When do I get my booster?" Or [laughs] it's like-

   16. ZDZubin Damania39:46

       I get those questions too

   17. MMMarty Makary39:47

       ... you got your booster.

   18. ZDZubin Damania39:47

       Yeah, exactly.

   19. MGDr. Monica Gandhi39:48

       You just got the best booster of all because-

   20. MMMarty Makary39:51

       [laughs]

   21. MGDr. Monica Gandhi39:51

       ... what that study showed us, especially with Omicron, but it would be f- true of any natural infection, is that you develop profound TB and T cell, B cell, and broad neutralizing antibodies across the whole virus. So that is the best booster of all, unless you got a Covaxin booster.

   22. ZDZubin Damania40:09

       So when these B cells are re-triggered, you get another process of what they call somatic hypermutation, right? So the B cells are constantly undergoing, uh, mutational process to diversify. And so it's almost like if you have natural exposure to vaccine and vaccine and maybe the two doses, plus or minus a booster, at that point you have a diversity of antibody response that should cover a lot of potential variant options, correct?

   23. MGDr. Monica Gandhi40:35

       Yes. I mean, there's now actually four papers that show this, but the most recent's in, is in Journal of Infectious Disease, but the best one I think was in Science, that, again, if you see a variant in the future, say, right now we only know about the variants are mostly a- across the spike protein. Of course, the Omicron has 50 mutations across its entire genome, just 32 is, are in the spike protein, that you produce antibodies direct to... They evolve. The word adaptive truly means you adapt your own immune system to what you see.

7. 41:06 – 50:03

   The Case For and Against Vaccine Mandates

   1. PAPeter Attia41:06

      I'm gonna switch gears for a second and continue down the path of vaccines, but again, talk about it through a very polarizing discussion, which is that of mandates. And again, I'll sort of ask everybody this question, but what is the best argument in favor of mandates?

   2. MGDr. Monica Gandhi41:22

      I'm gonna be the odd man out. [laughs]

   3. PAPeter Attia41:23

      Yes, yes. I w- I'm looking for a diversity and I'm looking for arguments in favor and arguments against. So tell me what the best argument is to mandate vaccination.

   4. MGDr. Monica Gandhi41:32

      Okay, 'cause Zubin and I had this discussion the last time we spoke, and I favored vaccine mandates, and he did not. And I know that one argument is that the vaccines reduce transmission, and that argument with each successive variant has been lessened, not just because the variants evade, at least Omicron evades antibodies more, even though T cells and B cells are intact, but because just with time from your vaccine, your antibodies decrease. The transmission argument has become weaker. However, the reason I did support vaccine mandates is because I work in a hospital, and there is no doubt that the people in the ICU and the people who are sick are unvaccinated adults. And if our entire purpose of a lot of what we did throughout this pandemic was to save hospitals, then not having hospitals have unvaccinated people when they could've gotten the vaccine allows us to work on other aspects of hospitalization. I recognize this is not a popular opinion, but that was my opinion until the Supreme Court.

   5. PAPeter Attia42:40

      I'm not convinced it's an unpopular opinion. I seem to think that... Has anyone ever done a straw man poll? Is there a Gallup poll on what percentage of Americans favor vaccine mandates versus not? I don't actually know the answer to this remotely.

   6. MGDr. Monica Gandhi42:51

      I think the vaccinated are more concerned about thinking that their vaccines don't work than the unvaccinated, which is a very interesting poll that was recent. Those who are vaccinated are more concerned about COVID than those who are unvaccinated. People are more fearful they don't trust the vaccines, in a way, if they're vaccinated. I think it's a failure of public health messaging

   7. PAPeter Attia43:09

      That reminds me of an interesting anecdote. I had to negotiate, or mediate's probably a better word, mediate a familial turmoil, conflict about an unvaccinated member of a family. So there's a member of the family, so it was the son of the family, so someone in his 30s, healthy, did not wanna get vaccinated. The parents of course were vaccinated, and they kinda brought me in to mediate the discussion, why could I not talk their idiotic son into getting vaccinated? I don't have any mediating skills, but I had an insight as I was listening to the debate between them, and I decided to ask a very simple question of the father, who was particularly distressed at the fact that his son was not getting vaccinated. And I said to him, I said, "What do you believe is the risk that your son will be hospitalized or die if he contracts COVID in an unvaccinated state?" I want you to remember, his son was in his late 30s and is very healthy. I'd like each of you to take a guess at what his response was, meaning what he believed the risk of hospitalization or death could be to his unvaccinated 38-ish-year-old son.

   8. ZDZubin Damania44:26

      I suspect he overestimated it at something like 50% or something higher.

   9. PAPeter Attia44:29

      [laughs] Yeah, any other guesses?

   10. MMMarty Makary44:32

       I think I s- I think I saw a survey when they looked at this that something like a quarter of people from one particular vantage point felt that the hospitalization rate was over 40%.

   11. PAPeter Attia44:42

       Yeah. Do you have a guess, Monica, what he thought was his son's fate?

   12. MGDr. Monica Gandhi44:46

       Yeah, I mean, even if he said 10%, it would be way too high. I mean-

   13. PAPeter Attia44:51

       Yeah, he, he said 50%. He said 50%, so good guesses, guys.

   14. MGDr. Monica Gandhi44:54

       Yeah.

   15. ZDZubin Damania44:54

       Hoo, I win. I win, price is right.

   16. PAPeter Attia44:56

       And we, yeah, we didn't price it right. And then I said, "Well, look," and it's really funny, this was one of the few times when my, uh, I actually had some emotional intelligence, 'cause I don't feel like I have a very high EQ, and I think my knee-jerk reaction would've been to, like, be, "You idiot, how could you possibly think that? Don't you know the data?" Instead, I flipped it and I was like, "Oh my God, I now understand why you are so torn up about this. If I thought my child was making a decision that was turning their risk of death into 50%, I would turn everything on its head to prevent it." And then I said, "Well, let's look at the data. This is actually his risk of hospitalization or death without the vaccine, and this is his risk of hospitalization or death with the vaccine," and there was about a tenfold difference, right? It was a log difference. But, you know, it was the difference between 0.001 and 0.001. I mean, it was incredibly small. But that feeds to your point, Monica, I think, which is I really wonder how many people who are emotionally full of anxiety need a little bit of a, maybe like a prep course on this stuff. Let's just do the facts again about how deadly this thing is, what's your risk of going to the hospital, what's your risk of X, Y, and Z. You'd think that we would know that by now, but I, I don't think that's the case, at least based on this one anecdote, right?

   17. MGDr. Monica Gandhi46:15

       You're so right that all that data is available, how much lower risk you are when you're younger, and it's a very interesting and different virus in the sense that young children are very low risk for severe disease, which isn't true of, for example, influenza, which affects young children and the extremes of age. And it has to do with receptors in, in noses of young children and also their innate immune system, and how our innate immune system probably mediates pathophysiology. But you're right that somehow people are so not aware of the epidemiology, and I will blame public health officials also for not clearly laying it out how much more at risk you are when you're older. I still blame public health officials for not even putting out this data of how vaccines really make you almost immune to the severe outcomes, even two dose, of COVID, unless you're in specific risk groups, in which case those specific risk groups really must be protected and they're vulnerable. I think it's a failure of messaging.

   18. ZDZubin Damania47:10

       One interesting thing, I think Peter kind of put his finger on it here, is emotion. So emotion and morality and our moral sort of taste buds. So when Monica says, "Listen, as doctors, we see it's clear it's unvaccinated people that are suffering the most in the hospital, and anything we can do from a care versus harm standpoint to ensure that people get vaccinated would be a good thing." And actually, so this is my personal take, looking at the emotions of this for mandates. If I could wave a magic wand magically and have every single person in this country that's eligible to be vaccinated vaccinated at a minimal level that prevents severe disease, I would do it. I would do it in an instant, because I know the net area under the curve of suffering would be much, much less. Where Monica and I have a different emotional spin on mandates would be I see the emotional reactance, the psychological reactance to a government that nobody trusts and a public health apparatus that people don't trust mandating something which then generates a response of, "You're not gonna tell me to do this because I don't trust you," which then damages our ability to vaccinate in the future or with future pandemics, and that's why I am always nervous about the public health policy tool of mandates being spun around, because I worry that it will backfire in a longer emotional way with a segment of the population that we could reach otherwise with education like the Swedes. They don't have to mandate anything. They trust their government, they've built this trust over years, and the vast majority of them are vaccinated. So I think we both agree that we want the best thing for the most people, and then it's just a question of how to wield the policy to make it happen.

   19. PAPeter Attia48:43

       And I think there's something else to dig a bit deeper into that. Now, obviously we're well out of fact and now into opinion-based thought, but I just can't think of too many case studies in my life, and this again goes back to things I learned in the hospital. Marty, think about all the times, I mean, all of us have had these discussions with patients when family members are on life support and they're brain dead, and you're having these discussions about withdrawing care. And if you go in there in a condescending way using guilt and shame and brute force, the outcome is always a disaster I saw a quote somewhere, it wasn't even talking about this, it was about something else, and it said, like, "Never in the history of civilization has shame and fear forced someone to do the right thing." It was a little more profound than that. It was more nuanced than that, but the, that was the gist of it. And, and I think that's what's interesting to me, is there's something about the mandate that feels very shaming and very fear-based, and I'm not convinced that that strategy works. And I agree with you, Zubin. I think that if we could take every person who would be protected by this and get them vaccinated, you would absolutely reduce the suffering to both the individuals and to society, right? To the healthcare system and all these other things. But I don't know. Maybe I'm just naive. I really wish it could be done with honest information and not with fear.

8. 50:03 – 1:00:46

   Risk in Context: Young People and Other Causes of Death

   1. PAPeter Attia50:03

      I pulled this analysis together yesterday. I actually asked one of my analysts to pull these data, and then I wanted to make some graphs, and we'll show them to folks. But I wanna show you guys this. I was sort of surprised at the magnitude of this. So can you guys see my screen? I know the listener will have to look at this in the show notes, but... So I had them pull up mortality data for people in the US under the age of 35, and I just wanted to look at four categories besides COVID, so motor vehicle accidents, suicides, homicides, and drug overdoses. And I looked at the data and I thought, "Okay, well, what's the easiest way to represent this?" And it turned out that just by dividing every one of those by COVID mortality, so you would make COVID mortality unity, then you could look at what the relative mortality was. So if you look at this graph here, what I'm basically showing you is by age group, so the under five-year-olds, the five to 14-year-olds, the 15 to 25-year-olds, the 25 to 35-year-olds, and the Y-axis is showing you how much greater that cause of death is than COVID for that individual. So for example, when you're looking at motor vehicle in the under five-year-olds, it's like 11 times greater. Homicide is almost 10 times greater, and drug overdose, which seems hard to imagine, you know, they're probably accidentally taking Tylenol or something, is two times greater. Fortunately, there are no suicides in that bin. As you go higher, as you look at now five to 14-year-olds, motor vehicle accidents more than 10 times greater mortality than COVID. Suicide, this is the most tragic to me. In five to 14-year-olds, the risk of suicide is six and a half times greater than that of COVID. The risk of homicide is five times greater, and the risk of a drug overdose is the exact same as that of COVID. And now you look at 15 to 24-year-olds. It's basically across the board nine to 10 times greater risk of death in the United States due to motor vehicle accidents, suicides, homicides, and drug overdoses. And even in the 25 to 35-year-olds, where we're now seeing, hey, I think the adjusted number is 6.9 deaths per 100,000, you're still seeing a drug overdose that is six and a half times higher than that. And then when you look at motor vehicle accidents, suicide, homicide, they're more than two times that. I guess I'm keep coming back to this thing about people are so phosphorylated about young people not being vaccinated, and this comes back to my point about being logically inconsistent. If we're going to be this phosphorylated about a 30-year-old not being vaccinated, that's fine, but then I expect you to be seven times more phosphorylated about how many of them are being killed by their own hands, by the hands of somebody else, by drug overdose, or in a motor vehicle crash. Isn't that the right thing to do if we're gonna get so phosphorylated about a 30-year-old not having a vaccine, especially when we've already established with this variant and the variants that are to come, it doesn't necessarily prevent transmission all that much, so we're really talking about the risk to the individual. I just think we need to get very upset about a lot of other things.

   2. MMMarty Makary53:10

      Gosh, that's so compelling, Peter. I mean, what you're showing is basically that motor vehicle accidents independently, each separately, suicide, homicide, drug overdoses, compared to COVID, just blow COVID out of the water. Not even close. These are the major public health threats facing young people. That doesn't mean that COVID's not a concern. It just shows how we have had massive blind spots during this entire pandemic. People don't just die of COVID. They die of depression and poverty and hopelessness and alcohol and stress and deferred cancer care and drug abuse, and that is the broader perspective. That's the context that I think we've lost. And if you remember when Joe Rogan had Sanjay Gupta, kind of joke around and say on the witness stand, but it was on his podcast, and he pressed Sanjay Gupta, and he said, "Do you feel good that you're immune, about your immunity and your vaccination status? Do you do stuff?" And he started parading around, "Yeah, I think people should feel good about their immunity, and I'm 50 or so. I'm healthy. I'm vaccinated. I feel good." And he said, "Well, so you're not concerned about COVID?" He basically said, "You know, I'm not concerned because I'm vaccinated." And then Rogan points out the data that a young, unvaccinated, healthy child, and that's an important stratification because the death and hospitalizations are significantly clustered in kids with comorbid conditions, and those are the ones that should be priority for vaccination. But for a healthy child, the risk stratification is different. And he said, "Do you understand how your risk is still greater than that of an, a young child unvaccinated?" And he's not suggesting we don't vaccinate kids, but he's saying, "Do you understand how parents are not that concerned just like you're not concerned?" And I think he was trying to elicit this sort of perspective that there's a lot of threats out there. Let's put them in context. Now, I don't know who y- the, um, parent was that asked you, that thought there was a 50% risk of their 30-year-old healthy child getting vaccinated.

   3. PAPeter Attia55:15

      Getting COVID. Yeah.

   4. MMMarty Makary55:16

      For getting CO- Was it Sonia Sotomayor by any chance?

   5. PAPeter Attia55:19

      I can't disclose my patients.

   6. MMMarty Makary55:20

      [laughs]

   7. PAPeter Attia55:20

      So sorry, Marty. [laughs]

   8. MMMarty Makary55:21

      Okay. Whether it was her or somebody else, the risk from COVID Net from the CDC's website is the risk of all people in the United States unvaccinated getting hospitalized is 65.9 per 100,000 per week, and that was roughly at the peak of Delta. That ended up being about one in 1,500 people in the population. Now, that one person is not a young, healthy 30-year-old in general. They tend to be the profile that Monica was suggesting. In other words, older. So we've never really talked about stratifying by comorbid condition. And to answer your question, I think immunity requirements make sense, I think, in healthcare for those who are patient-facing. I don't think it's the same calculus for an accountant who's working by home for the hospital. We've been sitting stagnant at 85 to 86% of the adult population in the United States vaccinated for a long time, and what I think happened is all these discussions of the mandates hardened a lot of people, and a lot of these immunity requirements do not account for natural immunity. So you have a hospital system in Washington State. They're in Tacoma and Olympus. It's called MultiCare, and MultiCare laid off 55 staff for not being vaccinated, and that's on top of the people who left before the vaccine requirement took in account. So a lot of these people had natural immunity. Healthcare workers, as you know, especially at risk and more likely to have natural immunity. So they were working on a real skeleton crew, and then what happened is they got more patients, as you always do in the winter viral season, a lot of them with COVID. This skeleton crew was so short-staffed, the hospital asked people who called in sick with COVID to come in back and work in the hospital, and this is a memo. This is reporting from Jason Rantz, where the memo is online. I tweeted it the other day. And it says basically, "Even if you have symptoms, if you've tested positive, come back, unless the symptom is fever." Then they told the managers, "Hey, when you assign these workers, try not to assign them to people immunosuppressed. If anything, try to assign them to patients who have COVID." The COVID staff take care of COVID patients. I mean, this is the insanity of blanket policies, hardening people, requirements that do not account for natural immunity. Ironically, the, um, state had this harsh few exception, no exception vaccine mandate in Washington State. Well, a lot of the snowplow workers, they work alone, they drive a snow truck, and they were fired. One of the main highways in Washington State then got snowed. It was undrivable. So the county, Kitasoo County, offers to then plow this road for the state. The state should be plowing it, but they don't have enough driver snowplowers, so they offer to plow it. The state says, "No, you're not allowed to because your snowplow workers do not have the vaccine mandate." They're not under the vaccine mandate. This is the lunacy of the hardening of the positions around this mandate talk.

   9. PAPeter Attia58:31

      So Monica, I want to bring it back to you because I really do want you to help me accept vaccine mandates. I respect you so much, but as you can see, my bias is that they're not logically consistent and they're bad policy. So in light of Marty's story, what's the case for why we should be mandating a vaccine?

   10. MGDr. Monica Gandhi58:51

       It's fair, and I learn from everyone as I hear what I just heard. I mean, I definitely think recovery or having had natural infection has to always be taken into account, always. And so, for example, there's a study soon to be published. They already actually published this in the med archives, so I won't saying anything that we don't know, that healthcare workers were equally as likely to be reinfected if they had been vaccinated versus had natural immunity, and severe disease was equally as protected. So recovery immunity always has to be taken into account for any mandate. I think that our country is unable to have nuance about COVID. What you just did and showed us the differential risk of COVID in the young and the old was so powerful, and yet our country, more than any other country, has kept schools closed in only certain political regions, have, in a way, restricted the young more than the old in this very strange backwards way, in a way that Europe didn't do. Without that lack of nuance, maybe I was saying vaccine mandates because we seem to have unable to have non-shaming nuanced conversations in this country. We will have a lot to do after this to figure out why we allowed healthcare workers to not drive the conversation about COVID, and we allowed people who don't have a lot of expertise in a way to drive the conversation. Maybe that's 'cause of social media, or maybe it's politicians or political, but I just know that I lived through HIV, and I continue to because I'm an HIV doctor, and never did someone with few credentials could drive the whole conversation. So I think it's a very complex topic. It's done. The Supreme Court has only said for healthcare workers, so I feel like they absolutely made a decision together that vaccine mandates aren't going to be-

9. 1:00:46 – 1:06:38

   Natural Immunity, Stigma and the Religion Analogy

   1. PAPeter Attia1:00:46

      Although the reality of it is the mandates are still happening. I have a previous podcast guest, and this person will remain nameless because I've spoke with them last week, and they said that they would prefer I not tell their story with attribution. They're fine with me telling their story, but not with attribution. This is a person who is a professor at an Ivy League university who does really remarkable work. I'm not just saying that 'cause I interviewed them on the podcast. I interviewed them because they do really remarkable work. This individual was fired from the Ivy League university for not getting vaccinated. The point being is the university could have its own mandate program absent the federal government. This person was fired in November of last year, in 2021. I read an article today that I believe said... I don't want to get the number right. This is a conservative. I think it was 150 of the Fortune 500 companies in the U.S. are gonna continue with mandates, even in the context of what the Supreme Court said. So in other words, I don't think this issue is over because of the Supreme Court. It sounds like states may choose to do this. I mean, certainly the states like California and New York may be still deciding, "Hey, we're going to create our own mandate." So I don't think this issue goes away. I would, do wanna ask you about something that I've never heard a straight answer to. Marty Zubin and I discussed this, so I don't know if you guys, Marty, Zubin, have thoughts since we last spoke about it, or Monica, you have thoughts to interject. Natural immunity seems to be this taboo word. If you say the words natural and immunity juxtaposed, it's like you're not on the COVID team. You're on the, what do we call ourselves? The COVIDiots.

   2. MGDr. Monica Gandhi1:02:22

      [laughs]

   3. PAPeter Attia1:02:22

      You're, you're a COVIDiot as opposed to a branch COVIDian. Is there a technical challenge in determining if someone is naturally immune? Again, there's no other example I can think of in the entire world of virology when natural immunity isn't a good thing. Why is it with COVID we've decided it's irrelevant, it's as though it doesn't occur? Is there an operational reason for that, that it's too hard to measure, or that somehow the antibodies when you're naturally immune are not amenable to our test kits? Like, I know that that's not the case, but I'm, I'm trying to come up with some reason why we've decided natural immunity does not count.

   4. MGDr. Monica Gandhi1:03:04

      But no other place does this, so it's a US thing. Europe, almost every single country in Europe, natural immunity is taken into account in passports and whatnot. So I think we have to cut this short and say it's something political in the US, but it doesn't happen elsewhere.

   5. ZDZubin Damania1:03:18

      Can I speculate one thing that's been speculated before, and I'm gonna use a word that you would think wouldn't apply to science, but it's called religion. So in a way, what we've done is we've created a God-shaped hole in our society over multiple years of secularization, which is, that's all fine, but what's happened now is you have a situation that polarizes people almost the way a religion would. So look at the natural immunity versus vaccine immunity. It is a sanctity versus degradation issue for people, a purity issue. So if you're a COVIDian, and you're in the thesis camp, and you're like, "No, vaccines are the answer. We get through this through vaccine-related immunity," you are unclean, unpure, undesirable, and unwelcome if you are not vaccinated. If you've gotten the disease previously, you already have a strike because you didn't mask up, you didn't distance, and you are unclean. So I think people will never say that, but they will feel that innately, especially when it's reinforced by mass media and culture at work and so on and so forth. Now, on the other side, there's an equal religious fervor, and that is the holy sacraments of hydroxychloroquine and ivermectin, and the conspiracy end times revelation aspect of these guys are trying to hide something from us, poisoning us by injecting our holy temples, our bodies, with vaccines. So both of the sides on this that are polarized have a religious aspect to it, I think, and that's why it's been so hard to understand why this is going on.

   6. PAPeter Attia1:04:44

      First of all, that is a really [laughs] interesting insight about the shame of having got COVID early in the days, right? Because if you're riding natural immunity from 2020, I mean, you must be a filthy person, right?

   7. ZDZubin Damania1:04:56

      [laughs]

   8. MGDr. Monica Gandhi1:04:57

      [laughs]

   9. PAPeter Attia1:04:58

      You are of low moral character if you dare had COVID. I mean, I actually know somebody, my brother, I'm ashamed to admit this, my brother had COVID in Q1 of 2020. Can you believe-

   10. ZDZubin Damania1:05:11

       [gasps] Oh, shame, Peter

   11. PAPeter Attia1:05:13

       ... what a human being he is? Yeah, he's, he's a, he is a filthy human being for having let himself-

   12. ZDZubin Damania1:05:18

       [laughs] Scared

   13. PAPeter Attia1:05:18

       ... come in contact with someone who went to Florida in 2020. Anyway.

   14. MGDr. Monica Gandhi1:05:23

       It's just a virus.

   15. PAPeter Attia1:05:23

       But you know what? He is still my brother.

   16. ZDZubin Damania1:05:25

       It's Satan's playground.

   17. PAPeter Attia1:05:26

       And I still, I still talk to him.

   18. ZDZubin Damania1:05:28

       [laughs]

   19. PAPeter Attia1:05:29

       I, yeah, I think I love him. I would go so far as to say that.

   20. MGDr. Monica Gandhi1:05:31

       I think Omicron is actually destigmatizing, though, and that's good. In a way, a very highly transmissible respiratory variant, it can't be eradicated, and like you just said at the beginning, Peter, this is now being recognized now by almost everyone, I don't think. And it's not shame. It's not that we weren't good enough. It's not that we weren't masky enough. It's a highly transmissible respiratory variant with animal reservoirs, a pre-symptomatic period, a long infectious period, and non-sterilizing immunity to the vaccines. All of that means it cannot be eradicated. But it can be made endemic. It can be controlled. And since everyone's realized that now, and now we're in this phase where people are converging and saying the same thing when they used to say different things, it is the time where the shame of getting a pathogen is being destigmatized, [laughs] I think. Yeah, so being in the HIV world, I really revolt against giving shame and stigma [laughs] to getting a infection. We used to hate people who did that in HIV in the early '80s, and now those same people are stigmatizing and shaming people who get a virus. But it's okay, because everything is changing now, and I think there's a convergence of thought.

10. 1:06:38 – 1:21:52

    Masks: Which Types Work and the Case for One-Way Masking

    1. PAPeter Attia1:06:38

       So I wanna talk a little bit about masks, because again, I think what's nice about this group is we have different views on things. And, and Monica, I know that you're gonna make a good case for why people should be wearing masks. So let's just start with the facts. What do we know today about the efficacy both at preventing transmission and preventing the receipt of the virus, [laughs] whatever the, the right way to describe that is, right? Protecting you versus protecting others when it comes to the following groups of masks: N95 and KN95, and if there's a difference between them, please tell us. Secondly, a surgical mask. Third, a cloth mask. Can you comment on those three categories of masks, and in the two domains, which is giving versus receiving virus?

    2. MGDr. Monica Gandhi1:07:23

       So actually, I've had a very consistent position on masks. My first podcast with Zubin was that cloth masks seem to reduce the severity of illness, and then there were some NIH studies that showed that actually it's probably the humidification of air when you're wearing a cloth mask that reduces the severity of symptoms. However, we're in 2022. The best way to reduce the severity of symptoms is to get vaccinated. [laughs] I mean, which one would I rather do, wear a cloth mask my whole life or get vaccinated? That has gone out the, uh, window, because that was a very specific utility for cloth masks for the individual. That's gone out the window now that we have vaccines. So this is how I feel about masks now. I have a very clear opinion. There are certain masks that seem to work best for the individual. We cannot be mandating mask mandates for the whole population anymore because transmission doesn't seem to be reduced by cloth masks, doesn't seem to be reduced by even surgical masks unless you really tuck them in and double loop them and so forth. That's not how people use them. So the Bangladesh randomized controlled study of masks was reanalyzed by a group at Berkeley, and cloth masks and surgical masks did little for the population level. But what a mask does is it one way protects you. And so what I would do if I were the CDC is I would say the right masks, which are N95s, KN95s, KF94s, FFP2s, double masks, or even tucked in surgical masks, put them on their website, which they did the other day, and say, "Hey, population, anyone who's worried about an exposure, please wear these type of masks." There are some people who want no exposure to Omicron. There are some people who really feel protected by their vaccine, and even if they have mild symptoms, they feel okay about that. There are some people who have no risk tolerance. There are some people who have high risk tolerance. You can't mandate for the whole population. I want my father to wear an N95 because he happens to be getting chemotherapy right now, and he's 87. I want my child, who's low risk and fully vaccinated, I don't have risk tolerance for him. So it can no longer be mandated, but if you tell people the right type of masks and one way masking works, that a teacher in a classroom can wear the right type of mask, and the students in the classroom, if a parent feels concerned, they can put that mask on their student, on their child. And if a parent is not concerned after they've been vaccinated or even not vaccinated, then they don't have to wear that mask. So that's where I think we are with masks, one-way masking.

    3. PAPeter Attia1:09:50

       So just to be clear, is the implication of what you just said, Monica, that the masks don't prevent you from transmitting the virus to someone else?

    4. MGDr. Monica Gandhi1:09:58

       My interest in cloth masks and my interest in masking were for the individual for reducing severe disease, and I think we do have that data now from the NIH with humidification of air. However, the Bangladesh RCT mask study, which was published in Science, has now been corrected because the raw data got put out. And so three groups looked at the raw data, and it didn't look like cloth masks reduced transmission, and even surgical masks actually was much less than originally said in the interpretation of the Bangladesh RCT in villages. Probably if you maybe, like, tucked it in and double looped it and, like, really sucked it to your face, you can make surgical masks work better 'cause of our polypropylene material. But at this point, we are this far into the pandemic. We have vaccines. There are some people who wanna wear masks and never have a risk. There are some people who don't and are okay with having a mild infection or getting exposed because they feel secure about their vaccines, and I think the entire equation has changed with masks. I have no tolerance for my father getting exposed because he's getting chemotherapy.

    5. PAPeter Attia1:11:01

       Just to be clear, Monica, when you go and visit your father, you're gonna wear a mask as well, I assume. I mean, I can understand why he should be in the KN95 or N95.

    6. MGDr. Monica Gandhi1:11:10

       Yeah.

    7. PAPeter Attia1:11:10

       Do you wear one then to go and see him?

    8. MGDr. Monica Gandhi1:11:13

       I haven't seen him since he's gotten his third dose of chemo, but when I see him, I will see him in a couple weeks, I'll either test and make sure that I'm negative before I s- hug him, or I'll wear a good mask, um, while I'm waiting for the test. Of course, I can't expose. He is in that category where he can have a severe breakthrough, yeah.

    9. PAPeter Attia1:11:29

       So the implication is that the mask, he wears a mask to protect him, and you will wear a mask to protect him.

    10. MGDr. Monica Gandhi1:11:38

        I will do that, but the point is that in where we are with vaccines, that may be my choice, but it is a difference between a mandate, and I'm telling you I'm in a state that mandates masks. So I'm really saying this very clearly. If we can tell people the right type of masks to protect themselves, actually his mask will protect himself. I may not need to wear something because his N95 protects him just fine. It's why he is right now wearing N95s when he goes out to a grocery store. His masks protect him. If you tell people the right type of masks, there are going to be people for the next three years who wear those right type of masks for themselves everywhere they go. I don't need to wear a mask to protect him.

    11. PAPeter Attia1:12:21

        I'm really pushing on this because on the last podcast, I was very vocal about my personal choice, which is I don't wear a mask. I never wear a mask. Luckily, I live in a state that is, what can I say without offending people, free. And so we don't have to wear masks [laughs] anywhere, and very few of us choose to. Kids don't wear masks in schools. It's just, it's a free-for-all here in Texas. And the amount of hate mail I got for that statement was, boy, I was surprised by that in a cute way. I couldn't believe how many people got so angry at me for not wearing a mask. They must be aware of data I'm not aware of.

    12. MGDr. Monica Gandhi1:13:01

        No, no. The data is very clear now at this point because we've had two years of data on masks, and I have been a huge mask proponent until the vaccines came out. So I was really, really into masks. It's, like, all people would interview me about.

    13. PAPeter Attia1:13:14

        I was hoping you were gonna smack me silly for not wearing a mask 'cause I wanna hear the case, right? I wanna understand it.

    14. MGDr. Monica Gandhi1:13:19

        No, no. At this point, I would actually advise people to look at Joseph Allen's work, Shira Donna's work. One way masking works. We have vaccines. Anyone who wants to wear a mask should. Anyone who wants no exposure should, and it should be specific type of masks, those six that I just said. And that can be for a child. That can be for an adult.

    15. PAPeter Attia1:13:41

        Can we recite those again?

    16. MGDr. Monica Gandhi1:13:42

        Ca- yes. N95s, KN95s, FFP2s, KF94s, a double mask with cloth and surgical, or the final option is actually a cloth mask with a surgical filter inside, a filter inside that's polypropylene material. That's probably the most comfortable option, so a cloth mask with a filter inside. Those have all been studied very well. They all protect the individual, and if I want no exposure, I can wear one of those masks. I want my father to have no exposure, he can wear one of those masks. But if I am comfortable with having some exposure 'cause I'm fully vaccinated, then I don't have to wear that mask, and that's where we should go to in this country. And again, I will refer everyone to Joseph Allen's work, because he has been working on COVID mitigation for this entire time, and he wants one-way masking now, and so do I.

    17. PAPeter Attia1:14:30

        So what's the group consensus on how long people will need to wear masks on airplanes, and in airports, and in federal buildings, and in places like California?

    18. MMMarty Makary1:14:40

        California, I think they're gonna start unmasking in 2054, generally. [laughs] No, just kidding.

    19. MGDr. Monica Gandhi1:14:48

        [laughs] I will say I live here. Everything's changing. There is the acceptance of endemicity is now being talked about at very high levels. So the Biden administration task force advisors wrote a piece in JAMA just two weeks ago that was similar to a piece I'd written in Time that said, "You have to accept that we have to live with COVID." And so I think there's gonna be four things that happen that are different now than before what used to happen in the world. We have to protect ourselves from respiratory pathogens as a whole. We're probably gonna always vaccinate. We need better treatments, and we need more of those treatments. The third thing is probably there's gonna be more attention paid to ventilation for all respiratory pathogens. And then finally, there will be people, and there will be recommendations by the CDC, that anyone who wants to mask can wear those six type of masks from now on. But I don't think it can be mandated, and I don't think it'll be mandated in California after February 15th, nor do I think it will be mandated in travel after March or whatever date Biden has said.

    20. PAPeter Attia1:15:47

        That is fantastic news to hear.

    21. MGDr. Monica Gandhi1:15:50

        One-way masking works. It's like your vaccine protects yourself, your mask protects yourself, too, and for those who are very concerned, I'm so happy for them that we now have such good data on which mask they should wear, including my father.

    22. PAPeter Attia1:16:02

        I was doing some video work last week for a documentary that I'm doing, and everybody has to get a COVID test right before, and everyone has to be negative. So you got a whole group of people that just had a PCR test that demonstrates they're negative. We're all on this very small, intimate set, and it's one of these things where I have to talk directly to a camera, which I can't do. I have a real block when it comes to talking directly to a camera, so the only time I can talk to a camera is when I have this thing called an Interrotron, which allows me to look at a person's face who happens to be sitting next to the camera. So everybody on the set is in a mask except me. I say to the woman who's in the Interrotron, who I'm supposed to be looking at, "Can you please take your mask off? Because the whole purpose of me being able to look at your face is to be able to read your facial expressions so that I can be speaking to you properly." And she said, "Well, I don't think the rules allow me to take the mask off." And I was like, "But everybody just had a negative PCR test. I think everybody's vaccinated here as well, for what it's worth. Why are we wearing masks? Oh, and by the way, you're about six feet away [laughs] from me." It was just, like, part of the rules of how this thing had to be done. You sort of now know a little bit about my personality, which is just how logically inconsistent things really are a challenge for my endothelial function via my blood pressure.

    23. MGDr. Monica Gandhi1:17:14

        But Zubin, you brought up the idea of religion. I mean, you brought up the idea of secularization in a society leading to almost semi-religious beliefs around different topics, and masks have become one of those in this country, but the data is super clear.

    24. ZDZubin Damania1:17:30

        Yeah, I think you nail it. So Peter, you are an impuritor. There's, again, a dirty sanctity issue that comes up, where people who are very conditioned about masks, who don't see it logically, feel it emotionally, and they see someone without a mask and they feel like this is a dirty person coming to invade the sanctity of their body. And this is how we've conditioned people, unfortunately. Like, the way Monica talks about masks is how I feel about masks. It's now an individual choice, and it's great. Like, for my parents, who are elderly with multiple comorbidities, absolutely. But logical inconsistency, you know, I have people in my studio, we're now four feet, three feet across from each other, talking very loudly. We're all vaccinated. We're all comfortable with our risk, even in the setting of Omicron, where, again, the great shaming mechanism has been leveled. And so hopefully some of the religiosity starts to dissipate, but I wouldn't hold my breath. I think it's gonna take some time.

    25. PAPeter Attia1:18:17

        Marty, do you have any sense of how many children in the United States are still being mandated to wear masks at school? Is it the majority or minority at this point?

    26. MMMarty Makary1:18:26

        I would say it's the majority. I mean, it's up to local school districts in many states, but I would say it's the majority, and unfortunately, a lot of them are wearing the cloth masks.

    27. PAPeter Attia1:18:35

        They're getting all the downside of hiding their faces, not learning how to read facial expressions, all those other things, and none of the [laughs] supposed upside.

    28. ZDZubin Damania1:18:42

        None of the benefit.

    29. MMMarty Makary1:18:43

        We talked about that Brown University study that talked about significant cognitive and motor delays in children that can only be ascribed to the loss of the human connection. When you look at the risk stratification in kids, it's just a whole different ballpark, as we've talked about. And honestly, we are now using policies designed around Beta and Delta in an era of Omicron, which is behaving very differently. So what happens when Omicron is essentially gone, and now we've got a wave a year from now, but it's parainfluenza, or we have a rhinovirus wave, which we have every year? Then what? Are we gonna cover their faces again so they're basically covered K through 12, and then of course, when they hit universities, they're gonna have to wear a space suit or something? There is a study that just came out since we chatted last time, maybe Monica you referred to this, but the Proceedings of the National Academy of the Sciences on masks that looked at N95s with a nose piece, N95s without a nose piece, and a surgical mask. They didn't even study cloth masks, I think because they recognized there's no value in it. So what they found is that if you have an infected person with direct contact with somebody else for 20 minutes, the risk of transmission with surgical masks was 10.4%. With an N95 without a nose piece, it was 4.2%, and an N95 with a nose piece, in other words, a good seal 0.14%. So that tells us a lot. That tells us that not only if you're infected and around somebody, you can significantly reduce the risk of transmitting, but it also tells us that the quality of the mask matters. Now, why are we learning this two years into the pandemic? From a public policy standpoint, which is the perspective I've come from, and I've had to dive deep into the immunology of it, but really, public policy has always been my interest. And what we're seeing here is a complete absence of fulfilling the role of providing data to the public by the NIH and CDC. So for two years, with their gigantic budgets, they couldn't do this basic study on masks. We're learning it on the very tail end of the Omicron wave. I mean, this is why we have so many political arguments about it. And I think given where we are, we need to, and I would encourage people, respect people with their opinion on masks. If you see somebody wearing a mask, don't make fun of them. We need to respect each other. I saw someone playing golf by themselves with two masks on. My immediate reaction was, "That person lives with a lot of anxiety." But you know what? Let them be. We gotta get away. We don't want kids bullying each other. We want-

    30. MGDr. Monica Gandhi1:21:26

        In a way, that anxiety has... I mean, it's so deep in our society right now because of how we messaged about COVID that I feel a great deal of compassion for people who feel that degree of anxiety, because facts isn't going to change their mind. And we have done a fear not facts messaging instead of a facts not fear, and I feel great compassion for people who are so scared right now.

11. 1:21:52 – 1:31:20

    Long COVID and Schools

    1. PAPeter Attia1:21:52

       So Monica, I know that we've only got you for about another 10 minutes. Luckily, the rest of us here can keep going, because there's so many other topics that people have asked about. One of the things that people did ask about that I know you are an expert in, and in fact, your institution is now doing a clinical trial that I actually tried to get somebody into, I want to talk about long COVID. So can you tell folks technically how we define long COVID and give us any other insights you have as to what it's about, what the incidence is, what the potential for treatments are, and anything else that you think is germane?

    2. MGDr. Monica Gandhi1:22:23

       So you're right, our institution, I'm not in that study, but our, at UCSF has a great study on post-acute SARS-CoV-2 sequelae. And essentially, actually it's true of any severe viral infection. If you have severe viral infections, you can get lingering symptoms, influenza included. And the pathophysiology seems to be twofold. One is that if you have no immunity to the virus, it can go multiple places. It won't stay in your body long term like HIV, but it can go multiple places. That's one mechanism. And then the second is that your innate immune response, if you have no immunity to the virus, can lead to inflammation that lingers. Luckily, after vaccination, two things happen, or after immunity, after you've had the infection before. You get adaptive immune responses. So quickly, when you get the virus in your system, like you're having a mild breakthrough infection, your immune response swoops in. There are actually T cell islands in the nose. Despite the antibodies going down, there are T cell islands in the nose. Your immune response actually swoops in, makes that virus not go everywhere. It's usually why the breakthrough infections are mild and up in the upper respiratory tract. So you've just lost one pathophysiologic mechanism by being vaccinated or immune because it doesn't go everywhere. And then the second is it's not your innate immune response that reacts. It's your adaptive immune response. So you don't have that kind of massive inflammation that can occur before immunity. So there was just a study this morning in Israel that those who are vaccinated don't get long COVID symptoms after having a mild breakthrough. In fact, they have long COVID symptoms at the same rate as people who've never had COVID at all. There's people who have had a, a lot of anxiety and depression during this time, understandably, and that can be mistaken for long COVID symptoms.

    3. PAPeter Attia1:24:13

       I don't think I was aware of that, Monica. You're saying that there are people who are being, quote unquote, "diagnosed" with long COVID who have never had COVID, and it's really just a manifestation of anxiety?

    4. MGDr. Monica Gandhi1:24:22

       There are some studies that what's going on in the world right now and how miserable everyone is, is making people have less cognitive function because it's just a miserable time. But this very good study, just from this morning, and essentially shows us that if you've had two vaccine doses, that you have fewer long COVID symptoms than people who have never had COVID. So basically, vaccination both brings your long COVID symptoms in check, so getting vaccinated for long COVID is one way to treat long COVID, and then also those who have mild symptomatic breakthroughs who have been vaccinated don't seem to get long COVID symptoms. There's basically three studies that show this now, including one from Israel this morning. So putting that all together, the biggest fear of the fact that this virus is endemic and not gonna be able to be eradicated among people who are getting mild infections are could they get long COVID symptoms? And there hasn't been any evidence of that, and we have had a lot of breakthrough infections through Delta and now through Omicron, and these are very good studies that shows our adaptive immunity prevents us from getting these longer symptoms. So I think that's very good news for long COVID.

    5. PAPeter Attia1:25:42

       Do we have a sense of what the incidence is of long COVID in presumably the unvaccinated, which is the majority of the people that it's being seen in?

    6. MGDr. Monica Gandhi1:25:51

       It depended on if you had severe disease or mild disease. So those who had severe disease, this is a very good nature study, you're more likely to get longer symptoms after that, and it was about 30%. If you had mild disease, it was very low. So it really depends on your severity of initial infection. However, at this point, we have so many people who have been vaccinated and we have so much natural immunity that our long COVID Population is going down and we're still treating, 'cause I know this from the clinic, people who had initial m- severe infection before the vaccines were available.

    7. PAPeter Attia1:26:23

       And the reason I'm interested in this question is, as we've all noted, there's still a substantial portion of the young population that's not vaccinated. So Marty, you said about, what, 15% of Americans are unvaccinated. Is that right? 15% of Americans over five years old are unvaccinated.

    8. ZDZubin Damania1:26:38

       Over 18, and about 20% over age 12.

    9. PAPeter Attia1:26:41

       Okay. So we could do the math on that and reverse engineer what fraction of people aged 20 to 40 are unvaccinated. Really, to me, that might be one of the more potentially compelling reasons to be vaccinated if you're otherwise young and healthy, is to mitigate the risk and the downside of long COVID. Is that a fair assessment?

    10. MGDr. Monica Gandhi1:27:02

        I agree. I mean, not only does vaccination help you not get long COVID if you get COVID, [laughs] but also it seems to be able to treat long COVID, because your more dysregulated immunity goes into a more adaptive and organized immunity. So again, I think it's profoundly important to say vaccination helps long COVID either after the fact or before the fact. So adaptive immunity seems to be the way to get to all roads lead to where we need to get to with this virus, which is having a lot of immunity to the virus. It's why before, in 2020, we didn't have any immunity to the virus, and we were much more nervous. Now, in this stage of the pandemic, we have so much more immunity to the virus. Again, 79% of people in South Africa, even though it's a 25% vaccination rate, there's a lot more immunity in the world. And then that relates to schools, I think.

    11. PAPeter Attia1:27:54

        Say a little bit more about that.

    12. MGDr. Monica Gandhi1:27:56

        Again, this is kind of facts not fear versus fear [laughs] not facts messaging. You really went over for us how much lower the risk is among the young, especially children, for severe COVID, and it has to do with there's clear mechanisms by why children are less likely to get severe COVID with these two receptors and their innate immune response, and that's true of long COVID as well. So all of that put together, we have to refocus our ideas now on schools not being a place of fear, because I think what Marty just said was really significant to me, that there will be parainfluenza, rhinovirus, influenza, there'll be other viruses that cause infections from now on, and we have to think of children's holistically as the place where they need to learn. I think the ill effects of school closures, I, I think there are very few people now who deny them two years into the pandemic. The ill effects include mental illness, anxiety, depression, eating disorders, and learning loss, and all of that put together means if I were in charge of the nation, [laughs] I would put my emphasis on schools, because children are our most... I mean, any society's from the beginning of history is the most precious resource. So we put a lot of fear, we ask children to shoulder a burden for older adults, and we have the vaccines, and we've had the vaccines now for a year. We need to now move towards normality for children in schools. You see it, like Harvard just said they're not gonna do asymptomatic testing or contact tracing starting in the spring semester. They're gonna have normal college. Johns Hopkins is still not having normal college. Some colleges are going normal, some aren't. Harvard being Ivy League hopefully will have a emphasis on others. Maybe Joseph Allen being there is helpful for the one-way masking argument. If you want no exposure, wear your good mask. So you're seeing things change.

    13. PAPeter Attia1:29:50

        Will they still be requiring boosters?

    14. MGDr. Monica Gandhi1:29:53

        They just announced over this weekend that they're gonna have normal school in spring semester.

    15. PAPeter Attia1:29:57

        I'll need to see the fine print on that, because I, I still-

    16. MGDr. Monica Gandhi1:29:59

        [laughs]

    17. PAPeter Attia1:29:59

        ... as you can tell, it's a real bone to pick with me that we're mandating vaccines in anybody, but boy, especially in college kids. And then to mandate boosters, I'm struggling.

    18. MGDr. Monica Gandhi1:30:08

        Yeah. Yeah. So fair enough. I will say that the idea that college students, I mean, Marty wrote a really poignant piece on this, but the college students should be more restricted than all those adults in the restaurants, and bars, and sporting events, and it would be the college students that would be most restricted. It was a very poignant article. And Harvard of all places saying they're gonna have normal school in the spring semester and accepting that we can't eradicate a virus for me was very hopeful this weekend.

    19. PAPeter Attia1:30:38

        Well, Monica, I really appreciate it. Thank you for making time today. I know you have to run. Zubin, and Marty, and I will have a lot to continue talking about, and we'll try not to talk about you too much and your crazy view on kids. [laughs]

    20. ZDZubin Damania1:30:50

        [laughs]

    21. MGDr. Monica Gandhi1:30:51

        [laughs] Actually, I will tell you that everything that we just talked about, this entire podcast was based on data, and I think it's good. We don't use a fear not facts approach, but data is the only way to get through this pandemic. We knew this in medical school the whole time, but it hasn't been data-driven in a lot of cases. It's been fear-driven. So I hope we can change people's minds with the data.

    22. PAPeter Attia1:31:12

        Likewise. Thank you, Monica.

    23. MGDr. Monica Gandhi1:31:14

        Thank you very much. It was great to talk to all of you.

    24. ZDZubin Damania1:31:16

        Thanks, Monica.

    25. PAPeter Attia1:31:17

        Great to see you.

    26. MGDr. Monica Gandhi1:31:19

        Thank you.

12. 1:31:20 – 1:47:32

    Sweden, Canada and Proportionate Responses

    1. PAPeter Attia1:31:20

       So guys, one thing I wanna build on that Monica indirectly alluded to, right, which was the importance of keeping kids in school, it kinda reminded me of, we're going in the way back machine now, but do you remember in spring, summer of 2020 when Sweden didn't lock down and everybody looked at Sweden as though it was crazy? I have not gone back and looked at Swedish outcomes. Do either of you guys know anything about how the situation shook down?

    2. ZDZubin Damania1:31:49

       I think Marty has more data and I have more anecdote. So maybe I'll start with the anecdote, and then Marty can fill in the blanks. So I get a lot of messages from Swedes Recently got a really good detailed one of somebody who's not in healthcare, but who studies this stuff in general and said... Remember, I think a lot of this that we're talking about, we have, as people, failed to see context where context is absolutely crucial. And so putting Sweden in context, you have a Nordic country that actually over years has developed a relationship between its population and its government that is trusting, and it took a lot of different approaches to do that. Their healthcare system's a certain way, their public welfare system's a certain way, and they have a certain type of population, a lot of whom live in single homes. It's easier a little bit to distance, things like that. So that all being said, they took a tack that said, okay, large events, large gatherings, there were rules about that. So it wasn't just like let her rip in the early days, but their public health officials, like Anders Tegnell and these guys, were saying, "Listen," in those days they did not know when a vaccine was coming. It could have been years. So they said, "We need to design a public health approach that's gonna be a long game approach, thinking years." So they said, "We cannot shut down schools." And they did not, if anything, for like a period of a couple weeks. It was never months there. Early on, what they found was they did have a higher mortality per capita rate than their neighbors, largely because the one big mistake that was made early on is failing to protect nursing home patients, who are the highest mortality, highest risk in the early days. After that, though, so 2020, in 2021, it seemed the data shifted to where actually, no, their excess mortality was not higher than their neighbors, and they actually did quite well. They continue to have trust, although there was a little bit of controversy, and overall they've stayed mostly open. They had some businesses that suffered that the government directly stepped in and paid salaries and things like that. So there was more of a social support network, but they really were playing the long game, and it seems like so far they've done quite well. So Marty, what are your data points on this?

    3. MMMarty Makary1:33:51

       Yeah, so Sweden is a fascinating case study because they took a radically different approach, and while there was early criticism of their strategy, nobody talks about them since that time, and it turns out that their data are very impressive. So the total population rate of the mortality per capita in Sweden, all in all, cumulative this entire pandemic, has been 1 in 663. Now, by comparison, in the United States, it's 1 in 387. We're talking about a radically different confirmed deaths per capita rate. Now, that's according to Statistica, and if you look at where Sweden falls, it's around the middle, but remember, most of the countries in the bottom half are not reporting reliably. Burundi is, you know, one of the lowest mortality rates in the world. They're obviously just not capturing a lot of cases. So it's a fascinating example of what happens if you do a selective protect vulnerable people strategy and then figure out a way to continue living life. Now, the real question is what is their excess mortality from non-COVID deaths? In the United States, there's a suggestion that excess mortality, you may have seen this report come out, is somewhere in the range of 20% higher than the COVID mortality rate. So there's been something like last year 385,000 COVID deaths in 2020, but the total excess deaths that year were about 430,000 or something like that. So there's some explaining to do there, and no one's taken a deep dive yet. We know about some very broad statistics on opioid or substance abuse deaths, but if you go to the CDC's websites, and this is where the politics may be playing in or just government incompetence, good luck finding numbers on suicide during the pandemic. Good luck finding numbers on substance abuse. They're very crude, they're broad, and they're early. They're more delayed than they need to be.

    4. ZDZubin Damania1:35:49

       One thing, guys, that this guy mentioned too is that their degree of vaccine uptake in 2021 is quite stunning. They did a very good job because they already have innate levels of trust in public health officials. It was public health officials like Anders who were doing the messaging. It was not politicians during much of COVID. So they did very well in 2021, probably partially because they got to vaccine. They've never focused on masks, and they did focus on protecting vulnerable, although there was an unspoken sort of idea among their leadership, it- it's felt, that they were willing to sacrifice some old and vulnerable early on to keep society as a whole running and younger people functioning and the economy going, and they never said this publicly because obviously that's a poisonous message, but that was the feeling. So they made these compromises that were really quite interesting, and then in the long run, the area under the curve of excess mortalities may well have been impacted positively by what they've done, although I think it's gonna take some years to really unwind what's going on everywhere.

    5. MMMarty Makary1:36:47

       Many of us sort of found it morally offensive that you would take a let it rip strategy, but those who defend what Sweden did will actually tell you it was not really a let it rip strategy. What they did is they tried to evolve the strategy based on the data, and early on there was a very focused attempt to protect the elderly and the vulnerable. If you went to a restaurant early on in the pandemic in the semi-open society in Sweden, they were distancing. They were still using some mitigation. So it was not a truly let it rip strategy, and I think to their benefit, I mean, the kids have been in school throughout, and they've not been masked. European CDC recommends against masking people in primary school. Looking back, there's, I think, some lessons there, and the people who advocated for us to do what Sweden has done, I mean, they are im- partially vindicated now with some of this data.

    6. ZDZubin Damania1:37:38

       The last thing, I think it's worth reading a line from what this guy sent me. He says, "My 15-year-old daughter spends a lot of time on YouTube, and when I asked her if there's anything she wants to add to what I'm telling you, she immediately said that she cannot relate to the COVID experience many talk about online. Her life has basically continued as before, and I don't see any long-term effects in terms of distrust and fear, that Sweden is held together in a way that's very encouraging. There haven't been big Draconian measures or big demonstrations of discontent and families and friends torn apart due to different views." So that's really quite interesting. That social fabric has held together, and that's important. It's like we ignore that at our peril. Again, the context of the whole thing, rather than just the little fragments that people tend to focus on, what's the overall context?

    7. PAPeter Attia1:38:21

       Again, just sort of digressing into anecdote, you know, I have very close friends in Canada, and a number of them are very seriously considering doing something I would have never imagined possible a year ago, two years ago, any point in time, which is moving to the US. Canadians are a very proud people. They tend to have this superiority complex over Americans, you know, the swaggering, arrogant Americans and stuff like that. And but when you look at the truly draconian measures in my home province where I grew up, Ontario, I grew up in Toronto, there are people that have basically said, "Look, we've historically loved Canada, but enough is enough." They're really looking to move to US states that have been far more open, and it's really extreme. So to give you some perspective, referring to a friend who had COVID, didn't get vaccinated, kids are not vaccinated. As a result of the fact that the parents had COVID but are not vaccinated and the kids are not vaccinated, the kids can't play sports. They're not permitted to play sports. You have to think about that for a second. So, like, what is the implication when you take kids aged 12, 13, 6, 7, 8, and you say, "Sorry, your parents aren't vaccinated. You haven't been vaccinated. You don't get to play organized sports." And of course, you're wearing masks in school and all these other things, and I'm sure people have heard that the province of Quebec is now trying to tax the unvaccinated. It's a sin tax now. Think about that for a moment. Again, if we're gonna be logically consistent, if we're gonna say we're gonna tax the unvaccinated, boy, we are gonna be taxing a lotta people, right? I mean, if your BMI is over 25, we should probably be taxing you too. If you're clumsy and you're doing high-risk sports, I mean, you should probably be taxed for that because you're more likely to end up in the hospital. Anyway, in going back to this example of a friend of mine, do you realize that an unvaccinated person in Canada cannot travel in Canada? So they can't get on an airplane. They can't get on a bus. They're only permitted to drive themselves, and they still won't be allowed to cross the border.

    8. ZDZubin Damania1:40:32

       [laughs] You know, there are countries that do stuff like this. It's called Sharia law, very aggressive, sort of fundamentalist countries that do this kind of thing based on religious belief. In a way, because I'm not sure we'd find data to support these activities, this is now, again, I'll reiterate, falling into the vestiges of religion. And the question is-

    9. PAPeter Attia1:40:52

       I wanna say something even more provocative, Zubin, which is isn't that almost now as radical as the most radical form at the opposite end of the spectrum, which is the most radical form of fascism, right? I mean, think about what was going on in Poland in the 1930s. So it's the totally opposite end of that spectrum, but you couldn't leave that country. You would have needed to escape that country for your safety. I'm not trying to for a moment to s- compare this to Nazism. I'm simply saying at some point, these completely opposite ideologic things meet in terms of-

    10. ZDZubin Damania1:41:27

        It's a circle

    11. PAPeter Attia1:41:27

        ... how restrictive they are. Yeah.

    12. ZDZubin Damania1:41:29

        Actually, you really think about that. You're in a country that can effectively be landlocked, and you cannot escape. You cannot leave Canada. It sounds like a great movie, Escape From Canada, and Toronto is a post-apocalyptic flaming wreck.

    13. PAPeter Attia1:41:42

        [laughs]

    14. ZDZubin Damania1:41:42

        But w- I could see Marty starring in that, the first brown, like, leading actor. I think we need that.

    15. PAPeter Attia1:41:47

        [laughs] What?

    16. MMMarty Makary1:41:50

        As I remember, the dean of the Harvard School of Public Health said, "A Canadian is essentially an unarmed American with health insurance."

    17. ZDZubin Damania1:41:56

        [laughs]

    18. MMMarty Makary1:42:00

        [laughs] Here's where the argument falls apart, Peter, with data. What happens if that same individual that you're describing is infected with influenza or parainfluenza? Then what? Oh, that's okay, I guess, right? Even though the case fatality-

    19. PAPeter Attia1:42:15

        Yeah, presumably they're allowed to get on an airplane, and they could probably even get on a bus or a train and maybe even drive across.

    20. ZDZubin Damania1:42:21

        They can kill people. They can kill people with influenza very easily. I mean, this is the, influenza kills so many people per year.

    21. PAPeter Attia1:42:28

        You know another thing that doesn't get a lot of attention, we have so many remarkable antiviral treatments for COVID now. I don't know about you guys. Have you guys ever had influenza, the actual real deal OG flu?

    22. ZDZubin Damania1:42:41

        Yeah.

    23. PAPeter Attia1:42:41

        Yeah, I've had it twice in my life. It sucks.

    24. ZDZubin Damania1:42:45

        It's the worst.

    25. PAPeter Attia1:42:46

        That is a bad virus, and we don't really have anything too good. Remember Tamiflu, how useless that turned out to be? People were stockpiling Tamiflu. Like, it did nothing. Influenza, which is about as bad as Omicron, Marty, correct me if I'm wrong-

    26. ZDZubin Damania1:43:03

        Oh, worse

    27. PAPeter Attia1:43:03

        ... influenza's worse than Omicron?

    28. MMMarty Makary1:43:05

        I mean, you're talking about the study, 52,000 people, one death. I mean...

    29. PAPeter Attia1:43:09

        I haven't got Omicron yet. I've been trying. Actually super annoyed that I don't have it yet 'cause I feel like I'm missing out on a booster shot or something. But when I look at all of my patients and friends who have had Omicron, yeah, I would say it certainly anecdotally appears far less severe than influenza, and yet when you get influenza, you don't have a drug that you could take if it gets really bad the way we have fluvoxamine and the other more recent Pfizer and Merck drugs. So that's another thing that doesn't really seem to get, in the spirit of what can you do as an individual to protect yourself, well, step one, get vaccinated. Step two, have access to therapeutics. Step three, have access to a healthcare system that has literally just spent the last two years doing a fellowship on how to treat this disease. I think one of you said it earlier, right? We're operating under assumptions that are two years old.

    30. MMMarty Makary1:44:01

        And an infection fatality rate of a prior virus. Omicron needs a PR firm because as long as it's COVID, people think they're using all the COVID historical data, and when you add population immunity and a more mild virus, it does change the calculus. It doesn't mean people don't get sick. It doesn't mean that any of us would ever wish anyone become infected and deal with this virus. Nobody would want that. But I'll tell you, I just talked to doctors in Egypt there this morning. They've had a real tough time getting people vaccinated. They've tried everything. They're very thankful to God that Omicron is what it is, because it is gonna confer large, broad population immunity, and otherwise there were just no other strategies to get there. The question is: how did we become so dependent on the CDC to adjudicate on every aspect of American life? And we know typically they draw on data from their MMWR reports that's historical. Everybody is so upset at the CDC over so-called messaging, in terms of I've done my five-day quarantine, do I get one test or two tests? Do I get antigen tests or PCR tests? Stop. Let's ask the bigger question: why are we even quarantining immune people who are low risk from other immune people? Right? Would we ever do this for parainfluenza or rhinovirus? This is where we've just sort of developed this intense dependency, and as long as we're waiting for the CDC to tell us whether or not we get one or two antigen tests because the sensitivity in the pre-symptomatic phase or asymptomatic phase is below 50%, so after you've done your five days of quarantine, you're still not getting a definitive answer. So why are we having these arguments when we need to just get back to common sense, which means if you've been exposed, then wear a mask. Doesn't matter what virus. If you are around someone vulnerable, be careful. Maybe stay your distance. And if you're sick, stay home. That is a pan-viral strategy that we need to adopt for general public health hygiene that gets us away from these crazy deliberations that we're having right now.
13. 1:47:32 – 2:01:53

    Agendas, Tribalism and Hive Minds

    1. PAPeter Attia1:47:32

       I was reflecting on an extension of that theme, again, thinking about how we were gonna be talking about this stuff today and sort of getting into some of the philosophy of it. But since the last podcast came out, which was a couple of weeks ago, I've obviously been a little more attentive to all things related to COVID, in the news, in the literature, et cetera. And truthfully, it hasn't been good for me. So my blood pressure's been running about 10 [laughs] millimeters of mercury higher. Unfortunately, most of that is just social media, and again, part of it is just I have this anaphylactic reaction to things that are logically inconsistent, but it serves no purpose other than to hurt me. But I got thinking, "Why is that?" We all have an agenda, and I've been really trying to understand my agenda, 'cause I have an agenda. You have an agenda. Everybody has an agenda, and I wish we could all wear T-shirts that said, "This is my agenda." So if I'm talking to you, I see your agenda, and I can use that to help me interpret what you're saying. I think I understand my agenda really well, right? My agenda, 'cause I'm not a contrarian. Like, I'm not the guy who wants to disagree with the mainstream view just to be different. Sometimes I disagree, sometimes I agree. I think my agenda here, we talked about this a little bit before, is I'm worried about the integrity of the profession and the broader discipline of science. I really have concern for the integrity of this, and I have many friends and some patients who have completely lost faith in this profession. That's my ax. That's the thing I'm grinding. I am very upset about what the implications of this are down the line, and I think that's what's coloring, for better and worse, how I feel about the situation that we're in today. Do you guys have a sense of your agendas?

    2. ZDZubin Damania1:49:24

       Absolutely. By the way, this is the kind of self-reflection that every single person should do when they think about this, because it then frames the whole conversation very differently, and it involves a degree... You said you have no emotional intelligence. Actually, you just showed that you do. Because I'll tell you the same thing. Since we did the show the, another couple weeks ago, and honestly, I've been weaning off talking about COVID prior to that, and you kinda reignited me thinking about this stuff, and it's been nothing but suffering for me, like [laughs] ever since. There is a feeling of, like, first of all, now you're interested in seeing what people say about it, and it becomes this agenda versus agenda, and it's an unconscious sort of thing. So my agenda with this from the early days has been somewhat shared with yours, somewhat shared with Marty, somewhat shared with Monica's, which is trying to find a synthesis of what is the best policy versus science thing for the most people and trying to bridge across this divide of misunderstanding and division and to, to try to understand all these positions. I call it alt-middle. I've started to think of it as like a corpus callosum that binds the left and right hemispheres. [laughs] Like, how do we build those fibers that connect these things together and help us think rationally? And my bias has always been that. Now, the way I'm criticized for that bias... So it's good, so you put it on your T-shirt. I'm alt-middle ZDoggMD. I wanna be the corpus callosum in the conversation. People will attack directly and say, "There is no middle ground here. It's mask or don't mask, or it's this or it's that." And that's fine, but at least then we know where our agendas are and where our biases are, whose hive mind has captured us. That's important to understand, because otherwise you'll never be able to bridge these different gaps and have some sanity.

    3. PAPeter Attia1:50:58

       And what about you, Marty? What would your T-shirt say? What's your deep, dark agenda here? I want us to be as open and as we can about this.

    4. MMMarty Makary1:51:06

       I would say to end tribalism, because that is the most offensive thing. It's not a different opinion. I'll hear somebody articulate a different perspective, and they'll come out entirely differently on what we should be doing or should be recommending. That is okay in the context of civility in my mind, and my thought is, you know, let's show the data on both sides to the best of our ability and let people make a decision. One of the few things that will be morally offensive is the automatic tribalism, the dismissal of people because of something that they thought early on, and nothing captures that better than how Jay Bhattacharya was dismissed early on, and now you see, like, hey, the data is playing out just as he said. I also feel that we made a tremendous sacrifice as a country. We're living like Grizzly Adams. I mean, I was at risk of growing a ponytail.

    5. ZDZubin Damania1:52:01

       [laughs]

    6. MMMarty Makary1:52:02

       We come out of this thing, and you have people that are saying that was absolutely the right thing to do, and we need to go back into the cave because of speculation of a more dangerous virus coming out of South Africa. And you want to say, "Stop. Let's look at the data." That sort of retreat I think s- many times is scientifically dishonest. When I see the universities, who ironically are supposed to be champions of data and scientific reason, revert to these sort of primitive practices that are almost barbaric, they're definitely cruel on students. You want to say, I remember in college, they would insist that everybody at a liberal arts college take a science course so that you understand the scientific method and process, right? They would force these philosophy majors to memorize rocks in geology class. Thinking why do they have to memorize the names of rocks for their future? Well, it's to understand the scientific mind and the scientific process. And then they do this complete rejection of any open scientific debate and cancel people with different opinions. To me, it's the tribalism that bothers me, and it's just sad to see it play out.

    7. PAPeter Attia1:53:10

       I'll say one last thing on this, and then we'll get back to what people care about, which is not our griping, but it's more the fact stuff.

    8. ZDZubin Damania1:53:15

       [laughs]

    9. PAPeter Attia1:53:15

       But I was actually really surprised at some of the hate mail I got after the last podcast. Now, I haven't gone back and listened to it, guys. I gotta be honest with you, I don't really have the time to go back and listen to podcasts I record, so I mean, I guess it's possible I came across as a racist homophobe, but I don't think I did because I'm not actually racist or homophobic. But some of the hate mail I got was, "You are a racist, homophobic piece of shit who lives in Texas. How can you say the things that you are saying about COVID?"

    10. ZDZubin Damania1:53:49

        [laughs]

    11. PAPeter Attia1:53:50

        First of all, I'm like a brown guy. Like who, who am I racist against?

    12. ZDZubin Damania1:53:54

        [laughs]

    13. PAPeter Attia1:53:55

        White? I mean, like just tell me, help me understand more where my racism is coming from.

    14. ZDZubin Damania1:54:00

        Self-hate. [laughs]

    15. PAPeter Attia1:54:02

        These were people that just went off. Like they went completely off. Somehow my not wearing a mask and moving from California to Texas, which technically happened before COVID, [laughs] but that's another story-

    16. ZDZubin Damania1:54:16

        [laughs]

    17. PAPeter Attia1:54:17

        ... is really all a sign of, I don't know, misogyny, racism, homophobic behavior. Like sometimes I get upset when I get nasty comments. This couldn't even upset me, 'cause I couldn't even under- I mean, like I was like literally interested in this. I was like, "Wow." I'm looking at the grammar of the person who wrote it. Like were they sane? Is this a person who is having, you know, kind of a mental break?

    18. MMMarty Makary1:54:38

        It's a bot in China.

    19. PAPeter Attia1:54:39

        Yeah, like [laughs] yeah, like...

    20. ZDZubin Damania1:54:39

        [laughs]

    21. PAPeter Attia1:54:41

        Anyway, um, I'm sure you guys experienced the same thing, right?

    22. ZDZubin Damania1:54:45

        Marty, unless you wanted to say something, I have some thoughts on this, and this actually relates to, say, the Robert Malone interview on Rogan.

    23. PAPeter Attia1:54:52

        We're gonna talk about this, 'cause I wanna make sure we spend some good time on this. We all get asked a lot about it, so.

    24. ZDZubin Damania1:54:57

        Absolutely, and actually this is an epiphenomenon of that interview in my mind, because he talked about mass formation psychosis in that interview, and this is a garbage term that he kind of made up from some crazy guy in Europe. But here's what's actually happening in my opinion, and why you see what you're seeing, Peter, and we're all seeing it. Everybody's seeing it. And I don't know if I said this in our last podcast, so if I have, you just stop me and say, "You already talked about this." But this is what I think is happening, and others, I've been talking about this in the sense making community online, people who are focused on trying to figure out how do we make sense of the world in a fractured information economy and so on. So David Fuller at Rebel Wisdom and other people like that, BJ Campbell. There's an idea that individual humans actually do instantiate these higher elements of thinking. We call them different things, group think, hive mind. He actually calls them egregores, which is a demon that emerges from groups of people and their thinking. And it used to be in the old days, you would share information in very slow and uniform ways, like whether it was mass media, just a few channels, or whether it's money as a way to exchange information because there are economic incentives. Like you build a city on a river because it's easy access to ports and so on. But now, with social media, you effectively have turned every human with a smartphone into an addicted machine that behaves like a neuron, and its neurotransmitters are likes, dislikes, comments, shares. So each of us is part of a network of people that acts, again, we're neurons, and we instantiate through these instant connections these hive mind, group think tribes that Marty said, "Hey, we're trying to reduce tribalism." So this is why they even exist, because instantly you can be a part of this and then be controlled by it without even knowing it, and it's lubricated by social media because now the neurotransmitters, like we get our dendrite receives the information from social media, we process it, we make a decision, we send it out. And what happens is whatever hive mind you're in has certain rules, and it is competing against other hive minds in a way that we're not even able to access. And so when you say something, Peter, like you say, "You know what? I don't think we should wear masks, and I don't wear masks," that particular hive mind that says, "You know what? Masks are important. We're liberal in our political ideology, and these are the rules of that," will say, "Okay, we recognize here an impuritor who left to go to Texas, which is a sign of disloyalty to this particular hive, and he's not saying the right things about masks. Therefore, he is absolutely evil outsider, must be stopped." And the people who are acting as the neuron in that network don't even know they're doing it. They actually believe this b- until they really introspect or they talk to you in person or something happens that breaks the spell. But I think that's what's happening. So the Malones of the world are captured by the antithesis group think hive mind. The, say, Faucis, Eric Topols of the world are more captured by the thesis hive mind. And who are we in this l- alt- middle corpus callosum hive mind? We're hated by everyone. That's my thinking on it.

    25. PAPeter Attia1:57:57

        Well, I will say this: some of the messages that meant the most to me were, "I have been morally opposed and opposed in every manner to getting vaccinated until I heard this podcast. I actually think I might get vaccinated now." That's worth all the hate mail in the world. And by the way, the, I don't think the purpose of these podcasts is to, hey, let's make sure we figure out a way to get everybody vaccinated, right? It's how about we give people the information so they can make the best decision in their best interest? But when someone says, "A buddy of mine who's the most anti-vax human being in the history of civilization just got vaccinated because of that podcast," I think, wow, that's fantastic. There is hope that information can trump fear.

    26. ZDZubin Damania1:58:36

        I get the same thing, and I'll say this, that I get a lot of criticism from v- hardcore vaccine absolutists in my messaging saying, "It opens the door. You and Marty Makary and Vinay Prasad and Peter Attia and Monica Gandhi open the door for people not to vaccinate. It's criminal, and you shouldn't do it. And making videos that say vaccinate and chill is irresponsible in the setting of Omicron that's killing so many people," and so on and so forth. And it, again, I just feel that hive mind's rejection, whereas we're seeing the outcome, which is people are actually making reasonable decisions based on information that's non-judgey and non-shamey.

    27. MMMarty Makary1:59:08

        Why I think you were effective in convincing that person to get vaccinated or the discussion was-

    28. PAPeter Attia1:59:13

        I, I don't think it was me. I think it was just the podcast, to be clear. It wasn't anything I did per se.

    29. MMMarty Makary1:59:17

        I think it's the honesty. I think people are starving out there for honesty on this topic that's not tribal. It's not an allegiance to a party line on what we have handed down to us as an edict. I think it's this very genuine humility around the data and a virus that changes and evolves, and we have to change our thinking in real time. So I personally think people are starving for honesty out there and data. And I also get millions of comments and emails, and most of them are, you know, thank you, but like all of you, I can't keep up, and we've had these conversations offline. But the one email or the one inquiry that I will actually carve time out of my day to have a conversation with is somebody who is on the fence about getting vaccinated. Spending time and just explaining things with a non-judgmental approach. By the way, we've been doing this as physicians our whole careers. We don't mandate somebody does dressing changes.

    30. PAPeter Attia2:00:18

        That's right. We don't mandate Whipple procedures for patients with pancreatic cancer.
14. 2:01:53 – 2:11:12

    Treatments: Monoclonals, Fluvoxamine and Convalescent Plasma

    1. PAPeter Attia2:01:53

       So let's get back to some fact-based insight for people. Where are we, Marty, on monoclonal antibodies as a therapeutic option? So let's come back to early 2022. Everybody's getting Omicron. Some people are getting a bad case of it. Are monoclonal antibodies effective? If so, which ones?

    2. MMMarty Makary2:02:12

       So two out of the three only work on the Delta variant, and by the way, the people over the last few weeks who have been showing up in the hospital in deep trouble medically tend to be heavily skewed towards the remaining Delta variant. Now, if the CDC estimates are correct, Delta is 1.7% of new cases As of January 14th or so. That tells us that the influx, the sort of the ongoing damage that this is causing in terms of severe illness, is really letting up right now just by the dominance of Omicron. So we only have one monoclonal that really works well, sotrovimab. It's a GSK Vir Biopharmaceutical product. It's a monoclonal called sotrovimab, and that's the only one that really works well on Omicron. But if Omicron is as mild as we're seeing, that tells us we should be using it selectively in high-risk individuals. We don't do a good job of that in healthcare. We can barely hold back throwing the kitchen sink at people, even when it's excessive. I mean, it's just a general pattern, and so what you're seeing is these industrial strength big guns like Paxlovid and sotrovimab are being used in very low-risk people, sometimes people with wealth and power and access that tend to get... And that's where we need to say, "Hey, wait a minute. We have all these tools in the toolbox. Let's use them selectively and wisely based on somebody's individual risk."

    3. PAPeter Attia2:03:40

       And any emerging data on the efficacy of fluvoxamine against Omicron specifically? Because obviously the Lancet trial, the Jama trial were all in Delta. Anecdotally, do we know anything, or has there been any way to update that insight?

    4. MMMarty Makary2:03:55

       The only thing new is some new data on lunacy at the NIH, because they wrote a summary of fluvoxamine where they described its benefit and impact on reducing hospitalizations and survival, and concluded at the end of it that there was insufficient data to recommend it, which was a conclusion that should not have been derived from that summary. So unfortunately, now you have this sort of militaristic, everyone just falls in line mentality in medicine by some physicians. Now, many of them are creative and smart enough, and they're like, "Hey, I read the studies. The reduction is dramatic. Just because there's not an official authorization around it at the FDA, I'm gonna use it for my patients." Those are the doctors we hear from. Those are the doctors saying thank you, and that's, by the way, a lot of doctors, maybe most. And then there's some that just say, "Well, the CDC doesn't say it t- for me to use it," or they say, "The NIH is not officially endorsing it." So they're up against that. Now, the people who did that study have told Zubin and I that they're close to what they believe might be some good news at the FDA around an authorization. That's just a gestalt, and it's not insider information. But unfortunately, this is a drug that has reduced mortality among people compliant by 91% in high-risk COVID patients, and we still have very little awareness around it. As a matter of fact, there was a paper that just came out on the preprint that showed, it was a survey of doctors saying, basically, when you get somebody with COVID, what do you recommend to them? What they said was kinda pathetic or sad. It was vitamin D, vitamin C, zinc, and something else that has no evidence really behind it. Now, maybe there's some value to vitamin D, who knows? But I mean, that's it? I mean, no discussion of convalescent plasma, which now in concentrated form reduces hospitalizations by 50%. That's been around, by the way, for two years. No mention of fluvoxamine.

    5. PAPeter Attia2:05:47

       Let's tell people about that. So convalescent plasma was talked about immensely in March and April of 2020, when we truly had nothing on the horizon, and then it kinda went away, and I don't know if it went away because it didn't have efficacy and it was demonstrated, or because we finally got monoclonal antibodies later that year. First of all, tell people what convalescent plasma is, and talk a little bit about it as a therapeutic.

    6. MMMarty Makary2:06:16

       So I'm just close to it because the authors of that study on convalescent plasma early on put a piece in MedPage Today, and I remember talking to them. So this was an, an exciting development. Convalescent plasma is the plasma from someone who recovered from COVID illness. That's what convalescent means. It means they've recovered. And so the plasma is not the red cells. It's not red in color. It's other fluid that the red cells circulated in your blood system, and that plasma contains antibodies. So basically what you're getting is you're getting infused a partially intact immune system. That is, you're getting infused real antibodies. And essentially, monoclonal antibodies that pharma companies make is the same thing. They're just antibodies made in a laboratory, and they tend to be all one type, hence monoclonal, as opposed to polyclonal antibodies. So in the convalescent plasma, you're getting a more diverse antibody profile. Arguably, that's better for the reasons Monica just laid out. So there was a lot of enthusiasm around it. It's been used, by the way, for a century. I mean, there's stories from people getting infections from gunshot wounds in war getting convalescent plasma, and so there's a lot of experience with it. It was the f- one of the first levers the medical community reached for when COVID hit us. And so people were getting it, and there was a benefit, but the benefit was small. I think it was, uh, reduced hospital stays from, like, 13% to 9% or something like that. So what you had was an announcement by Trump administration officials that had a lot of enthusiasm, and they used the term, head of the FDA at the time said there was an absolute risk reduction, and the technically proper term is a relative risk reduction. So people who may just hate the administration or hate anything that comes out of it just pounced, including in the medical community. They pounced, and this is a unfair representation of the data, and they just went... So there was this sort of backlash. It was, in part, in my opinion, politically driven. So then you, you didn't get a lot of attention around it. There was sort of this confusion, and the head of the NIH, Francis Collins, was asked to weigh in on convalescent plasma, and he said, "We need a randomized control trial," which is, in my opinion, kind of a cop-out. Here we had strong data in a non-randomized fashion, because they were telling people, "Hey, we've got this. Do you wanna try this on a trial?"

    7. PAPeter Attia2:08:39

       By the way, in his defense, I think that's a totally reasonable answer, even if done in parallel, right? It's like we should have an RCT of this stuff.

    8. MMMarty Makary2:08:47

       Yep, we should, but what he did is he threw water on any sort of interest in using it clinically. It w- a lot of it was in the sort of the news media distorted, but I agree. So then you had pharma companies basically saying, "Hey, we're making antibodies. Why use convalescent antibodies?" But there just wasn't enough to go around, and convalescent plasma fell to the wayside. Now, the authors of that study had told me, "Hey, we're not using this therapy. It's only 40 bucks. No pharma executive gets rich off of donated plasma. We need to start talking about this more." Well, around that time, another study, another study critical came out and said, "It doesn't really work hardly as well as the original trial showed." Now, I reached out to the study authors of the first trial that showed a benefit in The New England Journal, and they said that study was flawed, the design was flawed. "We need more research, and trust us, it's coming," and they were very frustrated. So they eventually published a study that came out very recently that looked at concentrated convalescent plasma, concentrated suggesting you're getting more antibodies in that infusion, and it showed a dramatic reduction in hospitalization, a reduction by 50%. Well-done study. Still, nobody talks about it. You don't hear about it much. It's, "Oh my gosh, can you believe there's not enough monoclonal antibodies from Regeneron?" Well, here's another therapy. It's not getting attention, the attention it deserves.

    9. PAPeter Attia2:10:14

       Is it safe to say that convalescent plasma presumably has a greater diversity of antibodies than a monoclonal antibody?

    10. MMMarty Makary2:10:24

        Sure, yes.

    11. PAPeter Attia2:10:25

        But we don't yet know how effective convalescent plasma will be against Omicron, but we know obviously for understandable reasons that at least two of the three monoclonals are not effective because presumably they're no longer binding to epitopes that are sufficient to kill the virus?

    12. MMMarty Makary2:10:43

        That's right. In general, when you are exposed to a virus, you get a more diverse antibody response or profile than you do with just a monoclonal infusion. There's two reasons why people think natural immunity is stronger and more effective than vaccinated immunity. One is you get a more diverse antibody portfolio in the response, and the other is the reason Monica alluded to, and that is natural immunity is based in the mucosa. It's more mucosal-based immunity, so it's more on the front lines of defense.

15. 2:11:12 – 2:30:36

    Evaluating Robert Malone's Claims

    1. PAPeter Attia2:11:12

       Okay, so therapeutics. Do we want to talk a little bit about Robert Malone? Tell folks who he is, Zubin, and why his name is on the lips of many, both disciples and non-disciples or those who, uh, want to banish him from the universe.

    2. ZDZubin Damania2:11:34

       Yes. Robert Malone is an interesting epiphenomenon, I think, of our division around this into these two churches of Covidian and Covidiot, and he's an interesting guy. He's definitely a scientist who was involved early on in some of the work on the mRNA technology in general, and in particular, wrapping that mRNA molecule in a lipid particle, in a fat particle that allows it to be taken up by cells. In that case, it was mouse cells looking at an HIV protein expression to work on a HIV vaccine, which it turned out didn't quite work out because it didn't generate an immune response, but the technology was there. So he was one contributor in a vast chain of contribution that actually led ultimately to where we are now. But his particular contributions and patents that he had had expired a while ago. He'd given up looking at that and had moved on into different directions on DNA vaccines and things like that. So he bills himself as the inventor of mRNA technology based on what I just said, where he is a small piece of this puzzle. But using that credibility and also the credibility of working as a consultant in different government entities and things like that, he makes a series of claims about vaccine safety that ultimately got him banned from Twitter, which got Joe Rogan's attention, and Rogan then gave him his platform to say, "Okay, if you're banned on Twitter, what are you saying here?" And so there are multiple claims that he's made, and I'll start by saying this. I think some of the things that he said that were correct are things like, A, you don't just give infinite boosters to people because that's not a good idea. That we already talked about earlier. He does question the financial incentives of pharma and different entities within healthcare to focus on vaccines, and I think that's not unreasonable. I think he downplays the point that there's lots of money in therapeutics, too. Those are the main things that I think establish his credentials as a heterodox thinker. Now, that's all. [laughs] And then every major point that he makes is fundamentally flawed, if not a parroting of an extreme anti-vaccine position on these things, and we can go through some of them unless you want to stop me and-

    3. PAPeter Attia2:13:50

       I'd like to go through some of them specifically. So maybe take them in kind of a point, counterpoint fashion, if you will.

    4. ZDZubin Damania2:13:56

       Yeah. So one of the things he says is that PCR is overestimating the number of COVID cases, and that it's not accurate. The truth is it is quite accurate. It's very sensitive, and it's quite specific. So that's just not quite right, and his point is, you know, we're over counting cases and so on.

    5. PAPeter Attia2:14:14

       Does he provide an estimate of the magnitude by which it's being over counted?

    6. ZDZubin Damania2:14:18

       I don't remember if he did, but I don't recall him saying specifically. He does make other magnitude estimates. For example, he says, "If we had just provided early treatments in the form of hydroxychloroquine, ivermectin, monoclonals, et cetera, it is a fact that we would have saved 500,000 US lives." And he provides no data to actually support this. That's, I think, an unsupportable claim based on information that we have, especially since there's not evidence that hydroxychloroquine and ivermectin actually do anything that's compelling. That's still being studied with ivermectin, but with hydroxychloroquine it was quite clear. He said that Hydroxychloroquine was shown to be active against the original SARS, but this is a bit misleading. The original SARS in vitro, they used chloroquine and it inhibited the virus in vitro, but there are millions of compounds that will do that. It was never shown to be anything beyond that, so that's a misleading statement. He then discusses that the spike protein that is used in current vaccines by Pfizer, Moderna, et cetera, was never tested for safety. Their spike protein was never tested for safety, but he then either is deliberately misleading or misunderstands the scientific process with this because that's what the clinical trials [laughs] with tens of thousands of people were doing, was showing, oh, the spike protein that we've coded for with this mRNA is safe and effective in a human population. So that's just not true. The other thing he says that's abjectly untrue is that there were no pre-clinical or animal studies on these particular vaccines or mRNA constructs, and that those are findable, they're all there. So that's just simply not true. Let me see here. There's a lot, he made so many claims. Pulling up some of them here. He made the claim that hospitals in particular are mischaracterizing COVID cases. Now, this is a claim that actually has some validity in the sense hospitals are paid more for COVID patients, this is true, so there is some incentive to code in a medical billing situation, up code this is COVID even though it may be like pneumonia or something else going on, MI, but he also has COVID. In the early days, they've kind of looked at this and it's not clear that that was happening, because to some degree there's a fraudulent component there, like that's just straight up fraud. So he specifically said there are gunshot victims being coded as COVID patients.

    7. PAPeter Attia2:16:40

       And by the way, that could be true if a gunshot wound patient has COVID, and if there's a greater financial incentive to take care of a COVID patient, you could do that. It would be unethical, I think it would be against the spirit of how one is to code, and I guess you could argue it could verge on fraud if the billing entities are rigorous enough to say, "Why was he admitted to the hospital?" and ask that question, right?

    8. ZDZubin Damania2:17:07

       Yes, that's exactly right. You nailed it. So it's fully within the realm of the possible, but I don't think in practice that it happens at a level where it would explain anything that would move the needle on the pandemic. And actually you can just look at excess mortality figures in the US to know that something is up. It's a combination of COVID and the peri-COVID phenomenon of our response to COVID and other things that COVID does.

    9. PAPeter Attia2:17:30

       By the way, what was the excess mortality in 2020? And do we have 2021 data yet? Absolute lives lost above and beyond 2019.

    10. ZDZubin Damania2:17:38

        I don't remember the excess mortality at the end of 2020, 'cause I'd done a show on this in the mid-2020s.

    11. PAPeter Attia2:17:44

        I looked at it in 2021, and I actually have the exact number so I, I almost don't wanna say because I'm sure I'm gonna bastardize it. I want to say it was close to 250,000 excess deaths in 2020 relative to 2019. But anyway.

    12. ZDZubin Damania2:17:58

        Got it.

    13. MMMarty Makary2:17:59

        Sorry, I've got the numbers here.

    14. PAPeter Attia2:18:00

        Okay, perfect.

    15. MMMarty Makary2:18:01

        477,000 excess deaths from March 1st to December 21st, 2020. So basically the 2020 number is 477,000, and 74% of them were due to COVID, that is match up with the COVID mortality.

    16. PAPeter Attia2:18:15

        So it was 400,000, 300 of which are COVID.

    17. MMMarty Makary2:18:19

        385,000 were COVID, 477,000 total.

    18. PAPeter Attia2:18:23

        Oh, okay, so half a million excess deaths. So you can't explain this with coding, if that's part of the argument, yeah.

    19. ZDZubin Damania2:18:29

        Well beyond coding. Now, some of it may be ancillary effects of lockdowns and so on, but some of it may be even undercounting of COVID cases, people just dying at home and not being diagnosed. So there's lots of different e- potential explanations.

    20. PAPeter Attia2:18:41

        This sort of begs a question which is were the people who disproportionately died people who were going to die within the next two to three years, and does that imply that there may be a reduction of death in 2022, 2023 when a lot of the people who were gonna die of natural causes, of heart disease, cancer, and things like that, the most vulnerable people who died in 2020 and 2021 basically died ahead of schedule, their lives were shortened by a year or two, and you'll see fewer people dying in '22 and 2023. Does that matter? No, but it's just kind of a curious epidemiologic phenomenon, right?

    21. ZDZubin Damania2:19:17

        This has been discussed actually quite a bit, particularly in online circles. It's this dry tinder theory that you took out people that were going to... They had a life expectancy, like you said, that was quite short, and all this did was knock them over. And we see this every winter in the hospital, like flu. That's why they say pneumonia is the old man's friend, right? Like, it's the final thing that in a very medically frail person. So again, what's the ramifications of it? I actually think it has this ramification in the sense that how much of the overall suffering under the curve was just expedited by a year versus how much is cutting off five years, 10 years of quality adjusted life years that's quite high. That then would justify or de-justify certain social policies [laughs] that we've put in place. So it's a good question. And I think relating to this, he, Malone, um, asserts that we don't have good vaccine monitoring at all and asserts that there are lots of vaccine injuries and damage that we are not counting. And he talks about VAERS, which is really a hypothesis generating system where anybody can report and so on, but he does not talk about PRISM or V-safe or the VSD, the Vaccine Safety Datalink. These are very robust vaccine monitoring systems that actually help to catch things like very rare events, like the vaccine-induced thrombotic thrombocytopenia of the Johnson & Johnson AstraZeneca vaccine. So I think that's quite misleading to say that. It's good that he's asking these questions, and I think people should ask questions about vaccine safety, but he's a little misleading here. Now, where he's directly misleading is he makes the assertion that the lipid nanoparticles from the mRNA vaccines are Concentrate in tissues such as ovaries, explaining things like infertility and menstrual cycle abnormalities in women. And the truth is he s- [laughs] the data he's citing is a rat study out of I think, I forget where, where they pounded these rats with super normal levels of this lipid nanoparticle mRNA, and they saw accumulations in various tissues, but no tissue damage, actually, and this has not been seen in humans. There are menstrual cycle abnormalities, so that's where he is correct, and NIH has actually funded studies on this, and what they're seeing is what women have reported, if we'd actually listened to women, that their menstrual cycles are abnormal for a cycle or two, either heavier, lighter, they skip a period. An Oregon study I think was preliminarily released with this funding actually showed that, yeah, this may be true at least for a period or two, but then reverts back. We have not seen widespread effects on fertility.

    22. PAPeter Attia2:21:42

        On that topic, Zubin, I remember the first one of my female patients to tell me this. She's an especially funny woman, and she said, [laughs] she said, we were actually, you know, it was actually in a social setting as well, so we weren't, like, in the, uh, office having this discussion. She said, "You know, it's really funny. It, it seems like I was stabbed in the vagina. Is that possible?" And I was like-

    23. ZDZubin Damania2:22:02

        Wow

    24. PAPeter Attia2:22:03

        ... "Yeah, say more." [laughs]

    25. ZDZubin Damania2:22:04

        [laughs]

    26. PAPeter Attia2:22:05

        And she's like, "Yeah." She's like, "Look, I've never had so much bleeding in my life," and that lasted for two cycles for her.

    27. ZDZubin Damania2:22:12

        Interesting. The speculation on why this may be has been rampant. Some of it is just with any infection with an immune response, there can be abnormalities in menstrual cycles, and it's that whole hypothalamic ovarian axis thing that I wish I understood better, Peter. I've never understood the lady parts. I'm gonna be fully honest. My wife will confirm this, but I think the fact that we take it seriously is important. So I'm glad at least Malone mentions it. He just mentions it in combination with just the wrong thinking. He mentions other things about ivermectin that are incorrect, like Japan recommending ivermectin for treatment of COVID. They did not. He says that the Chinese were using hydroxychloroquine to great effect early on and used that as an example of reason of why we should be using it. Simply not true. [laughs] So things like that along those lines.

    28. PAPeter Attia2:23:01

        And those are the types of claims that are difficult because you can't counter a negative. In other words, if someone says, "Look, I mean, it's been well known that the so-and-so hospital in China pioneered a study that then led to the mass adoption of this therapy," well, you can't search the anti-truth to that. Like, it's just, you can say, "Well, show me the data," but when someone's rapid fire giving you stat after stat after stat, it's very difficult to counter that.

    29. ZDZubin Damania2:23:30

        And this is why I think many people will not... They constantly want to debate. So Malone and others will say, "Well, we'll debate anybody," but of course we want our friend Steve Kirsch with us, who's funding some of this stuff, and Steve is known to do this. He will just throw out, "Well, what about this study? What about this? What about this data out of Uttar Pradesh?" When you actually have days to look at the data, you realize, wow, that's total bullshit, [laughs] but I, I could never have responded to that in real time.

    30. PAPeter Attia2:23:55

        Yeah, I've often thought that the only way to do a debate like that is to do it the way a court interacts, which is using a discovery, right? So you can't present evidence in court without the opposite side seeing the data in discovery, seeing the evidence in discovery, so that you don't get the surprises. You can surprise somebody with your interpretation or a question you're gonna ask. There can't be any gotcha moments with new data, and I've often thought the only way you could have an honest debate in any format, whether it's an Oxford style debate or otherwise, is to have everybody say, "This is the only data we're going to debate. Everybody can get as familiar with it as they want, and now let's talk about the opposing views and the opposing ways that we might interpret this." To me, that would be a much more honest way.
16. 2:30:36 – 2:41:34

    Exit Strategy, Scientific Freedom and NIH Influence

    1. PAPeter Attia2:30:36

       So if you guys have some time, there's still a few other things I wanna talk about, and one of them is what is the exit strategy? We talked about this a couple of weeks ago, which is it's always a good idea to have your exit in mind, whether you're talking about war, whether you're talking about an investment in a company, whatever it is you're doing, a vacation, you should always have an exit in mind. You should always have a plan for when you're gonna change this thing back to the new norm. So what's your reflection on that? I mean, I take some comfort in what Monica presented to us, which was that, hey, it might be the case that in the spring, colleges are gonna say you don't have to wear masks to sit in class anymore. That would be fantastic for young people, for every person. If airplanes, if the TSA and airlines say you no longer have to wear masks. Who's mandating that we have to wear masks in airports? I don't even know who that is.

    2. MMMarty Makary2:31:29

       FAA.

    3. ZDZubin Damania2:31:29

       FAA? Yeah.

    4. PAPeter Attia2:31:30

       Yeah, fair enough. Yeah, TSA. They're doing enough to us.

    5. ZDZubin Damania2:31:33

       [laughs]

    6. PAPeter Attia2:31:35

       So okay, like, do you guys think that in three months there will be no more mandatory masking anywhere in the country?

    7. MMMarty Makary2:31:41

       I think in a matter of a month or two, you're gonna have very low levels of Omicron around. Almost nobody left who's not already had it or strong immunity, and I think people are gonna be so giddy to move on that the fatigue is just gonna hit all-time highs and people are gonna turn the page, and I think you're going to see a sentiment really flip in most of the country. Now, if you remember, the opioid epidemic was nightly news every night, and we all were sort of in touch with it. And then overnight, in one day, the media shifted their attention, and it was almost as if within 24 hours people forgot we even had an opioid epidemic. And I think there's gonna be an even bigger flip pretty soon. It may be something distracting. It may be other news. It may be a concert in Central Park where people just finally feel liberated. It, it may be a landmark event, but I do think people are gonna shift their attention very soon when we get to very low levels of Omicron, which the UK and South Africa would suggest in a preview that that's about a month or two away.

    8. PAPeter Attia2:32:50

       Just to push back on that, Marty, we're gonna either have Omicron come back next winter or we're going to have Epsilon show up next winter, and presumably case rates will be high again and ... mortality and hospitalizations will be relatively low, but what will prevent us from backsliding into the state of panic?

    9. MMMarty Makary2:33:12

       Well, I think part of it's gonna be geography. I've really enjoyed my time in Florida during the pandemic. I feel like I'm just enjoying life. I'm a million times happier here. I don't have to get a colonoscopy to go into a restaurant in New York or anything like that. So I think people-

    10. PAPeter Attia2:33:27

        Think, think about all those missed polyps though, Marty. I mean-

    11. MMMarty Makary2:33:30

        [laughs]

    12. ZDZubin Damania2:33:30

        Yeah

    13. PAPeter Attia2:33:30

        ... there, there's a downside-

    14. ZDZubin Damania2:33:31

        Yeah, Marty

    15. PAPeter Attia2:33:31

        ... there's a downside to that

    16. ZDZubin Damania2:33:32

        It's, that's not very good public health messaging.

    17. MMMarty Makary2:33:33

        [laughs] So I think it's gonna be regional. I do think there's gonna be a big part of the country that's gonna say, "Hey, wait a minute, we could be looking at a new variant in the fall." There's gonna be respiratory pathogens circulating this fall, for sure. 10 to 25% of the public is gonna get some respiratory infection almost every year in perpetuity. That's the way respiratory pathogens work. So are we gonna put up a serious guard and have this sort of anxiety that we've had with the new variant of the fall or the following fall, but it's, we're definitely gonna see more variants, or are we gonna s- realize what Monica was describing, and that is the beautiful, amazing, gorgeous immune system of the human body, where adaptive immunity will increase our protection against future variants regardless of what they are? And I think there might be some anxiety, but at some point people are just gonna say, "I believe in the adaptive immunity."

    18. PAPeter Attia2:34:29

        So then what are the implications then for vaccine mandates? Where do we see this going? Let's put federal aside, so there's not gonna be a federal mandate, but states and employers, universities, where is that going to go? And look, he's become a bit of a meme, but let's look at Djokovic right now. I mean, the guy just got kicked out of Australia, does not get to defend his title in the Australian Open. I think there's two ways people are talking about this. One is the rules are the rules, you're not exempt, and I think that's a fair statement, right? If Australia has this rule and it applies to everyone, then it should also apply to the best tennis player in the world. Maybe the more important question is, is that a good rule to have, period? But I read a story today that said, look, he's not gonna be allowed in France, so he's not [laughs] gonna get to defend his title at the French Open. And if he's not gonna get to defend there, I mean, is he not gonna get to defend his title at Wimbledon? I mean, is Djokovic never going to play another major-

    19. ZDZubin Damania2:35:20

        [laughs]

    20. PAPeter Attia2:35:21

        ... because he's not vaccinated? To me, until this question gets resolved, there's no exit strategy. Where do we see this going?

    21. ZDZubin Damania2:35:29

        See, this is why we need to have these discussions, because what is the incremental value now of mandating vaccines? And Vinay talks about this a lot, Vinay Prasad. He says, "How many people are actually at risk of high complications, and of those, how many are unvaccinated, and of those, how many will mandates actually reach them?" And the answer is probably much less than you think. So instead there are these sort of shotgun mandates that affect a lot of people that really it matters much less. You have these epiphenomenon like Djokovic who now can't play, and we're polarizing society more along these, like, peri-religious lines. So at some point we just have to say what I think we've all been saying a little bit, and Monica is effectively saying, which is it's now an individual choice. You can vaccinate, you can wear a mask or not, and you can take the precautions that you need to, and Omicron will be the great equalizer that immunizes a lot of people, and we'll then be on the other side of this, where we don't need mandates and policy stuff. We have to have those conversations, but even opening your mouth about it is taboo within certain hive mind states. I think it also requires a degree of thick skin. Peter, you and I both have attested to being... It's a state of suffering having to even deal with this stuff because of the amount of craziness that we see. So we have to just thicken our skin and say, "No, but we're gonna keep talking about it," because what's the end point? What's the exit strategy?

    22. PAPeter Attia2:36:52

        I don't know why I find myself, we talked about this last time, having much more empathy for people who don't see eye to eye with me on vaccines, who are anti-vax. And even though I don't agree with them scientifically and I don't agree with the facts that they cite in some circumstances, if not most circumstances, I'm curious as to what it says about me as a person, good, bad, or indifferent, that I can't imagine that you would force somebody to get a vaccine in this situation. I reserve the right to say maybe one day a pathogen will come along that is so deadly, for which there is no treatment, for which transmission is eliminated by a vaccine, and for which the vaccine is so incredibly safe, where I might change my mind. I might reserve the right to say, "You know what? We're gonna have to mandate this shit." But I can't say it with this fact set.

    23. ZDZubin Damania2:37:44

        What you just did, where you said, "This is what would convince me to do something," is a key thing. Because I think what separates your thinking, which is nuanced, from, say, a hardcore anti-vax person who's just that conditioned, say, or even a pro-vax person, is there is no situation. Like, if you ask Robert F. Kennedy Jr., "Is there any example that you have of a vaccine that's done some good?" And I was part of this documentary that he was involved, so I've seen this. It's not been released. He says something to the effect of, "I don't know if I can even point to anything." It's like, well, so there's nothing that would convince you. There's no status. That's tough. Then you're talking about a real belief-based thing instead of a, like you said before, Peter, strong convictions loosely held. Like, what would dislodge that conviction?

    24. MMMarty Makary2:38:27

        I think when you know how the sausage is made, when you see the decision-making at, say, a state government level that is requiring a 25-year-old forest ranger to get a booster who's thin and already had COVID, and you see the absurdity of how they've brushed over the data, how there's this bandwagon effect, how the leadership has been dismissive of some of the data and cherry-picking other da- When you have that back knowledge, that's what makes it particularly difficult to watch, to address your point, Peter, because you see intrinsically this attitude of, "You're stupid. Don't ask questions. Just do it." And it's like, hey, wait a minute. That's not how I'm wired. So I do worry about another pandemic that has a case fatality rate not of two-tenths of 1%, which is probably retrospectively what it's panning out to be with COVID, to an infection with a f- case fatality rate of 5%. Spanish flu had a case fatality rate of 2%. Ebola has a case fatality rate of 50%. What happens when we get a virus with a case fatality rate of truly 10%, as we were worried about from the early reports of China, and we are acting like this sort of dysfunctional tribal big tech censored. I mean, we might be hosed. [laughs] I mean, we've got to have an NIH that responds in seven days with bedside clinical trials to tell us what's happening, what works, what's effective. We cannot be ignoring some therapeutics and parading around others. I mean, we've got to have a completely different mindset.

    25. PAPeter Attia2:40:03

        This is gonna be an unpopular and charged question, but I guess we can talk about it. What are the ethics of having the people at the top of the NIH be both in charge of funding any academic in this country, and yet also being the arbiters of what is appropriate to be said and not to be said? I've spoken very privately with people who have shared this middle ground view, who have said, "I am not permitted to speak about this. I am told I cannot speak about this, or I will lose my funding, and my entire career is based on what the NIH gives me, and I've been told explicitly, by the way, not implicitly. I have been told explicitly by my department chair, if I ever say anything that counteracts the narrative of the NIH, I will lose my funding." So we think about all the careers that are being ruined. This person that I mentioned who got fired in November for not being vaccinated from a very prestigious university. Talk about the Djokovic's of the world. This is a guy's legacy who could be altered by this. And then you talk about people who are now being silenced and not permitted to say anything that is at odds with the narrative of their funder. I mean, that's very problematic to me, especially within science. Science has a currency of objectivity. It's taken the single most precious currency and said, "Let's put that in the closet."

Episode duration: 2:53:03