The Peter Attia Drive - #189 - COVID-19： Current state of affairs, Omicron, and a search for the end game

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

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00:00:41.780 head over to peteratiyahmd.com forward slash subscribe. Now, without further delay, here's

00:00:48.140 today's episode. Welcome to this week's episode of the drive. This week, we have two guests

00:00:55.260 simultaneously being interviewed, something I don't do often. My guests this week are Dr.

00:00:59.360 Marty Macri and Dr. Zubin Damania, aka ZDoggMD. Both of these are close friends of mine who have

00:01:05.760 also both been previous guests. Now, I wanted to have Marty and ZDogg back on to talk about COVID,

00:01:11.400 which is not something I've done a podcast on in some time. In fact, when I did my last podcast on

00:01:16.200 COVID, I really thought that was kind of the end of it. And I was sort of done talking about COVID

00:01:19.900 publicly. I would obviously continue to stay as up to speed as necessary on all things relevant to

00:01:26.060 my patients. But I really was kind of done with talking about COVID policy and things like that.

00:01:30.040 But truthfully, in the past, I would say, month, I've become a little bit frustrated with what I've

00:01:34.820 seen around kind of shoddy science and even worse messaging around COVID. So I thought it was time to

00:01:39.040 revisit this. So this episode, we talk about a bunch of things. We talk obviously about Omicron and

00:01:43.780 what's known and understand that these podcasts are always dated, right? So the date of the recording of

00:01:47.840 this podcast was Monday, December 27th. And by the time this podcast is out, that's already been a

00:01:52.720 week. Three months from now, we'll know things we don't know today. That's just the nature of things.

00:01:56.400 But nevertheless, we talk about what is known today about Omicron. We talk about what we understand

00:02:00.600 about vaccine, both benefits and risk, focusing on the mRNA vaccines here and specifically looking at

00:02:07.400 the differences between Pfizer and Moderna, especially in the subset of young people and further

00:02:13.540 stratifying that by gender. We also talk about natural immunity, something that seems to be a

00:02:18.800 very taboo subject matter, but it's a very important thing to discuss. We also spend a lot of time trying

00:02:24.120 to explore the, what is the end game here? What is it that we're hoping to achieve from a policy

00:02:30.440 perspective to get to living in a world that looks more like it did in 2019? Is that even going to be

00:02:37.060 possible? What is the difference between a pandemic and an endemic? So this is a very conversational

00:02:42.680 interaction. It's partly an interview, but really in the end, it kind of is just a discussion between

00:02:47.560 the three of us. Just by brief way of background, Marty is a Johns Hopkins professor and public health

00:02:52.460 researcher. He's served on the faculty of Hopkins at the School of Public Health for the past 16 years

00:02:56.620 and served in leadership at the WHO. He's a member of the National Academy of Medicine and serves as the

00:03:00.620 editor-in-chief of the second largest trade publication in medicine called MedPage Today. He also

00:03:05.680 writes for the Washington Post, the New York Times, and the Wall Street Journal. ZDogg is a UCSF

00:03:10.780 Stanford trained internist and the founder of Turntable Health. He's also the host of a very

00:03:14.940 popular podcast, ZDoggMD podcast, as well as the co-host of an excellent podcast called the VPZD

00:03:21.820 Show. And that's with Vinay Prasad, who by the way, has also been a guest on this podcast. And we

00:03:27.120 reference Vinay here. In fact, I would have loved to have had Vinay on this podcast as well, other than

00:03:31.920 the fact that it would have been pretty cumbersome to have four people on a podcast. Final thing to note

00:03:36.000 here is that because we recorded this on December 27th with the aspiration of getting this out as

00:03:41.280 quickly as possible, our video team was not in town. So we did not do this on video and we don't

00:03:47.780 really have the staff this week to put out show notes. So we're doing this to be as quick as

00:03:53.200 possible and responsive as possible to some of the questions that many of you, I suspect, are asking.

00:03:57.280 So I hope you'll accept our apology that this will be an audio-only podcast and there won't be

00:04:02.000 show notes beyond just a number of references. So without further delay, I hope you enjoy my

00:04:06.040 conversation with Marty, Macri, and Zubin.

00:04:13.700 ZDogg, Marty, so awesome to be sitting here with both of you. As you know, not a topic I have been

00:04:20.060 spending much time on, certainly publicly. Obviously, anyone who's taking care of patients has to be

00:04:25.960 paying attention to what's relevant to them. So that's permitted me the luxury, I think, of being able

00:04:31.800 to offer my opinions to patients, my interpretations. But I did feel a need to go a little bit deeper in

00:04:37.800 the past few weeks and thought I'd reach out to you guys and we could do this as a discussion

00:04:42.060 because you guys have been spending a heck of a lot more time on this than I have. And in the last

00:04:46.100 five days, I've been drowning in this substance. Luckily, I have wonderful analysts who have been

00:04:52.720 able to organize information for me. But anyway, let's just start with helping me understand and the

00:05:00.320 listeners understand kind of what we know and don't know. And one of the ideas that we had talked

00:05:03.780 about at the outset, which I think you guys agreed was a good thing that we can try, is for the

00:05:09.320 listeners, helping people differentiate between what we believe is fact or what is knowable and

00:05:14.820 then what is opinion. Because I think we're going to very easily go back and forth between those two.

00:05:19.580 And I think people expect that, right? On some level, people want to hear our opinions,

00:05:22.480 but I think they also want to know when that's separated from fact. So hopefully between the three of us,

00:05:26.940 we can always kind of remember which of those pillars we're playing in. But what I'd like to do

00:05:33.340 is kind of start with some basic questions for you guys. So we're recording this on the, what is it?

00:05:40.540 The 27th, right? And obviously a lot of what we're talking about is in flux. Part of what's prompting

00:05:46.120 this is Omicron being a new surge. What do we know about this virus, this particular mutation,

00:05:52.520 and how it differs from Delta? And do we want to call the original one alpha or OG or what do you

00:05:59.140 guys call that? First of all, great to be with you, Peter, and great to see you again here, Zubin.

00:06:04.220 So I think we can compare Omicron to Delta because Delta represents sort of the worst of the previous

00:06:10.280 strains. And now we've got some pretty good laboratory data that tells us that Omicron is

00:06:16.220 not infecting lung cells, neither lung individual cells or what we call organoids in a lab, which is

00:06:22.880 a cluster of similar tissue types at the same efficiency. It's about 90% less efficient in

00:06:30.320 replicating in those lung cells. So we've got laboratory data now confirmed by three independent

00:06:35.540 labs that it's not infecting those cells as well. That's why we're not seeing the cough and the severe

00:06:40.000 disease and the systemic illness like fever as frequently with Omicron. We're seeing more of the

00:06:45.700 upper respiratory stuff, the nares, the bronchus symptoms. And by virtue of that, you're going to

00:06:52.340 blow it off more. And maybe that's one of the drivers of it being more contagious. But we've got

00:06:56.180 the laboratory data. We've got epidemiological data looking at South Africa, looking at the numbers down

00:07:02.940 now over 35% off their peaks. We've got a shorter length of stay there observed, about two and a half

00:07:08.540 days versus eight days. Hospitals were not overrun in a country with, you could argue, semi-limited

00:07:14.420 resources. And we've got bedside observation. So we've got epidemiological data, laboratory data,

00:07:20.100 and bedside data that all fits that it is, in fact, no longer an open question. This is a more

00:07:25.220 mild virus. And I guess one of the questions that I have around the mildness of the virus,

00:07:30.580 because there is also that I think it's that Hong Kong data that you're pointing at, that you have a

00:07:35.360 lot of upper airway replication, you know, some multifold over the OG strain and Delta. But this idea that

00:07:43.440 it's a milder clinical syndrome is a little complicated by the fact that in South Africa, you have a lot of

00:07:49.200 high seroprevalence of previous infection. And so the question is, how much of this is, we have now a degree

00:07:55.080 of natural immunity and some vaccine immunity in South Africa. And what you're seeing is a virus that's more

00:08:01.380 replicatable, maybe a little less pathogenic, maybe a little less disease, but in the setting

00:08:06.300 of a much more immune population. Because if you're looking at the kind of the three precepts of a

00:08:10.680 pandemic, it's a very transmissible virus that causes a lot of disease that we don't have great

00:08:18.040 immunity for. So those three things. And it looks like with Omicron, we have a very transmissible

00:08:22.020 virus that may cause milder disease that we have quite a bit of immunity to already. And so all those

00:08:28.120 things may collude to make this less of a problem than Delta in terms of what we care about, which

00:08:32.220 are actual outcomes. I mean, at the risk of asking maybe a naive question, is it still reasonable to

00:08:37.780 say that this is absolutely a COVID variant? Or at some point, will mutations of the OG strain

00:08:45.540 a la the Delta lineage get so far away from those strains, presumably in terms of virulence as one metric,

00:08:53.420 that we really ought to be thinking of them more as coronaviruses and not necessarily COVID-19?

00:09:00.560 Where would that line be?

00:09:03.740 Look, I think that is the ultimate question. Is COVID going to be the fifth seasonal coronavirus?

00:09:09.520 As I know you and Amisha Dalja had postulated early in this pandemic there, you know, as a reminder to

00:09:15.980 those listening for coronaviruses that circulate year to year, that account for about 25% of the cases

00:09:21.420 the common cold. This may be the fifth, and it may be in this version. Now, the Russian flu, which was

00:09:26.480 1889 to 1891, many are now postulating that that was a horrible pandemic of a flu season preceding the

00:09:36.100 Spanish flu. And that may have very well been a coronavirus that turned into one of those four

00:09:42.180 seasonal coronaviruses that we live with today. So we may have essentially a fossil of a previous

00:09:48.300 pandemic that mutated to a seasonal mild coronavirus, and it may be, in fact, one of those four

00:09:53.260 existing viruses.

00:09:55.360 Yeah, I think this dividing line is interesting, right? Because it really is, at what point do we

00:10:00.040 decide that's the case? Because, you know, a seasonal cold can actually kill somebody who's

00:10:05.380 medically fragile with comorbidities. We see it every winter. As hospitalists, we admit it's an impending

00:10:11.800 sense of doom. It's like winter is coming. Every time in October, we know that just standard flu,

00:10:18.580 standard seasonal cold, the coronavirus stuff that we already have, the adenoviruses, even RSV in

00:10:23.640 adults can cause a very nasty syndrome if you have a lot of comorbidities. And it fills up our hospitals

00:10:29.940 because the hospitals operate at capacity. So at what point is where we are now considered very

00:10:35.340 different from that? And that's a really operative question. Another interesting question, and again,

00:10:41.180 we're clearly now in the editorial phase, but we'll, again, we'll come back to some data later. But if you

00:10:45.880 were thinking about this through the lens of evolution, Omicron would be by far the best of the three so

00:10:53.840 far. Like if you're putting your virus hat on and you're saying what's in the virus's best interest, you have

00:11:00.440 the perfect virus. It is highly communicative and not lethal. And in fact, like the worst viruses are

00:11:07.860 the ones that are a little harder to spread and kill their hosts. So is there any evolutionary argument

00:11:13.500 to suggest that it's, we would expect this to be the evolution of the virus, that it's, as it gets

00:11:20.780 more evolutionarily fit, it should be killing people less and it should be spreading more?

00:11:25.980 It seems that that makes evolutionary sense on many levels. And actually, if you compare it to

00:11:30.860 SARS, the OG, the SARS-1, SARS-1 seemed to have a little higher case fatality rate, affected a

00:11:36.800 different swatch of people. But the way that it spread, you could detect it symptomatically when

00:11:42.500 it was contagious. And when you were asymptomatic, you weren't contagious. So we were able actually to

00:11:46.700 stop that virus through behavior restrictions, testing for people with what we consider now to be

00:11:52.000 hygiene theater pointing a, and this is editorializing, pointing a temperature gun at

00:11:56.500 somebody's head back then may actually have worked with that. But if you look at then the success of

00:12:01.320 the virus, that wasn't a very successful evolutionary virus. Whereas this one, oh boy, spreads when it's

00:12:05.800 asymptomatic, causes severe disease just in typically more vulnerable people. But there's so many people

00:12:11.880 that are vulnerable that you end up causing a pandemic level of drama. But as you start to evolve

00:12:17.660 it to Omicron, where man, it spreads so fast that everybody pretty much has a date with, you know,

00:12:23.960 Omicron at some point, but it causes less severe disease, we think, based on the data that Marty's citing

00:12:29.820 and emerging information. Well, that's a very successful virus, and that virus gets rewarded by being part of

00:12:35.720 the pantheon of our seasonal biome that affects us every year. And I think it would be very unsurprising if

00:12:42.100 that's the MO of evolution in this case. I like the temperature gun reference. For some reason,

00:12:47.580 those temperature guns scare me as much as a... But, you know, it may be that Omicron is nature's

00:12:57.400 vaccine. It is far more mild. And for the 93% of the population living in poor countries in the world,

00:13:04.260 they don't have access to a vaccine right now, and it's going to be very difficult. So

00:13:07.720 a lot of people out there are going to get vaccinated essentially by getting Omicron.

00:13:14.540 And it's ideal to get the vaccine over getting the infection, but it may be sort of a silver lining

00:13:20.980 of this variant, and it may be how a pandemic ends. We do know from a Johns Hopkins study that's now on

00:13:27.040 the preprint server that your T cell immunity, which is the most under-recognized part of the immune

00:13:33.760 system in the entire COVID discussion. That is still solid against Omicron, just as it was against

00:13:39.760 Delta. That the crossover is very high, and that if you get Omicron, you've got T cell immunity to Delta

00:13:46.940 and vice versa. That's now pretty... Can I jump in here on something? Because I'm glad you brought this

00:13:52.980 up, Marty, and I suspect both of you will have a lot to say on this. Everybody's heard the expression,

00:13:58.240 what gets measured gets managed. What we can measure, we tend to fixate on. And unfortunately,

00:14:05.260 when it comes to measuring immune strength, we really have one tool in the toolkit, which is to

00:14:11.260 measure circulating antibodies, which are not the same as neutralizing antibodies, which are part of

00:14:17.680 the B cell immunity. And then you have this other thing that you've alluded to, Marty, called T cell

00:14:22.400 immunity. I don't think we need to go into it in great detail. I did a podcast with Steve Rosenberg that

00:14:26.600 was cancer-focused, but we had a totally in-depth discussion on B cell versus T cell immunity. So

00:14:31.640 we'll send people there if they want the primer on it. But the upshot is we don't have a laboratory

00:14:39.000 test to measure T cell immunity. We don't even have a commonly available test to measure neutralizing

00:14:44.860 antibodies. We just measure circulating antibodies, so we can't really even measure what memory B cells

00:14:49.620 are doing. Do you think that's a little part of the problem here in that we're kind of flying

00:14:55.940 blind and making a lot of assertions about immunity based on arguably the least important

00:15:02.380 thing that you could measure? And again, I'm editorializing in my question a little bit,

00:15:06.040 but what do you guys think of that or push back on that if you think that we're undervaluing

00:15:10.800 circulating antibodies?

00:15:12.480 I definitely think that we are undervaluing circulating antibodies and cellular immunity as a

00:15:19.440 broad group. That is the memory B cells, memory T cells. Listen to our public health officials

00:15:23.720 from day one. They talk about the antibody levels jump up and then we see them go down. And then

00:15:30.040 initially there was a fear of reinfection. Well, we didn't see it clinically at the bedside. Then

00:15:34.220 when the vaccines came early on, they said, you know, you really have to get that second dose

00:15:39.200 because look at the antibody levels just go up tenfold of what they go up after the first

00:15:44.340 dose. Well, that's good, but it's good for activating your memory B cells and memory T

00:15:48.820 cells. It's good for the cellular immunity. Antibodies come and go. That's in the textbooks,

00:15:53.060 right? They linger for months in the system and then they wane. And by having this intense fixation

00:16:00.620 on only one aspect of the immune system, and that is antibody titers, what we have done is we've

00:16:07.440 created a scenario where we're chasing our tail to keep those levels high because when they're higher,

00:16:13.320 you're less likely to test positive. So what we have created, we've created this expectation that the

00:16:18.100 vaccine is somehow failing now when you test positive, even though that cellular immunity

00:16:22.480 is still strong and preventing severe illness. And it creates an almost a cascade of surrogate

00:16:27.480 markers that don't really measure what we're directly interested in, right? Because if you

00:16:31.520 have the surrogate marker of, okay, neutralizing antibodies, then that's trying to treat a surrogate

00:16:36.220 marker of cases, PCR positive cases. But what do we really care about? We care about people in the

00:16:42.700 hospital filling up the hospital, sick, dying. Maybe we can say long COVID is in that question

00:16:47.840 mark of things we care about. And so how do we really look at that? I think what Peter's

00:16:52.540 question really points out is, do we have good measurement criteria to look at, are we actually

00:16:57.700 immune against severe disease? Which is that sort of innate memory response that as antibodies

00:17:04.040 wane, you still are able to mount this, which means, hey, you're still going to get cold and

00:17:08.220 flu symptoms. You're still going to potentially be infectious during that period, but it's not going to settle

00:17:13.140 into cytokine storm ARDS and being proned in a ICU ready to die. And that's what we care about.

00:17:20.580 And I agree. I don't, I, you know, we talk about things like T-cell detect, which I actually don't

00:17:24.360 know much about. It's one of these, you know, commercially available tests. I don't know if

00:17:27.560 Marty knows more about it, but I really don't think we have good outpatient commercially available

00:17:32.920 tests outside of research that measure these things.

00:17:35.660 I mean, in the study that we're, and I'm not really that involved. I mean, I was involved in

00:17:41.040 some of the planning of it, but there's a study that's going on at the University of Indiana right

00:17:44.700 now. And it's specifically looking at long-term B-cell and T-cell immunity. And in speaking with

00:17:50.940 the investigators there, I mean, the assays to measure that degree of function are quite complicated.

00:17:56.720 I mean, these are not things that are amenable to commercial testing with any rigor. So I, I do feel

00:18:01.560 pretty confident in saying that we don't really have the tools to measure those things. And I

00:18:07.000 forget who, who I heard say this, but I'm paraphrasing somebody. They said, measuring circulating

00:18:11.880 antibodies and saying, you know, everything about a person's immunity is sort of like looking in a

00:18:17.860 person's bank account and saying, you know, everything about their net worth. It's probably

00:18:22.540 correlated, right? But you know, especially with a wealthy person, like the, their checking account

00:18:28.420 is really not representative of their net worth. You know, their checking account probably doesn't

00:18:33.440 have zero dollars in it. They're probably not overdrafted, but it's unlikely that a billionaire

00:18:37.980 is going to have hundreds of millions of dollars sitting in a checking account. So I think that's

00:18:43.420 sort of, to your point, both of you, I think created a series of metrics that are problematic,

00:18:50.820 especially when I haven't heard a clear articulation of what the end game is, right? So this is now a macro

00:18:55.860 question, right? Which is, I had to go out somewhere today and it's actually pretty unusual for Austin

00:19:01.700 because Austin really doesn't care about masks or anything like that. But I was surprised. I went in

00:19:05.500 and the woman said, you know, she took my temperature. And so I got the temperature gun in the face. And

00:19:10.540 then she said, oh, you know, we're, we're, we're wearing masks. So she handed me a mask. And, you know,

00:19:14.600 I don't, I don't argue with people over that kind of stuff because I feel like it's, this is just,

00:19:18.740 that's her pay grade, right? Like that's her job to tell me that fine. I'll wear a mask and whatever.

00:19:22.240 But I keep thinking like, well, what's the end game here is the implication. Cause if you're

00:19:26.920 making me wear a mask now, shouldn't it be implied that you're going to make me wear a mask forever?

00:19:32.420 Cause how do you extract yourself or walk back from this position of temperature gun mask,

00:19:38.960 you know, et cetera. So when it comes to what is the end game, what can we all agree is a reasonable

00:19:45.720 line in the sand beyond which the world goes back to 2019. I'm having a hard time understanding that.

00:19:53.120 So, so what do you guys understand with respect to that?

00:19:55.660 You know, from my end, so much of it, Peter is an emergent property of how we're measuring stuff.

00:20:01.360 It's actually the question that you asked in the beginning. It's like, if we care about

00:20:04.340 cases and neutralizing antibody levels, then it's going to be an infinite number of boosters

00:20:09.540 and masking into perpetuity. And even though the data is very questionable on all this stuff,

00:20:14.820 we keep doing it. This is a policy question. How do we want to be in the world? How do we want to

00:20:19.620 live our lives? What's the difference quantitatively and qualitatively between 2019 before we had this

00:20:26.180 pandemic, but we would have severe flus that would overwhelm hospitals in the fall and certain places

00:20:31.760 would go on divert. And we've all worked, you know, I've worked in those facilities when that

00:20:35.740 happens. It sucks. Every medical person grinds their teeth and gnashes everything, but we get

00:20:42.040 through it and we don't disrupt society. We certainly don't close schools. We don't inflict

00:20:46.060 masking on the public because we would never think to do that as a policy. So this is really a policy

00:20:52.340 question. How do we want to be in the world? And I think that's where all the division that's been

00:20:56.700 sown on social media through mainstream media, alternative media, you know, all this disinformation,

00:21:02.980 misinformation, I don't even know what that even means anymore, has created an environment where

00:21:07.460 we're so atomized by tribe that even the policy questions become tribal identifiers. So we need

00:21:13.740 to kind of really see that clearly from a perspective of a more holistic, you know, integral perspective

00:21:19.800 where we can go, okay, this is what's happening. All right. Well, what do we really care about? We care

00:21:23.980 about people not dying, not filling up hospitals, and we care about our economy working because health

00:21:29.240 actually is correlated to wealth, which is correlated to longevity. I mean, these are things that are

00:21:34.180 clear socioeconomic status. Education matters for that. So this is how we have to look at policy,

00:21:39.660 not a reduction as to how many cases can we prevent. And I think there's political stuff here that

00:21:44.300 happens, and it just becomes a complicated mess. Can you imagine, guys, if we tested for influenza

00:21:51.580 every flu season when, say, four years ago, we had 41 million flu cases in a matter of a couple months?

00:21:58.240 Can you imagine if we graphed on a daily basis the number of newly diagnosed flu cases and we'd

00:22:03.940 create mass hysteria? Now, it doesn't mean we blow off flu or we don't take it seriously or we don't

00:22:09.340 tell people some reasonable strategies like if you're around someone vulnerable, be careful. If you think

00:22:14.540 you've been exposed, wear a mask. If you have symptoms, stay home. I mean, that's kind of how we

00:22:20.300 live with a respiratory pathogen. 10% to 25% of the population will get infected with a respiratory

00:22:27.880 pathogen every year in perpetuity because there's a whole bunch of them. There's rhinovirus and

00:22:34.540 echinovirus and influenza and parainfluenza and the four coronaviruses we talked about.

00:22:40.760 If a parent brought their kid in, say, for their newborn evaluation, the first pediatrics visit,

00:22:47.020 and the pediatrician said, your child will develop five to seven pediatric respiratory infections

00:22:54.360 during their childhood. I mean, you could blow that up into a headline, but the reality is we're not

00:23:07.320 going to eradicate pathogens from planet Earth. Real quick, Peter, you mentioned something about

00:23:11.640 we're talking about the antibody titers and sort of chasing our tail. This just came out a day before

00:23:17.220 Christmas. From Britain, from the UK now, this is from the UK Security Agency. They're pulling the

00:23:24.000 data. They've got great data. So the vaccines, as they have had them with the primary series,

00:23:30.480 are 70% effective against symptomatic COVID. 10 weeks after a booster, it goes down to 35% for Pfizer and

00:23:40.800 45% for Moderna. So within 10 weeks, you're seeing even the booster wear off against your ability to

00:23:48.580 test positive or have a symptomatic case. But those memory B cells and T cells are still working. The

00:23:55.880 cellular immunity is still protecting against severe illness. So if we keep chasing antibody titers,

00:24:02.040 you might be getting a booster every first Monday of every month when you show up at work,

00:24:06.360 and it still won't work. I was thinking about something this morning, guys, that I thought

00:24:11.060 could help us kind of anchor a little bit into the evolution that we've undoubtedly all experienced.

00:24:18.440 So if I think back to March of 2020, I actually pulled my kids out of school about two weeks before

00:24:27.280 the lockdown. So two weeks before this got kind of insane, I was like, you know what? I don't know

00:24:32.640 anything about this virus. I don't like what I'm seeing outside of the United States.

00:24:37.100 We're going to keep our kids home. Oh, my daughter was furious. How could you do this to me?

00:24:41.440 Blah, blah, blah, blah, blah. So I look back at that and I think that was the wrong thing to do

00:24:46.200 because it didn't matter, but I didn't know better. And I think it was a reasonable precaution in the

00:24:52.560 absence of any information, right? Like if this turned out to be as bad as SARS-1, meaning it was as

00:24:59.860 lethal as SARS-1, but as infectious as SARS-2 would have been a good thing to do. Turned out it was

00:25:05.060 overkill. So I was thinking about like how many times has my view of this problem changed? And

00:25:11.820 the answer is many. And I think part of it comes down to a framework around what tools do we have

00:25:19.340 at our disposal? And what knowledge do we have about how to reduce morbidity and mortality for

00:25:25.060 COVID? And I was thinking about this because the first time I delineated this was in the spring of

00:25:29.860 2020 and now when I do it today. So tell me if you guys would add to or subtract from this. So I

00:25:34.740 break it into three broad categories. The first is preventing infections. The second is treating

00:25:40.060 infections. And the third is providing supportive care for people who end up in hospitals. In the

00:25:45.720 preventing infections, you have two things, basically vaccines and behaviors. In the treating

00:25:50.560 infections, you would have existing drugs versus new drugs and then supportive care. So back in the

00:25:55.740 spring of 2020, we had no vaccines. We had behaviors, but we didn't know which ones were right versus

00:26:00.460 wrong. Being indoors, being outdoors, wearing this type of mask, that type of mask, you know,

00:26:04.760 we didn't know anything. Stand six feet apart, stand 16 feet apart. I mean, it was just a whole bunch of

00:26:09.200 made up stuff. On the treating infection side, we obviously had no new drugs, but we had a whole

00:26:14.740 bunch of existing drugs and there was a whole slew of ideas around, well, would this drug work? What

00:26:20.520 about, remember remdesivir? We talked about that so much. And then of course you had half these drugs

00:26:24.520 became totally politicized, et cetera. And then in the supportive care side of things,

00:26:28.800 we didn't know anything, right? It was like, is this ARDS? Should you be oxygenating the bejesus

00:26:33.800 out of people? Steroids must be horrible. I mean, we really knew nothing. You have a whole bunch of

00:26:39.600 empirical insights. And when you consider where we are today on that front, I mean, I just kind of

00:26:44.740 jotted out a bunch of ideas. It's kind of amazing that in less than two years, we have multiple

00:26:52.060 vaccines. We have pretty clear ideas about which behaviors reduce the spread of infection and which

00:26:57.980 don't. On the treatment side, we have a pretty good sense of at least one existing drug that works,

00:27:03.660 which is fluvoxamine. We can discuss if there are others. And we've got at least two new drugs that

00:27:08.700 seem quite promising. I'm more familiar with the Pfizer data than the Merck data. And you guys can

00:27:14.960 probably speak much more to the therapy side, right? The supportive care side. But it seems to me

00:27:19.840 that ICU doctors and nurses have a way better sense of what to do today than they did a year ago,

00:27:26.420 let alone 18 months ago. Anything you guys would add to that framework? Because I think it's important

00:27:32.500 to differentiate between what the world looked like in the spring of 2020 with respect to those

00:27:37.940 data points or those parameters versus what it looks like today. So would you expand or subtract on that?

00:27:45.300 I can say a couple of things here. That's a really good framework. It's interesting because

00:27:48.480 in the prevention framework, you could also throw in, hey, you know, what about things like

00:27:52.600 vitamin D, treating metabolic syndrome, diet exercise, those kinds of things, which are a

00:27:57.520 little softer. So call it lifestyle. But no, I like it. I like it. Yeah. Like lifestyle modification,

00:28:02.040 which I remember in the early days, you were talking about things that you did. Things I did too were

00:28:06.840 because I said, oh, this is more like OG SARS than what, because we didn't know what the IF,

00:28:11.940 the infection fatality rate was. I was sitting there exercising like a lunatic and I stopped

00:28:17.300 drinking alcohol and I did all these personal things to try to improve my metabolic condition.

00:28:23.020 So that's a piece of it. And then there's a question of chemoprophylaxis. You know, some have

00:28:26.680 been, these politicized drugs, they've been advocating that they're more prophylactic as well. You could

00:28:31.420 take it, you know, ivermectin once a week and prevent this. I mean, it's worth exploring. I don't think

00:28:35.840 there's data that we have, but your, your comment that this has evolved so quickly is absolutely

00:28:40.780 a beautiful vindication of the scientific process when it's allowed to unfold. People, I think people

00:28:47.060 who've politicized this a lot on both sides say, oh, nothing's, you know, doctors aren't really trying

00:28:51.060 to do anything to treat this. We haven't really learned anything. No, the opposite is true. Multiple

00:28:55.260 good vaccines, things like dexamethasone in the hospital that have really improved mortality. And we've

00:29:02.060 actually thrown out things that don't work, which is actually just as important because those things

00:29:06.160 can actually cause harm. So the question of hydroxychloroquine, for example, you know,

00:29:10.060 Ianides' meta-analysis showing that maybe we actually cost lives by giving that much hydroxychloroquine.

00:29:16.540 These are things we need to actually really dive into. And it comes down to this, Peter, like,

00:29:22.860 let's say the IFR, this is how I think about it. If infection fatality rate, let's say it's,

00:29:26.520 you know, 0.2, 0.3, somewhere in that range, which seems reasonable, although we don't have the exact

00:29:31.880 data, how many people in the U.S. are roughly at risk then of dying based on the population of the

00:29:37.680 U.S. and the IFR of the disease? And I did a back of the napkin calculation a few months ago that was

00:29:42.620 roughly about 1.4 million Americans. If that thing was the actual IFR of the disease, if we didn't do

00:29:49.040 anything, that's at the current state of the IFR, that's how many people would die. We're at what,

00:29:54.720 800,000? So the question is, will we get to 1.4 or will it not reach 1.4? And if it doesn't,

00:30:03.640 what of those three buckets, I mean, what did we do to actually improve that? And I suspect it's a

00:30:09.600 mix of vaccines, therapeutics in hospital, lowering IFR by improving hospital care, and some behavioral

00:30:16.420 stuff like maybe avoiding big crowds when something's surging, something like that.

00:30:20.380 But that's kind of my current thinking on it is, you know, the goal is get that down from 1.4 million

00:30:26.840 as much as we can without destroying the fabric of society, which will actually push it back up

00:30:31.640 towards 1.4 through ancillary damage in terms of substance abuse, overdoses, mental health problems,

00:30:37.680 suicide, that kind of thing. Yes, it's amazing what we have in our toolbox, how far we've come,

00:30:42.620 scientific innovation. To me, what's almost equally amazing is how we've not incorporated

00:30:49.680 many of these new therapeutics into common practice. And that is probably a glimpse as to

00:30:57.400 what's broken with our broader healthcare system, the average 17-year lag for new evidence to get

00:31:03.960 broadly adopted into practice. And we're seeing that play out now. Now, maybe it's truncated,

00:31:08.280 maybe it's a three-year lag, but it's too slow for a health emergency. Yes, it's amazing how much

00:31:14.680 we've learned, but it's also amazing how we still have doctors telling folks, oh, you have COVID,

00:31:21.460 tough it out, stay at home. You know what? We should be telling them in order, based on evidence,

00:31:27.340 a list of things, and in no specific order, fluvoxamine reduces mortality by 91%.

00:31:32.940 Budesonide, a steroid inhaler, markedly reduces hospitalization. Vitamin D has been found to be

00:31:40.860 correlated with severity of illness in a German study in hospitalized patients. Hypertonic saline

00:31:46.840 is an age-old treatment that's been used to sort of rinse out the nasal cavity, and it's been used by

00:31:53.020 doctors for a long time with many viruses. And you've got all of these things that are not being

00:31:58.440 adopted broadly. And to me, we are still suffering from significant groupthink. We've been burned

00:32:06.260 badly with groupthink in medicine throughout this pandemic, in the failure to warn about it,

00:32:13.180 in the surface transmission idea, in the draconian and barbaric practice that doctors and hospitals were

00:32:20.180 complicit in to ban people from visiting their loved ones to say goodbye. Closing public schools,

00:32:26.620 ironically, with a less contagious strain out there. Ignoring natural immunity. Not talking

00:32:32.780 about fluvoxamine. I just saw another White House briefing. We've never once heard our public health

00:32:37.560 officials talk about it. The groupthink and not spacing out the doses. Maybe we wouldn't be talking

00:32:43.120 about boosters as vigorously if we would have spaced out the first two doses as we should have.

00:32:47.700 By the way, I want to make a comment on that. When the vaccine started rolling out,

00:32:51.280 I spoke with three immunologists, virologists. So, and these are, I won't name who they are just

00:32:58.720 for the sake of protecting their identity. But I mean, I explicitly talked to them about this and I

00:33:04.920 said, why the four weeks between first and second shot? That seems at odds with the little bit that

00:33:11.260 I know about the immune system. And they said, there's not a single reason to do that other than

00:33:17.200 they probably did the trial that way for the sake of speed. But they said, if you can drag your feet

00:33:24.120 as much as possible between those doses, do so. And I was like, well, do you think it's worth saying

00:33:30.680 that? And they're like, no, don't want to say, like, not going to say that. Just, just, you know,

00:33:35.520 drag your feet as much as you can show up three months later saying you forgot to get your second

00:33:40.960 shot kind of thing. So yeah, there's a little bit of this going on. By the way, I do want to go back

00:33:45.640 to one thing you said, Marty, that, that I have generally found the evidence to not be favorable,

00:33:51.220 which is vitamin D, at least supplemental vitamin D. So, because my patients ask me about this all

00:33:56.460 the time, I've said, look, don't confuse your vitamin D level that you acquired being in the sun

00:34:01.400 playing sports outside with the vitamin D level that you can get by taking 4,000, 5,000 IU of vitamin D.

00:34:09.180 I don't think those are the same. I think vitamin D might be a surrogate for health through other means.

00:34:15.420 Did this study that you're citing specifically look at outcomes being improved with supplemental

00:34:21.380 vitamin D or did it simply associate or note the association of higher levels of vitamin D and

00:34:26.200 better outcomes? The latter. So out of all the things I mentioned, that has the weakest evidence.

00:34:31.560 That was sort of a retrospective review of hospitalized patients just looking at their levels and they found

00:34:36.020 some correlation, but it doesn't imply causation necessarily. All the other stuff has randomized

00:34:42.700 controlled trial data behind it. The vitamin D thing was a retrospective review.

00:34:47.460 Yeah. So my, my take on that has been, and my practice has been not to prescribe vitamin D and

00:34:52.840 instead to get outside and exercise in the sun and get it that way. Zubin, do you have a take on any of

00:34:58.800 those, including the vitamin D thing? Yeah, that was my take on the vitamin D piece too,

00:35:03.080 is there's a correlation causation situation there. There is definitely something going on with

00:35:07.460 naturally acquired vitamin D that seems at least in a correlative way, protective. One thing that I

00:35:13.060 think is interesting. So fluvoxamine, again, I think when you've been through the hydroxychloroquine

00:35:17.680 ivermectin mill there, the group thing starts to shift and go therapeutics just simply don't work,

00:35:22.500 especially if they're repurposed drugs. There is a lot of group think in medicine and people are then

00:35:26.380 uninclined to look at these pieces. The other interesting thing about this particular pandemic

00:35:31.520 that makes it tough, Marty, is that, you know, 99.6% or whatever of people are going to get better

00:35:38.440 no matter what. In other words, staying home and doing nothing, they're probably going to be just

00:35:42.600 fine. And so it becomes this question of how do we, do we tell the whole world to take, you know,

00:35:48.840 budesonide and fluvoxamine and all of that the minute they get sick, like Omicron, it's going to

00:35:53.000 infect everyone. And I'm getting tons of emails. Hey, I have cold symptoms. I'm at home. Should I go get

00:35:57.280 monoclonal antibodies? Should I, you know, cause Peter has his defined patients. I have like millions

00:36:02.980 of patients who email me and I keep telling them I'm not your doctor. But what I, what I always say

00:36:08.340 is, you know, look, you have to look at your risk factors. You have to look at your age. You have to

00:36:11.900 look at where you infected previously. How'd you do with that? There's so many intricacies, whereas it

00:36:17.060 would be nice to say, you know what, if you're, if you have these symptoms here are low risk, high yield

00:36:22.080 things we can do. And I don't know, Marty, do you think some of those things on your list are

00:36:26.700 applicable to say anyone who gets COVID or would you risk stratify?

00:36:31.020 Well, we've got to risk stratify because one, it's, it's just overkill. Somebody who's young

00:36:36.460 and healthy, the German data just came out that between the ages of five and 17, not a single

00:36:41.720 healthy person died pre-vaccine. So when you've got someone vaccinated, it's probably a indicator of

00:36:48.980 overuse if we're using some big guns in that population. And, you know, I made a comment about

00:36:55.920 doctors being slow to adopt some of this stuff. And I just want to be clear. We have put doctors

00:37:01.980 in a terrible situation in the United States. We've put them in a very bad situation by putting

00:37:08.920 them on the front lines of this pandemic without any good data for a long time. When this pandemic

00:37:14.040 happened, it hit this country and every single person, all of our friends and everybody and

00:37:19.180 everybody who emailed you, Zubin, and by the way, sorry for telling people who email me just to email

00:37:25.220 you. Maybe I'll stop telling them to tweet. Yeah. You know, I'll, if it just pay me a nickel every

00:37:30.680 time that happens. And then as Peter says, if you do a, if you do a wallet biopsy of my bank account,

00:37:35.320 I'll have like at least a dime in there. It'll be great. But we were all getting the questions.

00:37:40.660 How does it spread? Do masks work? How long are you contagious for? Can you spread it pre-symptomatic?

00:37:47.360 All the basic questions of COVID. We did not have answers because our gigantic $4.2 trillion

00:37:54.000 healthcare system could not do the basic bedside clinical research. I remember Peter was even doing

00:37:59.560 a quick video about somebody please do this study. We were all saying the same thing. Labs were mostly

00:38:04.840 closed because there was no PPE. The NIH was unable to pivot their $42 billion to answer these questions

00:38:12.700 quickly. So what we did is we had a vacuum of scientific research and all the doctors were on

00:38:18.920 the front lines without any data to really answer these questions. And that's when the group thing

00:38:23.600 began. And guess what ended up filling that vacuum? Political opinions. So we just did this

00:38:29.500 study of NIH research funding last year. Less than 5% went to COVID research. Three months into the

00:38:36.400 pandemic, 0.05% of the NIH's budget went to COVID research. The average time for them to give a grant

00:38:43.040 was five months to fund a research team to then start the research. 257 grants on social disparities with

00:38:52.560 COVID, an important topic, but only four on how it spreads. And one on masks, which hasn't even read

00:38:59.400 out yet. So the most basic questions doctors needed evidence for, that was not being conducted.

00:39:06.660 I want to go back to something that you guys have both now alluded to. And I talked about this a little

00:39:11.680 bit on the podcast with Rogan. And I think it's worth mentioning again, because it's a fundamental

00:39:16.960 issue that I think we're going to talk about many times this afternoon. David Allison and I had a

00:39:21.840 discussion a couple of months ago, and he put this very eloquently. And it's something we all

00:39:26.820 understand, but I think I like the way he phrased it, right? Which was, always know the difference

00:39:31.960 between science and advocacy. And as we explain these differences now, I think people will inherently

00:39:38.040 understand it. But, and again, we're now talking in the realm of opinion. My opinion is perhaps the

00:39:45.220 greatest disservice that has come out of this has been that that line has been so blurred to be

00:39:51.960 non-existent. So science is messy. Science is uncertain. Science speaks in probabilities and science

00:40:01.280 constantly changes in the face of new information, right? So science is a process, not a thing, right?

00:40:08.040 Science says, this is what we know today with this degree of certainty. As new information becomes

00:40:14.180 available, the new truth will be this. So truth is not a constant within science, right? Truth,

00:40:20.640 we hopefully converges on greater certainty. And so when scientists speak, it doesn't really sound that

00:40:27.880 reassuring. I mean, you know, we know this because we interact with scientists a lot. They never give

00:40:33.560 you a straight answer because if they're doing their jobs, honestly, they rare, you know, outside of

00:40:38.740 really well-known phenomenon, we, we have to speak in uncertainty. I think for understandable reasons,

00:40:46.340 advocates can't do that. They don't have that luxury, right? If you're, if you're a public health

00:40:51.060 advocate, your job is to communicate something with complete certainty. But if you're observing this

00:41:00.080 as a member of the public and you don't know the difference, how do you know what to make of this?

00:41:06.640 So is it safe to say that Anthony Fauci is an advocate in COVID and not a scientist?

00:41:12.960 This is the central thing that's going on here. I think, Peter, I think you're absolutely right.

00:41:18.480 Because what it is, is if you look at Fauci say, or you look at Francis Collins, so recently leaked

00:41:22.900 email, Francis Collins talking about the great Barrington declaration, which was a bunch of scientists,

00:41:28.420 including someone who's been on my show, Jay Bhattacharya saying, Hey, as a matter of policy,

00:41:33.720 we think the following things should happen that would improve outcomes in this pandemic based on

00:41:40.140 our interpretation of what the best science is right now. There is no the science. This is our

00:41:45.280 policy interpretation, right? And what Francis Collins roughly wrote in this email was, Hey,

00:41:51.180 did you see these fringe epidemiologists coming up with this great Barrington declaration? Oh,

00:41:55.880 by the way, one of the fringe guys was a, is a Nobel prize winner at Stanford, Mike Levitt.

00:42:00.440 And if you haven't seen it, we need to do a devastating and, you know, decisive takedown

00:42:05.900 of this. And I don't see it out there yet. And so basically saying, ultimately what I would

00:42:10.700 interpret this as is, Hey, I disagree with this as a policy. We need to put out something that takes

00:42:16.900 it down as a policy. And there's not a discussion of, Oh, let's have, let's discuss the underlying

00:42:21.520 science. Let's actually have a discussion about policy. Like, does it make sense to treat healthy

00:42:26.620 people that are young, the same as elderly people at high risk? These are the conversations we ought

00:42:31.460 to have instead. They acted as advocates. Well, our position is do the lockdowns, make people mask,

00:42:38.120 promote whatever it is we're promoting. And that's our policy. So we need to advocate for it in no

00:42:42.700 uncertain terms, which means a devastating and immediate takedown of these quote unquote fringe

00:42:48.560 epidemiologists. And that, that's, that is as clear an aspect of the difference between policy,

00:42:55.000 politics, and science. But this is a scientist who represents our, one of our largest scientific

00:43:00.720 public agencies. So that was really concerning to me. I'm curious, Marty, what, what you think of that?

00:43:05.700 That was chilling when I saw that email from Francis Collins to Fauci, and it called for a devastating

00:43:11.620 takedown of another opinion, basically. I mean, they control the currency of academic medicine,

00:43:21.320 which is NIH funding. When you've got the head of that talking about taking down ideas and taking down

00:43:28.160 people, this is probably the greatest lesson we should learn from the pandemic. In addressing how do

00:43:35.960 we avoid groupthink in the way that it's burned us time and time again, we've got to openly talk about

00:43:44.220 the corruption of science itself, how there has been a shutdown of scientific discussion, how you

00:43:50.260 cannot talk about certain things. It started with Google suppressing any search of Wuhan lab leak. And

00:43:56.680 they admitted this openly. They said, you know, we, we suppressed any searches because we weren't sure.

00:44:01.880 And we didn't want people to get the ideas if they weren't sure. Well, that's not their role.

00:44:05.240 They did the same with the great Barrington declaration, took down Dr. Bhattacharya. I was

00:44:09.400 skeptical of the declaration early on, but look at what's happening in Sweden now and tell me if

00:44:14.460 there wasn't some truth in what they were talking about. Martin Kulldorff, very well-known vaccinologist

00:44:21.340 from Harvard on the CDC ACIP committee, basically dismissed openly. He told me this, and he said,

00:44:29.500 I could say this publicly. I've written about it in the Wall Street Journal, dismissed from the

00:44:32.760 committee for having a different idea. He was upset about the J&J pause being too prolonged

00:44:37.940 and creating vaccine hesitancy, asked to leave the committee. FDA bypassed their own expert

00:44:45.040 advisors called VRPAC on the boosters for young people vote. CDC, with their expert advisors on

00:44:52.200 boosters for young people, told that committee specifically, you're voting on older folks.

00:44:57.720 We are not holding a vote on boosters in young people. And then they go ahead and recommend it

00:45:03.840 for young people. Two senior FDA officials quit, including the head of the vaccine center at the

00:45:09.820 FDA. Academic bullying. How many people have reached out to us and said, thank you for talking about

00:45:16.780 natural immunity. I see it in my patients. I can't talk about it. I'm told we have to keep one message,

00:45:22.800 and that is to get everyone vaccinated. And, you know, thank you for speaking up. I can't do so.

00:45:28.740 Why is the NIH not done a study on natural immunity? They keep saying, we don't know.

00:45:33.740 They're ignoring the 141 studies that have been documented by the Brownstone Institute.

00:45:39.080 It's not that hard. Go to New York where people had the infection, interview them, test their blood.

00:45:45.700 I mean, why is my research team doing this without NIH funding? Because the NIH is not only not funding it,

00:45:51.260 they're not doing it, and they're relying on two really flawed studies that the CDC put out.

00:45:55.980 This is the distortion of science itself, shutting down scientific discussion. And that should be our

00:46:02.880 greatest lesson. I want to come back to something you said about natural immunity, because now I want

00:46:06.400 to kind of get into, let's talk about what we know. So let's start with that. What do we know about

00:46:13.100 naturally acquired immunity? You know, it's interesting because there are multiple studies showing that

00:46:17.880 natural immunity is actually a real thing. It's a real phenomenon. It generates really good protection

00:46:22.320 against either reinfection at a lower rate or severe disease at a much higher rate. And then there

00:46:28.280 are a couple of studies that are CDC-sponsored studies that Marty has reviewed in depth that say

00:46:34.360 the opposite. And what's interesting is as a matter, again, as a matter of policy then, the policymakers in

00:46:41.600 the U.S. have chosen to go with that approach saying, listen, it doesn't matter if you've had

00:46:45.380 natural immunity, you still need two vaccines and a booster. And by the way, you cannot space them out

00:46:51.100 beyond a certain point, or they will not even count for the mandates that we're talking about. So

00:46:55.800 where policy actually contradicts evidence that we have, it becomes, at this point, it's pure advocacy,

00:47:03.180 pure policy, and that distinction between public health and science, where public health says we have

00:47:07.140 to speak with a monolithic voice that simplifies complexity into binaries. Otherwise, no one's going to

00:47:12.580 listen because Americans are too stupid. That's the subtext. Versus actual scientists who are like,

00:47:17.560 wait, no, wait, wait, wait, wait, wait. And those are the emails we get, right, Marty, the people who

00:47:21.380 can't even talk about this nuance because they'll get censored in their own academic institution. So

00:47:26.500 back to you. Well, I do want to ask a technical question. Is there a precedent for a respiratory virus

00:47:32.760 to not generate natural immunity? In other words, like, what would be your prior

00:47:36.920 on this if you knew nothing? Like, wouldn't, I don't, again, this is so outside of my wheelhouse,

00:47:43.180 guys. I'm not an immunologist. I'm not a, more importantly, I'm not a virologist, right? I think

00:47:47.520 that's the real question. And none of us are. So do we know if it's actually the norm that once you

00:47:55.060 have a virus, you tend to develop natural immunity to it? I mean, that was sort of my understanding from

00:47:59.580 medical school, but have things changed significantly? And what would be our expectation here?

00:48:04.560 Yeah. So just real quick, strep throat, which is a bacteria, that can reinfect you and reinfect you.

00:48:11.260 So you cannot have a viable vaccine. Respiratory pathogens in general, you can get reinfected,

00:48:17.360 but your immunity against severe disease tends to be quite strong.

00:48:21.880 Alternatively, when they're just changing, right? So of course, like the flu, you could get

00:48:25.880 theoretically every year, but that's because you're getting a novel pathogen effectively, correct?

00:48:30.640 That's right. And even then, even the novelness of the pathogen is actually not

00:48:34.420 as novel as a real phase shift in the antigens you're presented with, like maybe would happen

00:48:40.440 in H1N1 swine flu or a new bird flu. So yes, it's a spectrum all the way up to measles where

00:48:46.020 it doesn't change that much, even though it's an RNA virus and you can get true permanent sterilizing

00:48:51.020 immunity from natural infection for the rest of your life. And that's why we don't even vaccinate

00:48:55.280 people who were born before say 1960, because we assume they all got measles and they have

00:48:59.880 immunity. So Marty, I'm curious your thoughts.

00:49:01.920 Yeah, no, I look, I think one of the little known secrets is we all have our group of go-to

00:49:08.700 people. We've got our immunologists, our vaccinologists, our infectious diseases experts,

00:49:15.260 and we go to them frequently and we learn to trust the judgment of many of these. And I even heard

00:49:21.560 Paul Offit on your podcast, Zubin, talk about how there's that spectrum. So let's look at the

00:49:28.520 hot coronaviruses, what I call the hot coronaviruses. The cold ones cause the common cold and they're

00:49:34.300 seasonal. The ones that cause severe illness or the hot coronaviruses, there's only been three in

00:49:39.620 history and that's SARS, MERS, and COVID-19. Now SARS was studied 17 years out and the natural

00:49:46.820 immunity was solid. MERS was studied three years out and the natural immunity was solid, probably longer,

00:49:52.240 but that's just the time points at which they studied the viruses that no longer circulate. Why

00:49:56.880 would you study it much longer if it's no longer in circulation? So the starting hypothesis, in my

00:50:03.040 opinion, should have been natural immunity appears reliable. We don't see people getting reinfected with

00:50:09.540 severe illness on the ventilator and the ICU. And once we start seeing that, we can change the starting

00:50:16.160 hypothesis. But let's use the starting hypothesis that natural immunity works, at least in the time that

00:50:21.600 it's been around. And what you had was a series of studies come out from early on, two months into

00:50:27.680 the pandemic, rhesus monkeys were re-challenged with the virus and they did not get reinfected.

00:50:35.020 The Cleveland Clinic then came out with their big study of hospital workers who were around COVID all

00:50:39.420 the time and found no reinfections and the vaccine did not add anything to their immune protection.

00:50:46.300 Then you had the Washington University study, which actually did bone marrow biopsies and looked at the

00:50:50.800 T cell, activated T cells in the system. The very difficult experiment that we talked about is

00:50:56.820 not as simple as a blood draw. And they concluded that immunity from COVID is likely lifelong. It's

00:51:03.100 lasting. And study after study kept coming out. Then we got the biggest study ever done out of Israel,

00:51:09.080 a population study showing that natural immunity was 27 times more protective, adjusted for age than

00:51:16.680 vaccinated immunity. Tell me a little bit more about that one, Marty. That seems difficult to quantify.

00:51:22.140 Can you, can you tell me a little bit more about what that actually means?

00:51:25.840 Sure. So what they did is just, they have all the positive testing data as the CDC does, but they won't

00:51:32.440 release it of people who test positive and then subsequently testing positive again. They also have

00:51:37.400 all the vaccine records. So if you tested positive and did not get a vaccine, they looked at the rate of

00:51:42.860 testing positive again. And it was, there was something like a 13 fold difference, but adjusted

00:51:48.120 for age, because we know every age group is different. It ended up being an age adjusted 27 fold

00:51:54.160 difference. Now, when that came out, it was a few weeks before the data came out on boosters, reducing

00:52:00.320 hospitalizations by tenfold in people over 65. The tenfold reduction in hospitalizations with a booster in

00:52:08.340 older people. Dr. Fauci immediately described it as quote unquote dramatic data and wrote up a lot of

00:52:13.620 policy around that immediately. The data on natural immunity being 27 times more protective, not

00:52:20.080 mentioned once ever by public health officials. There's a general fear I hear in my private

00:52:25.200 conversations with public health leaders, that if they talk about natural immunity, people might just go

00:52:29.840 out there and try to get the infection. And we don't want them to do that. And I agree, we don't want

00:52:34.220 them to do that. But we can be honest about the data and encourage vaccination at the same time.

00:52:40.020 Look how many careers we've ruined. Teachers, nurses, soldiers getting dishonorably discharged.

00:52:47.180 They have antibodies that neutralize the virus, but they are antibodies that the government does not

00:52:53.880 recognize. That has been a tragic misstep. And I think it's one of the reasons why the government

00:52:59.040 has lost credibility. There's a lot I want to talk about there. But can you talk about the two

00:53:03.640 studies by the CDC that suggest that natural immunity is not lasting?

00:53:10.220 Yeah. These studies would not qualify for a seventh grade science fair. The methodology was so poor.

00:53:17.900 Is that fact or opinion, Marty?

00:53:19.600 That is my opinion. But I think any honest scientist will tell you that the conclusions cannot be derived

00:53:27.640 from the data. The first study was a study looking at a narrow two-month period in the state of

00:53:32.960 Kentucky. And they looked at reinfection rates. And they didn't say anything about whether or not

00:53:37.400 they had symptoms or were hospitalized or anything. And the rates in both the vaccinated and natural

00:53:43.360 immune group were exceedingly low. They were 0.01% over that two-month interview,

00:53:50.480 interval. But because they were both so low and they weren't equal, one happened to be 2.3 times higher

00:53:55.860 than the other in the natural immune group. So they concluded those with natural immunity were 2.3 times

00:54:01.980 more likely to get the infection again. It's too small a sample. So what happened was the CDC has

00:54:08.320 data on all 50 states for 15 months of the pandemic at the time. They did something called

00:54:13.720 phishing. And anyone in research knows this technique. You find some small sliver of data

00:54:18.640 in some locale, in some narrow time window that supports a foregone conclusion that you've made

00:54:24.940 before reviewing the data. So they found one state over a two-month period that supported their

00:54:29.340 hypothesis. Why don't they release all of the nation's data on reinfections? They've never done

00:54:34.040 that. In the other study, they surveyed people in the hospital and asked them if they've had the

00:54:39.280 infection in the past. And they make conclusions about population-level risk by surveying people

00:54:45.660 in the hospital. You simply can't do that. How can you derive a population-level risk without knowing

00:54:51.380 the denominator? So both were highly flawed. No one really defended them, except for a lot of

00:54:57.260 politically appointed physicians were just kind of mum about it. And yet these numbers get quoted

00:55:02.240 all the time, like the Maricopa mass study, highly flawed, wouldn't make its way into any, hasn't been

00:55:07.800 published in any journal that has a review process, just the little MMWR rag that the CDC puts out.

00:55:15.700 Now, has there been a meta-analysis, Marty? Because one way to address a body of literature this vast,

00:55:21.700 because as you say, there's always going to be, I mean, you're always going to find a signal,

00:55:26.340 and you're always going to find noise. A good process meta-analysis could sift through that.

00:55:32.160 Has someone done that definitive meta-analysis on this question?

00:55:36.080 Yeah. So Martin Kudlor, who was the Harvard professor, now he's at Brownstone Institute,

00:55:41.680 has summarized the 141 studies on natural immunity. And so when Fauci gets on the TV and says,

00:55:48.200 we just don't know about natural immunity, well, do the study. How hard is it? This is not the riddle of

00:55:54.660 the Sphinx. You can figure out how many people have been reinfected from the original days of

00:56:00.520 New York and had severe illness. And when this issue was coming up, I reached out to Zubin and

00:56:05.740 I said, hey, are you hearing about reinfections after somebody truly was sick, not just an

00:56:11.080 asymptomatic test, but they were truly sick from COVID. Have you heard of anyone coming back to the

00:56:16.520 hospital on a ventilator or dying? And look, I'm sure there's some rare case out there, but he said,

00:56:23.880 no, look, I haven't heard about it. It's becoming like Bigfoot. Everyone thinks they've heard about

00:56:28.680 it, but there's no good documentation. And anecdotally, I think we see the opposite,

00:56:33.380 right? I mean, I know many people who have been reinfected with COVID. And I can say without exception,

00:56:39.380 every one of them had a much, much milder course the second time. Now, some of that's confounded

00:56:45.640 because some of those people also got vaccinated, right? So they got the first way, they got the

00:56:49.940 first illness pre-vaccine. That was pretty bad. That was, again, in a healthy young person,

00:56:56.360 that could still be like a bad case of influenza. Some of them just went on to get another COVID a

00:57:00.960 few months later pre-vaccine. Some got vaccinated and got another COVID. But I think the point here is

00:57:06.800 this is knowable. There are some things that are not knowable. There are some things that are

00:57:11.240 knowable. This falls in the bucket of knowable. And therefore, it's frustrating when we don't have

00:57:15.900 information on things that are knowable, or when we claim we don't have information about things

00:57:19.580 that are knowable. And I think this points again at Marty's assertations that as a policy,

00:57:24.600 we haven't chosen to devote resources to this. And it is a central question. And I think our anecdotal

00:57:31.120 experience, again, speaks to the difficulty of preventing reinfection with a mucosal

00:57:36.580 pathogen like a coronavirus. And that's why, you know, you can get a cold year after year,

00:57:41.260 but you don't die. That long-term immunity, you know, prevents severe disease. And we see that

00:57:45.760 anecdotally. Now, speaking of anecdotes, one thing I want to say about that, everybody has an anecdote

00:57:50.720 of somebody who broke through vaccine or did this or that and ended up getting sick and died. And

00:57:55.960 hospital people are really good at this because they see an enriched sample. So they'll be like,

00:57:59.580 well, there was a pregnant mother who was 20, who had no problems, died of COVID and this and this.

00:58:03.320 And all that can happen. But when we now have an internet where these anecdotes can be amplified

00:58:09.960 into larger level distorting sort of data sets, I think it influences a level of fear and policy

00:58:18.120 decisions then that spring from that. And that's something we have to kind of tease out by actually

00:58:22.660 doing science, actually studying the stuff directly and saying, okay, no, this is actually a well-designed

00:58:27.620 study that says, actually, no, it can happen, but it's a 0.001% risk. And so do we make policy to

00:58:34.160 prevent that risk? And the answer is probably not because it has costs.

00:58:38.700 Yeah. This gets back to, I'll just keep harping on this idea of science versus advocacy, science

00:58:43.000 versus advocacy. I mean, again, on the other side of the spectrum, you have a whole group of people

00:58:46.800 who are saying, hey, vaccines are horrible. They should never be used. Nobody should be vaccinated.

00:58:51.560 Natural immunity is the only way to go. Vaccines don't even prevent illness because look at all

00:58:55.120 these breakthrough cases. And again, I think a very arrogant approach is to say, shut up.

00:59:04.140 Vaccines cure everybody. Put your head in the sand, you knuckle dragger. But that would be an

00:59:10.180 advocacy position, right? A scientific position would be like, no, you're absolutely right.

00:59:14.860 Vaccines, it's a probabilistic game. Vaccines reduce the probability of infection,

00:59:20.220 the severity of infection, but that's all probabilistic. So if you take a hundred

00:59:24.960 vaccinated people versus a hundred unvaccinated people on an individual basis, you can't make

00:59:31.340 any assertion. That's what science is. And again, I go back to this thing, which is you look at all

00:59:38.420 of the amazing things that have happened in the last two years that really speak to the scientific

00:59:43.180 method. So imagine this pandemic took place in the 16th century, like before we even had the

00:59:51.060 scientific method. So let alone the capacity to generate drugs and all these other things,

00:59:57.680 totally different game, right? And yet, I mean, to think we have monoclonal antibodies,

01:00:02.820 we have novel antivirals, we have vaccines, we've got all of this stuff done in less than 24 months.

01:00:09.220 What bums me out, and I've said it before, opinion, not fact. I think that this is a pirate victory

01:00:19.120 for science. I think it has, what's the expression? Like we've, we've won the battle and lost the war

01:00:26.240 from a scientific perspective, right? Which is, yeah, you know what? 800,000 people died instead of 2

01:00:32.700 million. That's an awesome victory. But it came at such an erosion of trust that the next time one

01:00:40.020 of these things comes around, when you actually do need to take really draconian measures, good luck

01:00:45.740 with that. This idea of the Pyrrhic victory of science, I think, is really central here. Because

01:00:52.480 one thing you said about advocacy, this advocacy position, maybe it's a good advocacy position to say,

01:00:57.740 no, vaccines, you're dumb if you don't take them. They're absolutely essential to ending the

01:01:02.380 pandemic. The only way through is with vaccines. But even that as an advocacy position is ineffective

01:01:08.220 because how has that worked? It generates psychological reactance among people who are,

01:01:13.460 have ideological and moral reasons to be skeptical of these vaccines. Whether they're politically

01:01:20.560 aligned with someone who's skeptical, whether they don't like authority telling them what to do,

01:01:24.460 whether they distrust science, whatever it is, that approach to advocacy only serves to shore up people

01:01:29.980 who already agree with you. And it creates reactance in others, which is the problem with

01:01:33.820 mandates, which is the problem with the inflexibility of recognizing natural immunity.

01:01:38.780 So even as a policy standpoint, all we've done is serve to do exactly what you said, Peter, which is

01:01:44.040 erode our trust and ability to understand science. And then the next thing that happens is potentially a

01:01:51.760 huge disaster. If we had a supercomputer to calculate all the downstream effects of what we've done during

01:01:57.260 this pandemic. So let's say we saved, you know, a million lives, let's say, but how many did we cost

01:02:03.200 in terms of future distrust, in terms of childhood vaccines that now people are reluctant to get

01:02:08.280 because they're so burned by this whole thing with the COVID in terms of all the whatever screening for

01:02:13.740 cancer we didn't do during the time that COVID was going on, substance abuse, the mental illness,

01:02:19.120 the further fragilization of our children through this culture of safetyism and overprotectiveness

01:02:25.460 and teaching them that, you know, words and people who disagree with you are evil and violent and so

01:02:30.980 on. So that's something that I think we really, if we don't wake up to that, then it doesn't matter

01:02:35.960 how good our science is. It's not going to actually affect anything in a positive way.

01:02:41.040 You may have seen the Brown University study that just came out. I'm going to read the conclusion.

01:02:44.620 We examined general cognitive childhood scores in 2020 to 2021 versus the preceding decade.

01:02:52.820 We find that children born during the pandemic have significantly reduced verbal, motor, and overall

01:03:00.580 cognitive performance compared to children born pre-pandemic. We are in uncharted territory. We are

01:03:07.720 playing with fire. We're now going to have a generation now living with this. We've got a mental

01:03:13.420 health crisis declared by the Surgeon General in children. We've got a 51% increase in self-harm

01:03:19.780 admissions to a hospital among young women. We have yet to comprehend how significant many of these

01:03:27.400 restrictions have been on the most vulnerable members of our society. And that is children who

01:03:32.300 don't vote, who have been subject to so many of these policies. One of the things about this that

01:03:38.400 is odd to me is, again, when you contrast 18 months ago with today is, based on what we know,

01:03:48.360 these proposed policies and mandates don't even make sense. So let's talk a little bit more. Let me get a

01:03:55.480 little more data so I can create a thought experiment, which you know I love. What is the best available

01:04:01.680 evidence we have for how much a vaccinated versus unvaccinated individual reduces the ability to

01:04:10.680 spread an infection to some other person? In other words, how much do vaccines reduce the ability to

01:04:17.620 spread the infection? I think one of the great mistakes we made as a medical community was to

01:04:25.620 suggest that somehow being vaccinated was going to eliminate that risk of transmission. And we've set

01:04:32.360 that expectation and now people run around saying they don't work when in fact the vaccines are very

01:04:37.040 effective in downgrading the severity of illness. But the transmission piece now, it's pretty clear,

01:04:42.620 is not significantly affected by the vaccines because the virus lands in the mucosal area of the nose and

01:04:52.380 upper airways replicates and you blow it off faster than the systemic immunity can kick in.

01:04:58.540 Now, the natural immunity is more based in the local area of the mucosa. And so therefore,

01:05:04.640 that's why some think it's more effective. But when you look at this Lancet study that just came out

01:05:10.020 about a month ago, the peak viral shedding was equal in those vaccinated and unvaccinated. The difference is

01:05:17.940 the window of contagiousness was more narrow among those vaccinated. So we're talking one day versus

01:05:24.800 about three days on average. So we could, again, this is a very crude assessment, but we could say

01:05:31.460 there's a 66% reduction in transmission if you believe all things are otherwise equal?

01:05:38.280 You could, but if you show up to the same daycare center or same workplace every day,

01:05:43.200 you're still going to, on one of those days, be shedding virus at a high level.

01:05:49.140 Okay. Zubin, anything to sharpen that analysis? Because that's, again, to me,

01:05:53.720 that's a very jugular question when I think about a policy decision, right?

01:05:58.840 Yeah. I think it's interesting because there's two ways that I think we can see a reduction in

01:06:04.840 transmission. One is the narrowing of the window, which Marty talked about. The other is that there is,

01:06:10.300 including in current data, and I can't cite the specific studies, I'd have to dig them up, but

01:06:14.380 there is a reduction in symptomatic infection overall, which means the operative question becomes

01:06:21.860 when a vaccinated individual is asymptomatic, and I'm not talking about pre-symptomatic,

01:06:28.940 like they're eventually going to develop symptoms. And often we found pre-symptomatic people are quite

01:06:33.200 contagious, but they're asymptomatic, but they would test positive by PCR, say, are they infectious?

01:06:38.600 And this is in the realm of speculative now, right? But the answer is probably not.

01:06:44.420 And the more people that are vaccinated around them, probably even the less infectious they'll

01:06:48.920 be because those people have an innate resistance even to infection unless the inoculum is quite high,

01:06:54.580 which is why Delta was kind of a real drag if you look at vaccine numbers. With Alpha, vaccine very

01:07:00.260 effective, but then the combination of waning, neutralizing antibodies plus a very high R0 virus in

01:07:07.560 the form of Delta made it more likely to break through in terms of infection, mucosal replication.

01:07:13.440 So again, I think there's those two main mechanisms by which, but then you have the emergent phenomenon of

01:07:20.860 a community effect. And I'm not using even the term herd immunity anymore because it's just,

01:07:26.840 it's gone by the wayside. It's more that there's this community cocooning effect, and you see it in a

01:07:31.740 place like, say, the Bay Area where the vaccination rates are 90 plus percent. There really aren't that

01:07:36.700 many cases. And if I talk to my friends here, they're like, yeah, you know, there's a few really

01:07:40.220 morbidly obese elderly people that are in ICU, but in general, it's not happening and kids are doing

01:07:44.680 just fine even prior to being vaccinated and schools are, you know, opened up and stuff is happening.

01:07:50.120 There is this kind of effect. So I think it's more complicated than has currently been measured

01:07:54.940 easily, but that doesn't mean we can't measure it.

01:07:57.280 If you say it, look, let's just take the most extreme, like let's say it's reducing transmission

01:08:01.780 by two thirds and it's clearly reducing severity of infection by at least 90%. I mean, I think that

01:08:09.820 would be a fair assessment in some demographics, probably more than that, but it's a good log

01:08:17.240 reduction in severity. So, and then you, you take on top of that, do we have effective agents

01:08:24.880 to treat it? I think the answer is we have lots. So now imagine a different world. Imagine a world

01:08:32.880 in where you had a vaccine that didn't reduce severity of illness by more than 50%, but it

01:08:42.320 reduced transmission by 99%. Would we want to at least discuss whether there would be a different

01:08:49.020 policy view? Yeah, that makes perfect sense because if you're, if the main goal is dropping

01:08:54.640 transmission, but it's not, but for the people who do get sick, they still get very sick. Then your

01:08:59.360 policy changes to, Hey, you know, as many people as we can get vaccinated, the better it is. That's a true

01:09:04.540 herd immunity kind of goal there. We can do that. Measles, et cetera. But if it's the opposite, then your

01:09:12.020 calculation of policy changes dramatically. And here's why I think it does. At this point, like you said,

01:09:17.680 we have treatments, we have prophylactics in the form of vaccine. We have prophylactics in the form

01:09:22.840 of an N95 or KN95 mask. We have prophylactics in the form of you don't go to that concert or go out

01:09:29.680 to eat if you really are that paranoid, right? So at this point, we've shifted from a community level

01:09:34.780 decision risk to an individual level decision. I can get vaccinated if I want to prevent severe

01:09:40.620 disease in myself. I might have a little cocooning effect on my family. That's fine. So we don't want to

01:09:45.140 minimize it, but we don't want to maximize it either because it may not be true in a maximal

01:09:49.560 sense. If it's true, it's on some continuum. And then if I don't want to get sick and I'm high risk,

01:09:54.440 I don't have to go to that thing, or I could wear a KN95 or an N95. And then if I do get sick,

01:10:00.140 I'm going to demand, you know, the right monoclonal that is Omicron, you know, sensitive and

01:10:05.900 fluvoxamine and all the other stuff, right? So at this point, we've turned something from,

01:10:11.040 you know, out of your control entirely to something that becomes a much more individual

01:10:15.020 decision, which is why policies that use the mechanism of the state to actually influence

01:10:21.860 your behavior may be less effective, less relevant and backfire in a bigger sense. And it goes with

01:10:27.300 colleges too, when you're mandating kids be double vaccinated and boosted, quarantine for 10 days in

01:10:33.280 their room, getting DoorDash if they test positive. Well, why? Who exactly are they harming? Their

01:10:40.200 own risk is low. Their professors are vaccinated and can wear masks. So it's kind of like at this

01:10:45.340 point, what are we really doing? So the underlying situation matters to what policy you want to

01:10:50.720 actually instill. Yeah. And I think what I'm struggling with is you could paint two extreme

01:10:57.180 cases. So again, you imagine a scenario where the vaccine does not really reduce transmission,

01:11:02.800 but really reduces severity of illness versus a vaccine that really reduces transmission,

01:11:08.500 but not so much on severity of illness. Well, again, any person with common sense could say

01:11:13.940 you have a totally different set of recommendations. And if you're going to wave a policy hammer,

01:11:20.280 you're going to do it totally different in those situations. It seems to me that we're using the

01:11:25.760 wrong policy tool. Again, opinion, not fact. We're using the wrong policy tool for the tools on the

01:11:30.980 ground. Even when you talk about kids, which I'm sure you'll talk about, the policy tools we have

01:11:35.580 are not concurrent with the situation on the ground in terms of these parameters that Peter

01:11:40.960 discussed. Look, Peter, I think that's a very reasonable opinion. But here's a fact. That is,

01:11:47.240 the therapeutics we have today have cut COVID deaths to zero in the clinical trials. And once they get

01:11:54.880 distributed, remember, they were just FDA approved. Once they get distributed and out there, no one should

01:11:59.540 be dying of COVID right now with rare exceptions. With all the state-of-the-art care, with the

01:12:05.440 randomized control trial data behind it, and Paxlovid and Molnupir, no one has died from COVID

01:12:11.960 in those clinical trials, period. Now, in fairness, Marty, still relatively small, right? The Pfizer

01:12:18.020 study only had about 1,000 in each arm. Is that correct? Yeah, a little over 600 in each arm.

01:12:23.240 Okay. So we used to have a joke when I was at the NIH at the NCI, whenever a small trial would come out,

01:12:28.500 a phase two that showed an amazing result, the patients would say, can I get that drug before

01:12:34.480 the results change? You know, like once the larger trial comes out. But so just to set expectations,

01:12:40.760 right? I mean, people are going to die even still through these drugs. But I think the point is

01:12:45.780 when you look at this protease inhibitor, which is the new Pfizer drug, and this RNA replicating

01:12:52.120 blockade that's the Merck drug, they're kind of remarkable. And presumably we will come out with

01:12:58.420 another set of monoclonal antibodies that will be reactive to whatever strain is relevant,

01:13:05.660 just as Regeneron was very effective against the OG, reasonably effective against Delta. I think we

01:13:11.980 can talk about how effective it is against Omicron. But yes, I think your point is kind of what we've

01:13:17.760 been saying, like, oh my God, we have tools today we couldn't fathom 12 months ago.

01:13:22.960 So good point. Now, 23 people died in the placebo arms collectively of the Molnupivir and Paxlavid

01:13:31.840 trials. Zero died of COVID in the treatment arms. Now, it may not end up being, you know,

01:13:37.420 that dramatic in a real population. But whatever it is, it's significant.

01:13:42.160 It's very impressive.

01:13:43.080 It's very impressive. Then you add to that the GSK-Vir monoclonals. Problem is we've got the

01:13:48.360 monoclonals out for the Delta variant. We just can't sequence quick enough to know what to give

01:13:52.580 people. That's the dilemma. But-

01:13:54.300 Well, especially, by the way, Marty, sorry to interrupt. When you start stacking these things,

01:13:58.320 right, this is where it starts to get very Bayesian. You're vaccinated. You have access

01:14:03.580 to monoclonal antibodies. You have access to a new therapeutic. You have access to existing

01:14:09.860 therapeutics is in fluvoxamine. And you have ICUs that are ninjas compared to what they were two

01:14:18.340 years ago. That's right.

01:14:20.140 That's five pieces of Swiss cheese you can put on top of each other. And you still have to try to get

01:14:24.820 a piece of, you know, a pencil through there is pretty tough.

01:14:27.280 That's right. And you add fluvoxamine, budesonide. I mean, it's amazing. So we're all in agreement.

01:14:34.120 The therapeutics now have matured once they're actively available everywhere. It changes the

01:14:40.080 calculus. So if people were jumping out of an airplane and some people chose to use a parachute

01:14:46.860 and other people chose not to, you would say, you know, people not using a parachute are making a very

01:14:53.560 poor decision. And you might even mandate parachutes of anyone jumping out of the plane.

01:14:58.500 But if the plane is flying at a very low speed, only 15 feet above an inflatable mat,

01:15:09.180 that changes the calculus on the entire necessity of instituting martial law to require parachutes

01:15:17.340 or whatever the mitigation is. And right now it's as if there's this mild illness that people with

01:15:24.640 immunity can develop. And we're bringing all of heaven and earth down to lock up these college

01:15:30.540 students in solitary confinement for 10 days, requiring them to get a booster just so they

01:15:36.480 can go to class despite no evidence that boosters right now help young people and maybe some evidence

01:15:42.480 that there's harm. Now that could change, but that's the evidence to date. And look at what we're

01:15:47.620 doing to ourselves. I mean, we've moved to a second pandemic after COVID-19, which is a pandemic of

01:15:54.880 lunacy, which is this overreaction to mild illness. What becomes so frustrating, Marty, is when we talk

01:16:04.080 about this stuff, and you and I are pretty aligned on this, and this is an opinion based on the best

01:16:09.500 evidence we have. So it's a mix of sort of editorializing. And I will get emails from, say,

01:16:15.380 an ICU doctor who will say, but I'm still seeing sick people in the ICU. And to which I will reply,

01:16:22.960 okay, so what in our societal policies would actually prevent that short of locking everybody

01:16:28.680 up in their house and forcing vaccinations on them and then telling them they can't do anything

01:16:33.960 that they normally do? And what's the cost of that? And the same ICU doctor will tell me, well,

01:16:38.280 my son's actually having a lot of anxiety in high school right now, has to see the counselor because

01:16:42.200 he was kept home and away from his social network. And then the pressure of using Zoom,

01:16:46.780 and he's an introvert, and it didn't really work out. And so I'm sympathetic to that. It's like,

01:16:50.620 well, okay, now multiply that by how many millions of kids we've done this to for something that

01:16:55.560 eventually it seems to me, and I'm editorializing, is going to be fully endemic in the sense that you

01:17:01.700 have a respiratory pathogen to which initially we had no immunity or limited immunity. We now have

01:17:06.860 much better immunity against severe disease. We get reinfected every year like the common cold,

01:17:11.860 but people who get very sick have a series of therapeutics at their disposal to prevent them

01:17:16.360 from dying. Some old and frail and comorbid people will die like they do from a common cold,

01:17:22.440 but we don't have to really change society over it because it's another common pathogen that we have.

01:17:28.160 Next, do we really need to vaccinate every single child for this when every single child,

01:17:32.800 every single season after they're born is going to be infected naturally. They're not going to get

01:17:37.800 severe disease because their parents pass along some degree of immunity, even in breast milk.

01:17:42.320 And as it is, we're blessed that the kids don't get very sick typically from this unless they're

01:17:47.160 very sick otherwise. And so they're going to develop immunity. And so in less than a few years,

01:17:53.220 we won't even need to vaccinate anybody because all adults will be exposed or vaccinated.

01:17:57.540 All children will be exposed and we'll have another common circulating endemic coronavirus.

01:18:01.800 So that's what I think is where we're headed. And yet, so why are we destroying our society

01:18:07.400 in the process and generating so much division? We're squandering our community for this thing

01:18:13.820 that just doesn't make sense to me. Now that's editorializing.

01:18:17.040 Well, I'm going to keep editorializing for a minute, and then I want to come back to

01:18:20.260 something you said, Marty, which is let's now look at the data around the risks of vaccine.

01:18:25.700 Because again, I think one of the challenges of the scientists being conflated with the advocates is

01:18:34.060 that no one's allowed to ask that question, right? As though somehow, you know, statins,

01:18:40.860 like let's take a drug that, I mean, just demonstrably reduce the risk of cardiovascular

01:18:46.600 disease. Like you just, you know, you've got to look far and wide to figure out over the right

01:18:52.820 time horizon. If you give statins for a year, you might not see a benefit, but demonstrably

01:18:57.080 the biggest sea change we've had in the reduction of risk for the most prevalent chronic condition

01:19:03.040 in the developed world. Would anybody with a straight face say that there aren't risks of

01:19:07.940 statins? Nobody with a straight face could tell you that statins don't harm some people.

01:19:14.380 And there's nothing bizarre about that, right? There's nothing odd to say that. I mean,

01:19:19.000 like, don't we talk about this every time we give patients a drug? You give somebody a

01:19:24.660 prescription for something. Hey, let us know if you develop a rash. If you do, it could be really

01:19:28.700 severe. You know, you please call us right away and let's stop it. You might be one of the 4.9%

01:19:33.600 of people that is susceptible to this side effect, right? So somehow it's become impossible to have

01:19:42.140 the discussion, if you're coming at it from the sort of the advocacy point of view, that there might be

01:19:47.680 a risk associated with a vaccine. Until, you know, something like the J&J thing came along

01:19:52.340 and then the response seemed the exact opposite. So this is the thing I'm struggling with, okay?

01:19:57.880 So this is a long rambling question because I don't understand something. I don't understand how

01:20:02.540 when the first J&J data came out and said, I believe it was six cases of VTE in 7 million doses,

01:20:12.700 so about one in a million incidents, the drug was pulled, the vaccine was pulled. And in a moment,

01:20:19.540 we're going to talk about myocarditis with Moderna. Nobody wants to talk about that?

01:20:26.780 Why the difference? I'm asking for opinion because, I mean, we can talk about what the facts are,

01:20:31.580 which we'll get to. But the broader question is, help me understand the difference because I'm

01:20:36.360 getting questions from patients of mine saying, I don't want my 18-year-old son getting a third

01:20:44.220 mRNA booster, which is being mandated by his university. Do you think I'm crazy? To which

01:20:50.640 I say, no, you're not. Here's the data that tells me you're not crazy. And I'll let Marty answer this,

01:20:55.520 but I just want to say this. I think it comes down to the difference between peacetime and wartime

01:21:00.440 vaccine communication. And again, this is advocacy versus science. So in peacetime vaccine

01:21:05.400 communication, you have children who need to get these series of vaccinations in order to prevent

01:21:11.320 common, what would re-become common diseases like measles, mumps, et cetera, if we didn't get a

01:21:18.000 certain degree of herd immunity that happens, which is above 90-odd percent. And so the messaging has

01:21:23.820 always been, hey, listen, there are very rare side effects of these things. And by the way, they can

01:21:28.460 be quite serious, but they're very rare. But as a community benefit, pretty much the risk to your

01:21:34.220 child is so small. And the risk of the communicable disease is small, right? In an absolute sense,

01:21:39.920 absolutely small. But if we don't do this as a community, we're going to have a problem. And you

01:21:44.260 see it when vaccine rates drop below 90%. You see measles outbreaks and that sort of thing. So the

01:21:48.820 public health messaging has always been, hey, zero tolerance for anti-vaccine discussions. We don't

01:21:54.420 talk much about the risks of them because we just need to do this and they're mandated for schools and so

01:21:58.980 on. Now, there's merits and demerits to that approach, but that is the peacetime approach

01:22:04.600 to vaccines. The wartime approach where you have uncertainty, you have changing data, and you have

01:22:11.720 risks and benefits that are stratified by age and comorbidities, we're applying the same peacetime

01:22:18.320 approach, which is vaccine absolutism with no quarter. And anything you say against the vaccine

01:22:24.600 is taboo. So it becomes almost an unspeakable curse like in Harry Potter. You can't use them or

01:22:32.160 you're excommunicated from the tribe of medicine. And it has become a tribal thing. Well, now I think

01:22:37.700 it's become this kind of absolutist thing that they've applied in wartime to something that it

01:22:42.280 just doesn't apply to, which is this vaccine, which as you mentioned, has risks that actually are worse

01:22:48.700 for younger people and benefits that are much less for younger people. So we ought to be looking at

01:22:54.820 it clear-eyed. So I'm sorry, Marty, over to you. That's just my rant.

01:22:59.800 No, look, you're spot on here because what we now see in this tribalism of medicine, and we've seen it

01:23:07.100 in the group think of so many aspects of COVID that the establishment got wrong. And the reality is we've got

01:23:12.980 a few people making all the decisions on COVID. A very small group of non-age-diverse, non-ethnically

01:23:22.660 diverse political appointees with political allegiances making all the decisions on COVID for

01:23:29.480 the country. And quite frankly, I think they're detached from the life of a young person in Baltimore

01:23:35.460 City who was barely hanging in school pre-COVID. It's not as easy to hand that person an iPad and

01:23:43.660 say, we're going to do remote learning as it is in the Hamptons or in Santa Barbara County.

01:23:49.580 So what we developed was this sort of tribalism whereby if you would question anything that might

01:23:58.360 result in an answer, albeit scientific, that could threaten to vaccinate every human being with two feet

01:24:05.380 message, then that needed to be suppressed or squashed or ridiculed or labeled an anti-vaxxer.

01:24:12.740 It could be natural immunity. I think that's maybe how I initially got sort of seen as, hey,

01:24:20.080 is he one of us with the vaccine community? Last year, I was calling for lockdowns beforehand,

01:24:25.540 warning of this thing, wrote the first piece calling for universal masking to keep society semi-open.

01:24:30.840 And then the vaccine rollout came along and I said, hey, wait a minute. It needs to be simply

01:24:36.360 age-based. And those who have natural immunity need to step aside in the vaccine line so we can

01:24:41.600 save more lives. And let's just focus on the first doses because the immunity is pretty good for three

01:24:47.320 months. We can save more lives. Tens of thousands of people could have been saved if we adopted those

01:24:52.040 policies. And some people would suggest, hey, wait a minute. If you're saying hold off on the second dose,

01:24:57.640 you're kind of anti the vaccine. And if you're telling people with natural immunity, they can

01:25:02.100 wait a little bit based on the data, that's kind of anti-vaccine. And if you're asking about the

01:25:06.940 myocarditis complications, trying to understand the rate of them, that could scare some people off.

01:25:12.920 And therefore, you might be putting an anti-vaccine message out there. The VAERS data system,

01:25:18.760 which is the self-reported system the FDA set up, is such a shoddy, poor way to track complications

01:25:26.240 that it's basically unreliable. It's overloaded. And yet at the same time, it's very cumbersome to

01:25:33.380 report into that. Most doctors that tell me about a complication have say they haven't reported it to

01:25:38.620 VAERS. You really get almost no follow-up. There's been deaths in children in the United States

01:25:43.620 immediately after the second dose from myocarditis. And the CDC says they are going to investigate one

01:25:49.820 of them. That was several months ago. We never heard anything. So if you ask questions, it's almost

01:25:56.220 as if, how dare you? Now, look, the vaccine still makes sense in a certain context, in a certain way

01:26:02.340 in young people. It's often to present MIS-C and hospitalization more than it is to prevent death in

01:26:09.040 children, but it's nuanced. It's not a one size fits all strategy, especially with those who have

01:26:14.460 natural immunity. So let's talk a little bit about that. ZDogg, Vinay did a great video on this just the

01:26:19.940 other day, but let's talk a little bit about what we know. And now let's just talk in fact for a moment,

01:26:25.900 right? Let's not editorialize anything. What do the data suggest with respect to the Pfizer vaccine

01:26:32.380 and the Moderna vaccine with respect to the incidence of myocarditis in males and females

01:26:39.740 below the age of 40 and stratify that as much as you see fit? So I'll give the high level and Marty

01:26:46.160 can dive into the details because he's a vastly bigger nerd than I'm capable of being. But I'll say

01:26:51.640 this, the party line has been that, and you'll hear pediatricians around the country telling their

01:26:59.620 patients this when asked about vaccine. They're kind of reiterating what CDC says, which is the risk

01:27:05.680 of myocarditis in young people is exceeded from a vaccine, is exceeded by the risk of natural COVID

01:27:15.200 infection causing myocarditis. In other words, if they were to go out and get natural infection,

01:27:19.640 they're X-fold more likely to get myocarditis than any risk of myocarditis from either of the vaccines,

01:27:26.980 Pfizer or Moderna. Now, this is in the setting of not knowing the denominator of how many people

01:27:35.420 are actually infected with COVID out in the community. They're just looking at kind of

01:27:38.920 hospitalized patients and so on. And of course, those patients are sicker. Of course, they have

01:27:43.080 more cardiac side effects and so on when they're infected with COVID. There's two counting issues

01:27:47.740 there just to clarify, right, Zubin? The first is you have a negative selection for patients and then

01:27:53.320 you have a underestimation of the denominator. That's right. So in other words, we don't know

01:27:58.600 how many people got infected with COVID out in the community that did just fine. We're guessing at that

01:28:03.820 using incomplete tools. And so that's part of the problem in the calculations. Whereas with vaccines,

01:28:08.360 we can say, oh, these guys got vaccinated and there were this many cases of myocarditis and they were

01:28:12.660 hospitalized for this many days and they had this kind of cardiac function at discharge and these

01:28:16.440 were the complications and so on. So you can actually look at that data. Now, looking at all that same

01:28:20.860 data that was available, the European authorities said, you know what? Actually, we see a bigger

01:28:25.200 risk with Moderna for myocarditis that especially when we have Pfizer, which seems to have less

01:28:30.660 myocarditis. So we're just not going to recommend Moderna for men or people under 30. Now, that's a

01:28:36.920 huge difference between US and European policy based on data sets. Now, this is where the newer data

01:28:42.060 comes out that Marty can talk about saying, hey, you know, this may not be true that actually

01:28:46.340 natural infection is more myocardiogenic than the vaccines. Yeah. So we generally recognize this rate

01:28:55.460 early on to be somewhere in the range of one in 7,000. And that is young boys and young men. So

01:29:04.200 in the age group 15 to 25, the rate was about one in 7,600, according to a New England Journal

01:29:11.240 study after the second dose. The complications, 90% of them were clustered around the second dose

01:29:17.180 and the myocarditis cases, the vast majority of which were mild, but two were severe in the New

01:29:24.420 England Journal analysis out of Israel. And one person died. That is a 22-year-old died. I know

01:29:30.680 you can barely say that because of the sort of trigger that it creates. But look, by and large,

01:29:37.300 this is a safe vaccine. But for parents asking these questions about vaccinating their kids

01:29:44.320 against an illness that has an ultra rare rate of death in healthy children, this is a reasonable

01:29:52.600 conversation to have. Maybe the rate of death from the vaccine parallels the rate of death from COVID in

01:29:59.120 a healthy child. Now, the CDC reports there are 668 deaths over two years. So let's say roughly 300

01:30:07.300 some deaths a year from COVID in everyone under age 18, all children. Who are those kids? We believe,

01:30:16.380 many of us believe that they are nearly all in children with a comorbid medical condition. Now,

01:30:23.660 they're still important members of our society. We need to do everything we can to protect them.

01:30:28.360 But it does change the calculus now for healthy kids when we recognize that the vaccine is not

01:30:35.160 halting transmission. So to subject all healthy children to a vaccine, when the risk of myocarditis

01:30:43.880 can be as high as one in 7,000 young males and boys, then all of a sudden you're talking about a

01:30:51.820 very nuanced decision where some pediatricians might say, you know what, how about we do one dose?

01:30:57.640 There was a study of kids 5 through 17 in Germany that just went on the preprint server.

01:31:05.860 Of all the deaths in Germany over the 15 months of the pandemic, right up until around March,

01:31:12.420 March, April, there were zero deaths in healthy children. No healthy child has died. 100% of the

01:31:19.160 deaths were clustered in kids with a comorbid condition, 100%. So that changes the calculus now

01:31:25.540 to a parent that says, hey, my kid's healthy. I'm a little concerned about the rare side effects.

01:31:32.400 I'd like to talk about the data. This is a conversation. It is not a one size fits all

01:31:37.900 strategy as we are being told. And especially when you get to boosters. I mean, here's the New England

01:31:46.880 Journal paper from December 8th, looking at boosters and no boosters in kids. Well, I call them kids

01:31:53.480 because I'm on a college campus. In people under age 30, okay? In people under age 30 who are vaccinated

01:32:01.040 with the primary series, there were zero deaths. This is population data from Israel. Zero deaths

01:32:07.660 after the regular primary vaccine series. You cannot lower that any further. You cannot lower the number

01:32:13.280 zero further with a booster. Well, they looked at those with boosters and as you would expect,

01:32:18.340 zero deaths in that group. And then in Germany, they looked at people really essentially over a

01:32:23.020 period when there was no vaccines and the rate was also zero for healthy kids. That tells me

01:32:29.720 the kid has a comorbid condition, get the vaccine. Otherwise for healthy kids, it's a nuanced discussion.

01:32:36.920 If you look at the circulation paper that came out in July of this year,

01:32:39.640 the knock on this is it doesn't distinguish between Pfizer and Moderna. So we'll talk about

01:32:46.260 that in a second. But I think to me, the most interesting table in there is the one that

01:32:51.140 stratifies by age. And then it does risk and benefit male for female, which again, seems to me a

01:32:57.840 very reasonable way to think about this, right? So when you looked at 12 to 17 year old males and

01:33:02.800 females, and again, this is all mRNA vaccines, we know now, I think, can we say that unequivocally

01:33:11.700 the Moderna vaccine is three to four times more likely to be associated with myocarditis or

01:33:18.680 myopericarditis? At least. At least, yeah. Okay. The supplemental data that came out

01:33:23.960 literally two days ago looks like it's five times worse, but let's be conservative, say three to four

01:33:29.620 times worse. So keeping in mind, I'm giving you blended data, 12 to 17 year old, females,

01:33:36.440 eight to 10 cases of myocarditis per million doses, males, 56 to 69 cases, blended, benefits,

01:33:46.520 saves 38 ICU admissions, saves one death. So here's where I'm struggling, right? Now, if you look at this

01:33:55.340 and you say, look, you're going to give 70 cases of myocarditis to save a death, what's the natural

01:34:01.280 history of those 70 cases of myocarditis? So Zubin, how many of those kids make an unremarkable

01:34:08.820 recovery? How many of those kids are going to have a chronic issue with their heart? They're going to

01:34:14.820 have a reduced EF for some point of their life. And will any of those kids die?

01:34:20.320 And this is the thing, we don't have enough data to be able to actually answer some of that.

01:34:25.340 I think there's a degree of uncertainty. And when you're talking about the quality life you're

01:34:28.980 saved in a kid, if you're going to in any way impinge on their ejection fraction of their heart

01:34:35.160 in the future or cause any scarring or cause what we may even be underdiagnosing, whether there's

01:34:40.840 arrhythmia happening, it becomes a really open question that this ought to be looked at very

01:34:45.640 carefully. Now, Marty may have his hands on some of the more specific data on the outcomes. You

01:34:50.000 mentioned the 22 year old that died. It's also a little difficult to peg causation sometimes,

01:34:55.000 because some of these kids had also preexisting cardiac abnormalities. We always think about

01:35:01.540 sudden cardiac death in athletes and children and whether to screen or not, and those kinds

01:35:06.600 of things are outstanding questions. But even if this were to provoke that to happen, say,

01:35:12.400 if they were to get myocarditis, you're impacting a child and tons of life years that are affected,

01:35:19.080 as opposed to say a 90 year old who maybe the vaccine gave them a fever that pushed them into

01:35:23.640 cardiac arrest. I'm just speculating, right? It's a very different quality of life years

01:35:27.680 saved kind of calculation. So I don't have the specific data of like how many of these kids go

01:35:32.880 on to have chronic problems or even the hospitalization risk, right? So a certain percentage

01:35:39.720 of these 86% in one study that I saw get hospitalized for an average of about three days. When you

01:35:46.400 hospitalize anybody, you put their life at risk because they're in the most dangerous place on

01:35:53.460 the planet because medical errors happen, infections in the hospital happen, complications happen.

01:35:59.060 That's why staying out of the hospital is a good idea if you can do it. So you have to look at that

01:36:03.060 as well. And I just don't, I haven't seen the data that compellingly says, oh, this is the answer to that.

01:36:08.260 The argument I hear, by the way, because I, you know, a few days ago, I saw something that was

01:36:15.220 ranking colleges or something like that. And I made some snarky comment on Twitter, like,

01:36:19.700 can we start ranking the dumbest colleges? You know, when I was going to put my alma mater,

01:36:24.440 you know, going to put Stanford and Hopkins there, which are two of the idiotic colleges in my view,

01:36:29.340 by the way, this is opinion, not fact, who are mandating, you know, boosters for kids and not

01:36:35.440 letting them back to campus without them. And I couldn't believe the people that were just furious

01:36:44.400 with me. How could you possibly suggest this? Of course, those kids need to have their third shot.

01:36:52.140 And the argument was they're putting so many other people's lives at risk by not having booster shots.

01:36:59.300 And I'm thinking, explain that to me. Like, again, this is every six months I do something

01:37:06.740 stupid, which is I engage on Twitter. I need to, I need to create sort of like a testicular tasing

01:37:13.360 device that is hooked up to the Twitter app where anytime I look at Twitter, I get like 120 volt

01:37:20.220 tase to my testes. And it just says like, don't ever do that again. Like don't ever, don't ever go on

01:37:26.380 Twitter. Like nothing good comes of it. It's a DEC device guys, a direct epididymal current.

01:37:33.200 And when you apply at least 73 joules to your joules, it will dissuade you from ever clicking

01:37:39.780 on that stupid app. No, no, I actually just real quick on this because this is, this is the thing.

01:37:44.380 This is the tribalization. So what you did is you behaved as an out group to the in group of

01:37:50.620 whatever public health doctor e types that are on there. And this idea that, that these

01:37:55.280 vaccinating, triple vaccinating these kids at Stanford, and by the way, closing campus for

01:37:59.900 two weeks because of Omicron, which is what they've done. How have we got this far in the

01:38:04.440 podcast without Marty, you referring it to Omicold? Cause this is your term, right? So, so, so for,

01:38:11.920 we're going to close the campus for two weeks because of Omicold. Continue Zubin.

01:38:16.040 Omicold rips through. Marty is, you know, cashing in his royalty money from every time someone says

01:38:21.880 Omicold. And at this point, the argument is, oh, well, they're protecting professors. They're

01:38:26.900 protecting other people in the community. And this is my take, and I'm editorializing. We have no data

01:38:31.220 that that's actually at scale true. We talked earlier in this podcast about the transmission

01:38:37.140 effects with younger people too. First of all, who are they exposing? Well, it's professors and

01:38:41.960 family and community. Okay. Those professors and family and community can make the decision to

01:38:46.620 triple vaccinate, to wear a mask, to stay away from big crowds. In fact, a lot of the professors

01:38:51.060 are teaching remotely as it is. So who are they really exposing? Other kids their age who are low

01:38:56.980 risk, who also have been vaccinated. And if they don't get a booster or they get a booster,

01:39:01.420 what's the marginal benefit? How many cases of myocarditis will you cause where that kid is out

01:39:06.020 of school for three to six days in the hospital? We don't know the long-term effects of it,

01:39:10.320 although I suspect they are generally mild, but that's a more editorializing.

01:39:15.540 These are the questions you have to ask. So when people behave in that rubber stamp way,

01:39:19.000 now I'm guilty of it too, because I editorialize in this way. I think this is crazy. I think these

01:39:23.280 schools are out of their mind. I think we're promoting a culture of safetyism and fragility

01:39:27.400 in children, and we're teaching them that this is okay to do. And who's doing it? People with power,

01:39:32.880 the elderly Uber class that can sit at home on Zoom, they're doing it to young people who this is

01:39:37.800 their chance to be in college and engage with other young people in person. That's what college

01:39:42.360 is. It's not about learning. That's a side effect. It's about the other stuff. So that's my take on it.

01:39:48.480 The WHO has put out an official statement very recently, two weeks ago, saying that universal

01:39:56.440 booster programs threaten to prolong the pandemic. They recommend against these booster programs,

01:40:04.640 and they warn that they will increase global inequities because 93% of the population of

01:40:11.160 poor countries has no vaccine, and one dose is better than no dose. So they're taking a global

01:40:16.500 perspective. Now, look, people ask me, I'm over 65. Should I get a booster? The answer is if you

01:40:22.260 haven't had the infection, yes, it's going to reduce your risk of hospitalization. But if you just

01:40:27.400 bring up what the WHO has already concluded, somehow that's considered an outlier idea that we

01:40:34.200 cannot discuss in the United States. WHO tells people under age six, they should not be wearing

01:40:40.280 a mask. The European CDC says that kids in primary schools should not be wearing a mask.

01:40:47.080 Many European countries have restricted or banned Moderna vaccine from anyone under age 30 because of

01:40:54.900 the risk of myocarditis. So all of that suggests that in many ways, the United States is lagging behind

01:41:01.840 in terms of implementing scientifically wise policies, suggesting that we're making errors in our

01:41:10.780 policy that are ill-informed by science. Certainly the FDA bypassed their technical experts, what we call

01:41:19.020 the VRPAC, which is their external advisors. So the VRPAC had to vote on boosters for everybody. They voted

01:41:26.900 against it. They voted 16 to 2 against it, in part because of the stuff we're talking about,

01:41:32.080 myocarditis and other concerns and a lack of benefit demonstrated.

01:41:35.320 And that was in what age group, Marty?

01:41:37.020 That was for everyone over age 18. So it was boosters across the board.

01:41:42.040 Oh yeah, I see. I see. Yeah. The second wave of boosters. Yep.

01:41:44.620 Yep. So they voted it down. The experts said no. These are smart people. Then the FDA made a second

01:41:51.240 internal push in the agency weeks later. And they chose this time during this process not to convene

01:41:59.480 their experts, to circumvent their own experts because they didn't want the input of people who

01:42:04.820 were opposed to it. And they unilaterally authorized boosters for young people. CDC did the same.

01:42:12.820 And so what we now have is this dramatic vigor of enthusiasm around boosting every 16 and 17 year

01:42:21.060 old in this country with really a lot of experts saying, hey, we are not on board with this. And

01:42:26.760 a lot of the world is not on board with it. And so that's where we ended up where we are today.

01:42:31.620 It's group think. If you think about it, when Omicron came up, it was almost like,

01:42:36.440 here's an opportunity to push boosters in young people. Pfizer puts out a press release saying that,

01:42:44.080 hey, if you get a booster, it will help with Omicron. Okay. Nobody knew anything about Omicron at

01:42:49.120 that point. There was speculation it was mild. Now we have a lot more information.

01:42:53.260 The next day, the next day after Pfizer's press release about an experiment they did in the lab

01:42:59.500 without releasing the underlying scientific data, the next day, the CDC rigorously puts out a strong

01:43:06.620 recommendation to boost every 16 and 17 year old. Is that what we've come to now? Pharma puts out a

01:43:12.760 press release. And the next day, we bypassed all of our internal experts. And we have this bandwagon

01:43:18.420 effect of colleges and universities, which are supposed to have smart people, requiring boosters

01:43:24.880 in a population that Germany found doesn't have any deaths in five to 17 year olds without any

01:43:32.480 vaccine. I'm not recommending that, but what are we protecting them from?

01:43:37.940 And again, this is not measles. This is not sterilizing immunity. This is not high level

01:43:41.780 herd immunity that we're giving them by vaccinating them.

01:43:44.000 Again, I just, I'm so troubled by this because of what I think about as the long game, right?

01:43:50.620 The long game is, I mean, how many times has Anthony Fauci said an attack on me is an attack

01:43:56.740 on science? I mean, I actually had to go and look some of those things up because I'm like,

01:44:03.360 no, he didn't really say that. That's just a mean, you know, like nobody would actually say that.

01:44:09.600 He's had a rough year.

01:44:10.820 And he didn't say it once and he didn't say it twice, right? I lost count of how many times

01:44:16.480 he has said that. So, you know, there's a part of me that's very empathetic to Anthony Fauci,

01:44:22.880 right? I think that's a horrible position to be in, right? He was sort of thrust into this position

01:44:27.120 as the world's, or at least the nation's expert on infectious disease matters in a moment when

01:44:33.260 nobody knew anything, right? So he's having to sort of wear a mask, don't wear a mask. And,

01:44:38.740 but I think the lack of humility in expressing uncertainty and the doubling down and then the

01:44:48.040 statements around, I mean, I have to tell you, I didn't want to get too political today, but I was

01:44:51.980 very disheartened to see how vociferously he denied NIH funding gain of function research in the Wuhan

01:45:00.680 lab. I mean, I don't really understand how you can deny that. Francis Collins still thinks it's

01:45:06.820 unlikely it came from the Wuhan lab. I mean, the head of the NIH, he just said that last, uh, last

01:45:12.400 week. How do they not just deny it? I mean, you look at his exchange with, with Senator Rand Paul,

01:45:18.820 like this is beyond denial, right? This is attacking anybody showing you the evidence that

01:45:24.780 your Institute has funded gain of function research in a particular lab through an intermediary. Like

01:45:30.500 where's the ambiguity here? Well, where's the humility? People are hungry for honesty right now.

01:45:37.800 And if I were Anthony Fauci or Francis Collins, I would say, look, we were out there parading around

01:45:44.260 gain of function research, giving grand rounds and lectures around the country, writing

01:45:48.540 op-eds about the importance of doing gain of function research. We came, we came at it from

01:45:54.400 a perspective that was a little old fashioned back in the days when it took months to sequence

01:45:58.960 a piece of the gene. Now we can do it in 20 minutes. There's no need to, to Frankenstein up viruses

01:46:06.440 just to study them. We feel terrible. We don't believe the dollars from our research funding went

01:46:12.660 directly to do this type of research, but they went to the lab. And for that, we're sorry.

01:46:17.220 Let's agree now to ban all gain of function research in the future in perpetuity forever

01:46:23.600 of all kinds. And let's make that an international treaty. They could show leadership on that,

01:46:28.420 but instead that it's almost like they're defending it.

01:46:31.200 Yeah. And what I struggle with, and I think you'll both appreciate this. I know, I know you

01:46:35.360 will. Cause I've heard you both speak on this is when bad outcomes happen in medicine,

01:46:41.180 the doctors who get sued versus the doctors who don't get sued. It doesn't come down to the

01:46:48.680 grievousness of the error. It comes down to the arrogance and the humility with which the physician

01:46:53.380 interacted with the patient. Every one of us, I know have made mistakes with patients.

01:47:00.920 And when you say to that patient, I really screwed up. I mean, like I sent you to get a CT scan and it

01:47:07.260 wasn't even supposed to be your scan. That was a clerical error on my part. And you got exposed to

01:47:12.720 radiation unnecessarily. Or even the most extreme examples of errors that have happened.

01:47:19.920 You go to that patient and you say what you did and you fess up. And if you want bonus points,

01:47:24.880 maybe even explain what could be done different the next time so that it doesn't happen to somebody

01:47:29.540 else. I don't think there's a scenario under which a physician under that situation has been sued.

01:47:34.380 You start lying and you start posturing and you start denying and you start in the face of

01:47:41.940 overwhelming evidence. And you sort of make the person feel like they're crazy. I mean, guess what?

01:47:47.880 Like there's going to be a little packet coming your way from a lawyer. This is like the highest

01:47:52.380 order example of this, right? That's a really good analogy, actually, because we've all been in those

01:47:56.820 positions. And I tell you, I've thrown myself at the feet of patients' families saying,

01:48:01.200 this was a mistake I made. Here are the things we're going to do to make it better. I'm sorry.

01:48:05.320 You know, and again, I have not been sued, knock on wood. But with Fauci, it's interesting because

01:48:09.920 let's, I'm going to play Fauci advocate for a second. Here's a guy, because I was part of a

01:48:13.680 documentary that hasn't been released prior to COVID. They had interviewed Fauci and, you know,

01:48:19.860 Hotez and some other people about vaccine advocacy and the anti-vaccine movement and things like that

01:48:25.180 prior to COVID. And, you know, he has just been kind of filleted by a lot of the sort of more

01:48:31.260 activist conspiracy angles on things and really did feel like science itself was under attack to some

01:48:38.740 degree. Now you throw in, okay, he's under a lot of political attack. He gets all this hate mail and

01:48:43.840 all of this. He's probably doing what humans do, which is entrenching, solidifying his position and

01:48:48.860 becoming an absolutist, which is not what we need. It's not what we need. If he had insight or a good

01:48:53.860 therapist, they could probably tell him, dude, bro, this is not good. You need to be honest.

01:48:58.180 Like if you think masks shouldn't be used because we're really trying to save them for healthcare

01:49:02.680 professionals, just tell the public that. And I think that that's it is, you know, these are human

01:49:08.320 beings. He's 82. And we forget that 81 now, 81. Wow. I mean, that's just had a birthday. Nice. Happy

01:49:15.560 birthday, Anthony. And, you know, and I was on, I was on a call with Anthony Fauci during Ebola that I was

01:49:21.140 invited to, where he was trying to talk to public health people about, Hey, here's how we can think

01:49:24.580 about Ebola. He was rational. He was calm. He was logical. He was science-based. He diffused a lot

01:49:29.900 of fear. I thought it was brilliant. Right. And so to kind of see this transition is, is, is difficult.

01:49:37.360 And to be clear, and I'm glad you said that by the way, I'm not saying I would be one bit better.

01:49:41.260 Like I just want to be clear everything I'm saying to be, to be critical of advocacy versus science here.

01:49:47.180 I'm sure I would be doing the same thing. I'd probably be worse. He seems to have a much nicer

01:49:51.420 disposition than I do. I agree. Yeah. Yeah. Yeah. But it doesn't change the fact, right? What's the

01:49:55.920 aspiration here? And maybe this shouldn't be all on one guy's shoulders. Because to your point, how

01:50:01.660 exhausting is this? Like I'm sick of this and it's not my job. Yeah, me too. Like I am sick and tired of

01:50:09.720 this. And I have the luxury of getting to focus on stuff that I actually find interesting.

01:50:14.380 So yeah, maybe this shouldn't be one guy.

01:50:18.340 It shouldn't be one guy. We should not be putting our entire faith and trust in one individual. We

01:50:25.160 should be hearing about multiple different medical opinions. And we should from the, we should have

01:50:29.880 from the start, you know, I called in, as you know, I was very nervous about the pandemic and what it

01:50:35.780 could do beforehand, following what was happening in Wuhan and calling doctors there. And as editor in

01:50:42.900 chief of MedPage today, I wrote some pieces and was reading articles coming in. And it was pretty

01:50:48.020 clear to me that our country needed to wake up. So I had some relationships with the White House for

01:50:52.840 my work on price transparency, made a phone call into the White House and said, this was in February

01:50:58.860 before the pandemic. I said, look, this is going to be really bad. We need to drop all kinds of

01:51:03.280 contingency plans as a country, stop non-essential travel, get testing up and all this stuff went through

01:51:08.820 the whole gamut. And they were shocked. And they said, you know, what you're saying here is would

01:51:14.780 be a major shift in how we're approaching this. And I said, yes, I look, I've talked to the experts

01:51:20.900 and I believe firmly in this. This is stuff we need to do. About a week later, I got a call back

01:51:25.940 from them. And I, they said, well, good news. We got a chance to talk to Dr. Anthony Fauci and he says,

01:51:32.940 we're going to be okay. Now, look, we all make mistakes and that's okay, but you've got to evolve

01:51:37.900 when the data come in. And he had hedged his bet watching SARS-1, that is SARS in 2003. It just

01:51:44.740 petered out in Asia. And he kind of hedged that that's the way it was going to go. And yet every

01:51:48.920 media outlet going to him saying, hey, do I need to worry? Do I need to worry? And as you know,

01:51:53.420 as a physician, it's much easier to give reassurance than it is to say, yes, I'm very concerned.

01:51:58.720 So that's how, I don't know whether or not to blame him or meet the press and face the nation

01:52:06.000 and all these, that just incessantly ran one opinion and not that of Amisha Dolja and so many

01:52:13.860 other infectious diseases doctors with the chops to say, hey, you know, they've got a different

01:52:18.420 perspective. Can I ask something heretical at this point though? At this point in the pandemic where we

01:52:23.800 have Omicron and we have a vaccine, we have therapeutics, does it even make sense to push

01:52:30.280 such widespread testing, whether it's antigen testing or PCR? I want to throw this at you

01:52:35.300 guys and see what you think, because I'm curious the answer to this.

01:52:39.140 I'll share with you my opinion. I don't think so. Because someone's already, one of you has already

01:52:42.580 made this point, which is there really isn't a precedent for tracking rates of infection for

01:52:49.840 respiratory illnesses. What we pay attention to, and as has been noted by many people,

01:52:55.420 what we pay attention to is hospitalizations, severity of illness, death. So morbidity and

01:53:00.400 mortality effectively is the statistic that matters. And somehow infection rate has now become a metric

01:53:08.640 that matters. So you can measure it, look at measures, matters. We don't measure influenza infection

01:53:14.880 rates. I've never taken a test for it. I remember when I had H1N1 in 2000, what year would that have

01:53:22.280 been? Nine? Nine. I had it. I never got tested for it, but we finally put two and two together

01:53:27.500 because my LFTs hit a thousand. I mean, I was sick as a dog. I was literally on the verge of getting a

01:53:34.920 liver biopsy before my doc went, wait, I think that illness you had a month ago or two months ago was

01:53:42.140 H1N1. Let's wait another month before we stick a needle in your liver. And sure enough, my LFTs

01:53:48.300 returned to normal. So, I mean, I'd fully support, I think, or at least noodle the idea a lot more

01:53:54.660 that what if we never tracked infection rates and we used it as epidemiologic data, right? So we did

01:54:01.300 some sampling perhaps so that we could understand movement, new strains and things like that. Maybe

01:54:06.440 even use it to develop predictive models that might tell us when there might be an uptick

01:54:10.380 in hospitalizations, but it no longer became a metric. Like you didn't see it on the news every

01:54:15.640 day and people didn't talk about it as the thing that needed to go to zero.

01:54:21.180 On top of that, I think there's the personal downside and upside of testing. So I'm a young

01:54:25.880 person. I have a few symptoms or I'm screened. Let's say I'm screened, asymptomatic, you know,

01:54:30.720 to do whatever I need to do at school or whatever. They screen me with an antigen test and I'm positive.

01:54:34.500 Well, now I'm stressed. I have to quarantine for 10 days or five if you're listening to CDC's advice

01:54:40.840 on hospital workers, which apparently is different and has been downgraded in terms of time because

01:54:46.100 of need. I'm sitting there freaking out. Well, let me see. Do I get monoclonal antibodies? Should

01:54:51.300 I take this? Should I do that? Whereas my pretest probability of anything happening to me is so low.

01:54:56.840 And in fact, the pretest probability of this being a false positive is quite high in an antigen test.

01:55:02.020 Isn't that causing a degree of harm and cost? And it might be. Now, the upside is, of course,

01:55:08.400 that person, if it was a true positive, can stay home and doesn't infect other people. But if it's

01:55:12.540 already so widespread, does it really make a dent in something like Omicron that's so transmissible?

01:55:19.280 Now, with an old person who's symptomatic, you're going to test them anyways, because at that point,

01:55:22.320 they do need therapies in the forms of monoclonal fluvoxamine, et cetera. So again,

01:55:27.680 it's a stratified by risk, it seems. But a mass population testing.

01:55:32.100 Another way to think about this is don't order a test unless the outcome would change how you're

01:55:36.700 going to manage the patient. And in the case of therapeutics, for someone who's symptomatic,

01:55:41.740 the answer is, yeah, it might be worth testing. I think the idea of asymptomatically testing

01:55:47.160 athletes is one of the most ridiculous things I've ever seen. Like, we're going to just

01:55:51.120 test everybody in the NFL and NBA and NHL and NC2. I mean, it's like, serious? Like,

01:55:56.180 what is the logic of this?

01:55:58.680 If you test athletes or anyone in the population for meningococcus bacteria in their nose,

01:56:08.140 10% of the population will come back positive because that bacteria lives in a colonized,

01:56:14.400 you know, non-virulent form everywhere.

01:56:17.340 We need to put these people in a neuro ICU, Marty. Do you understand how deadly that bacteria can be?

01:56:23.820 I mean, can you imagine what the neuro ICU rate is going to do at this point? This is,

01:56:30.160 by the way, what if we just checked everybody for staph on their skin? Like, how many people

01:56:35.100 are walking around with MRSA on their skin?

01:56:37.400 Quite frankly, guys, you're not invasive enough. I would do urethral swabs on everyone to screen for

01:56:42.980 gonorrhea and chlamydia because, God knows, if you have an asymptomatic case of chlamydia, I mean,

01:56:48.480 your nuts could fall off. So, you know, there's all kinds of... Again, I like Peter's basic

01:56:55.140 medicine, internal medicine idea here. Don't do a test unless it's going to change your management

01:57:00.620 in some positive way.

01:57:01.900 Look at what we've done to physicians. And this is what I've sort of the complaint that I hear from

01:57:08.740 the infectious diseases doctors I respect. We've done a terrible thing to physicians in the United

01:57:13.180 States. We put them on this singular mission to block viral replication, hunt it out, find it,

01:57:21.160 block it at all costs. And what we've lost track of is treating the entire person. And we've lost track

01:57:28.380 of the sustainability of any system to do this. If we start mass testing everybody in the population

01:57:35.460 on it, you could test every child every day when they show up to school in perpetuity. It is going

01:57:41.460 to create a burden that's unsustainable. It's going to bankrupt our system. Look at what we're doing

01:57:46.600 right now with the mixed message coming from public health officials slash the White House. And look,

01:57:53.220 I don't have a political bone in me, but this has been an endemic problem with government,

01:57:57.060 regardless of any political party, red party, green party, it doesn't matter, no party.

01:58:03.140 You've got the government right now saying, if you want to gather for New Year's or whatever,

01:58:09.420 you need to do this massive testing of people coming in. And at the same time, they have a very

01:58:15.680 limited supply of about 500 million tests that'll be rolling out over three months, which is about

01:58:22.240 160 million tests a month. You would need one to 2 billion a month to do what they're saying.

01:58:29.460 So they're telling you to do something and then you don't have the tools to do it. It's putting

01:58:32.980 people in a very difficult decision paralysis. And then we've got, we put doctors on this crazy

01:58:38.560 mission of hunt out all viruses, block replication at all costs. We've done a terrible thing to the

01:58:45.480 entire medical community right now. Yeah. With no end point. Has anybody in the driver's seat

01:58:52.280 signaled what the end point is? Cause I do think that is an important question is let's use a totally

01:58:59.500 unrelated example, right? So a person who's working their tail off to make more money because they

01:59:05.620 believe that at a certain dollar amount, all their problems are going to be solved, right? Once I have

01:59:10.660 this amount of money, I don't have to work this hard. I don't have to act this way. I don't have

01:59:16.220 to ignore my family. I'm sort of making something up, right? You always have to ask, well, tell me

01:59:20.740 what's going to change. So tell me when you have that many dollars and you retire, what's going to

01:59:29.680 change? So how many dollars do you need and how will it change things? So when you bring that sort of

01:59:35.620 silly analogy back to this, I really haven't heard a clear articulation of that, which is not to say

01:59:40.960 one hasn't been made in defense of those who would make it, but I haven't heard it. Have either of

01:59:45.320 you? I haven't heard it recently. It's been an evolving thing. In the beginning, it was a bend

01:59:49.860 the curve until we get better therapeutics and possibly a vaccine, which we don't know if is going

01:59:53.500 to work or not. Then once we had a vaccine, okay, just try to get to the point where we have enough

01:59:58.560 herd immunity from vaccine and natural immunity that we'll get to that point. Well, then it turns out that

02:00:02.800 shifts with new variants. So now the question is, oh, well now with Omicron, the variant's so

02:00:07.500 contagious. Well, we don't know. At this point, we have to go back to the same things we were doing

02:00:11.260 before, which is masking and forcing people to vaccinate, including children and so on, to get

02:00:16.940 to, I don't know what, so that our hospitals don't get overwhelmed. But no one, I have not heard a public

02:00:22.500 official say, oh, this is how we transition to an endemic virus, or this is the goal where we're going

02:00:27.840 to have a virus that lives with us forever and it's going to be okay, but we just have to get to that

02:00:31.540 point, which means let's not overwhelm our hospitals. So maybe we should shore up our

02:00:35.440 staffing. Maybe we should pay nurses and doctors a little bit of overtime bonus, whatever it is to

02:00:40.360 get them through this. That's the thing. And we haven't even calculated in like, well, how many

02:00:45.440 lives were saved, say from the, and this is kind of irrelevant, but looking at the area under the

02:00:50.720 curve, how many lives were saved from preventing influenza for two years, basically, which we've done.

02:00:55.680 And then how many lives were cost by substance abuse, overdose, economic disaster, and in the

02:01:02.200 third world, starvation from economic problems and so on. So we don't look at things holistically and

02:01:07.300 then we don't have an endpoint. So even if we looked at them holistically, we'd have nothing

02:01:10.780 to shoot for. So it's been quite frustrating. It's so hard because people are conflating two

02:01:17.360 different problems that are happening simultaneous in the United States right now. One is the sort of

02:01:23.640 residual COVID-19 public health threat, which is mostly Delta, but it's the virus infecting the

02:01:31.640 10 to 20 million Americans who are still at significant risk. These are adults who have

02:01:39.280 no natural immunity and no vaccinated immunity, and they continue to show up in the hospital and

02:01:43.800 go on ventilators. And that is a problem. That is a real problem. And it's very precise. It's about

02:01:49.440 10 to 20 million adults with no immunity whatsoever. And they're going to keep showing up in the

02:01:54.660 hospital and it's going to be during the viral seasons. And we can't downplay that. That is still

02:01:58.880 a problem. We still got to encourage them to get vaccinated. But the separate thing going on is that

02:02:04.940 250 million Americans have some form of immunity and they're at risk of mild illness. And we're waging

02:02:12.400 World War III to transiently beat back a mild infection or one that doesn't result in hospitalizations.

02:02:20.060 And we're not putting that in context. And if you say anything to say, hey, we've got to learn to

02:02:24.560 live with this. It's like, hey, there are still people dying. But yes, that's a very precise group

02:02:30.760 of adults with no immunity and some very older people who are unboosted who are coming to the hospital.

02:02:36.720 About 7,000 Americans a day are coming to the hospital being hospitalized with COVID. About 7,000

02:02:43.800 of them have no immunity. These are adults often with a risk factor like obesity, which we don't

02:02:49.840 talk about. And about 700 or so are unboosted older people. So that is a very precise problem that's

02:02:57.900 addressable. But look what we're doing to the 250 million Americans or everyone else out there. We're

02:03:03.240 holding them hostage right now saying, you've got to take this seriously and go into, you know,

02:03:08.420 make significant sacrifices. Here's what I think the end point is. People are fed up. They're pushing

02:03:15.840 back. And here's what the Australian prime minister just said. Now, if you remember, Australia had the

02:03:22.600 toughest lockdowns maybe in the world. Draconian.

02:03:25.640 This is where sort of zero COVID was a goal.

02:03:28.580 That's right.

02:03:29.240 Yeah.

02:03:29.580 Yeah.

02:03:30.560 That's right. So they did a total 180. I mean, they saw people just, you know, protest this and say,

02:03:37.540 look, we're not, we're not, we don't want to live like this. They did a total 180 on their lockdowns.

02:03:42.320 And the Australian prime minister just made this statement very publicly. He said, we've got to get

02:03:48.900 past the heavy hand of government. We've got to treat people like adults. We have to move from a

02:03:56.740 culture of mandates to a culture of responsibility. That's how we're going to live with this virus in

02:04:02.580 the future. And that could not summarize it better, in my opinion.

02:04:07.840 All of this relates down to the form and function of COVID. So our response, right? So the form takes

02:04:15.640 all kinds of different forms as masks and mandates and lockdowns and schools and so on and so forth.

02:04:21.820 But what's the function of it? The function of it is to obtain some outcome that we all agree is

02:04:27.180 reasonable. Well, I think it's reasonable to say we don't want our hospitals to have bodies piling up

02:04:33.200 in the ER parking lot. Well, so when and how did this happen? Well, occasionally it did happen in

02:04:38.840 certain areas, but on mass it has not. Is it happening now? Well, so far we're not seeing it with

02:04:44.200 Omicron. How do we prevent it? Well, targeted, focused protection of the groups that Marty mentioned

02:04:50.580 that are still at risk is the highest yield way to do it. Boosting and triple vaccinating

02:04:56.660 an 18-year-old college student is not a high yield way to do it, especially when the rest of the world

02:05:02.960 is still begging for vaccine. So there are policy solutions to get the function that we want using

02:05:10.860 forms that are less disruptive. And I think, I don't know, Peter, you shared with me like what

02:05:15.820 Ontario's hospital numbers look like and their ICU utilization, and yet they're going on lockdown.

02:05:21.480 And I looked at those numbers and I was like, man, Peter, like I've taken calls with more ICU beds

02:05:26.920 full than that. Like why would they shut down an entire province for this? I mean, I'm curious what

02:05:33.560 your thoughts are. Well, again, it comes back to the price that will be paid for this. Do we have

02:05:39.800 data on what the last year has done to the vaccination rates for children, vaccines like

02:05:48.680 MMR and things like that? Have we seen a noticeable shift? So the kids who should be getting those

02:05:53.760 vaccines now, what's happening? Are we seeing it go up, down? So I don't know if Marty has the specific

02:05:58.940 data, but I've seen articles written about this and the, at least on an anecdotal level,

02:06:04.740 kids going in for routine vaccinations have dropped dramatically into the more like the 80%

02:06:09.720 ish range, because again, parents are frightened and there's also a backlash against vaccines in

02:06:15.980 general. It's a complex scenario, but what will the outcome of that be, right? That's a huge open

02:06:21.440 question. I've said this now at least twice, but I just can't say it enough, which is what is the,

02:06:28.940 what is the long-term consequence of this for a generation? All the people who have been

02:06:34.580 marginalized, all the people who have been dismissed in their concerns, all the people

02:06:39.840 who have been told you are a horrible human being for questioning a vaccine. You are a horrible human

02:06:46.540 being for not getting a booster shot. You are, I mean, I just wonder what the, so let's assume,

02:06:52.680 let's come at this from the lens of the people in power want to stay in power. That's a

02:06:58.440 natural human reaction. I'm sure if I was in power, I'd want to stay in power. So, so if you're in

02:07:02.280 power, you want to stay in power and presumably staying in power has something to do with the

02:07:07.720 people who put you in power, keep you in power. Don't you think there would be some logic that

02:07:14.060 would say, I want to make sure that if I want to stay in power as long as possible, I should take

02:07:20.360 the most long-term view of doing what is best. And yet you just see this doubling down on things that

02:07:29.520 seem less and less logical. So in other words, with a very myopic view of power, again, totally

02:07:38.040 not the right way one should be thinking about this, but just as, you know, we're trying to think

02:07:42.560 about Omicron through the lens of evolution, I'm just trying to think of the natural history of power

02:07:48.040 and wanting to consolidate it and preserve it as long as possible. This is not even in the best

02:07:53.800 interest of those in power. Feeder is just so logical, right? It's, it's just one of these things

02:08:00.140 where it's, please don't be so logical because what you're saying is making so much sense. I think

02:08:05.740 people at very high levels got a taste of what it's like to be king and they've got the keys and

02:08:12.740 they don't, they don't want to hand it back over. It's just a theory, but I don't think our

02:08:19.340 policymakers are getting good medical advice. Look at what happened. As soon as Omicron cropped up in

02:08:24.620 South Africa, immediately our public health officials retreated to the one blunt tool that

02:08:30.840 they know, which is we got to now give anyone a third dose across the board, including young people.

02:08:36.660 Now, older people, there's data and young people, there is not data to support it. Masks, half of

02:08:42.460 New York city closed down. What about therapeutics? What about learning to live with it? What about

02:08:47.820 all these other things? And what you saw is this retreat to the same blunt tools that we've had

02:08:54.300 and not start talking about Paxlovid and fluvoxamine and treatment and learning to live with it.

02:09:01.260 Yeah. You know, Peter, I think, I think you, again, your rational thinking is not exactly how

02:09:07.280 politicians actually tribalize in our world now where it's tribal identity and it's a badge of,

02:09:12.940 of identity to say, oh no, no, I believe in this and this and this and this, regardless of what the

02:09:17.100 long-term outcome is. I know it will rally my base. I know it will, you know, it's Covidians versus

02:09:22.880 Covidiots, right? It's the people who, uh, on the left feel this way about all these responses because

02:09:28.120 it's been politicized that way and the right feel this way. And so in a way they're playing

02:09:31.860 broadly to their base. Like what did they do when Omicron happened? They stopped travel to South

02:09:36.840 Africa because that's easy. That's a politically expedient thing, except for the South Africans who

02:09:41.960 suffer and the Americans who have family there and others. And of course, Omicron's already everywhere,

02:09:46.200 which we were saying from the beginning. So that blunt tool did absolutely nothing, but it's,

02:09:50.560 it's politically expedient. If you look at what say the administration's doing now, well,

02:09:55.220 the key thing is keep case numbers down because if case numbers are high, then it's going to be much

02:10:00.220 trickier to get reelected, say. Well then, so what do you do? You want to make sure you get as many

02:10:07.240 people vaccinated and do the kind of blunt instruments that try to reduce cases, which

02:10:11.920 is surprising that they're actually encouraging testing because that's going to actually increase

02:10:15.420 the number of cases. Trump was very explicit. He's like, don't test. You won't see any cases.

02:10:19.660 You know, don't let the diamond princess dock because it'll triple our cases. He was at least

02:10:23.720 quite explicit about it, what he was doing. So I think it's quite complicated and there's this weird

02:10:28.880 political tribalization that makes it irrational to people who are looking at it from an objective

02:10:33.540 standpoint. You said, you said earlier something that I think is also interesting, which is like

02:10:39.160 sort of the, what did you call them? The COVIDiots and the- COVIDians. COVIDians, right? So I can't

02:10:44.980 describe myself as either. I know the caricature of what both of those represent because I've interacted

02:10:50.420 stupidly against my better judgment with both of them. And I feel like I'm trying to understand

02:10:57.820 what's your guess on how many people are in the middle. So on the one hand, it's, this is a

02:11:03.300 conspiracy. The whole purpose of this thing is so pharma can make more money, blah, blah, blah, blah,

02:11:09.100 blah. The only thing that works is ivermectin. Like you've got that whole sort of group and then

02:11:14.380 you've got the people we've largely been talking about here. Sort of everyone needs to have a

02:11:20.320 booster every Monday and we never, ever want to see the world as it was in 2019 again until this

02:11:29.840 virus goes the way of smallpox. Yes. This virus will one day be in a museum and until that time

02:11:37.440 it is a zero COVID policy world. So you've got, so, so how many people are not at one of those polls?

02:11:43.580 That's the operative question. And I'll tell you my experience with my platform is we have created

02:11:50.060 what we call this alt middle and it's not a politically central position. It is the synthesis

02:11:54.660 position. So if you consider COVIDians to be the thesis position, Peter Lindberg of the STOA talks

02:12:01.360 about this, the thesis position that lockdown, zero COVID, vaccines for everyone, mandates, closed

02:12:07.180 schools, that position is thesis. Antithesis position is the other position you described, the

02:12:12.340 ivermectin therapeutics. This is all about control. The thing is not as serious as we think, et cetera.

02:12:18.600 What is the synthesis of those positions? Where do you find truth? There's everything is a little

02:12:23.020 bit partial. So this alt middle perspective is, you can call it the center, but it's really a synthesis

02:12:29.100 position, an integral holistic position. I would say, and every single political group says this,

02:12:36.540 that there's a silent majority of people who actually, if you really ask them and you tell

02:12:43.460 them, well, let's think about it this way, forget about all the soundbites, forget about Twitter,

02:12:46.380 let's just talk. They will espouse an alt middle synthesis position or will resonate with it in a way

02:12:52.860 that is really quite profound, which means common sense is there. I think critical thinking is there

02:12:58.880 if you walk people through it a little bit and to a one, I've never talked to a thesis or antithesis

02:13:04.120 person in person that hasn't ultimately settled on a more synthesis position. So it makes me think

02:13:09.340 there's hope, but the way we're doing it publicly is we're rewarded for polarizing into one of the

02:13:14.780 extremes, COVIDian, COVIDiat, thesis, antithesis. And what we need to do is change our basic structure

02:13:21.440 so that we reward a more alt middle kind of perspective. I don't know how to do that, honestly.

02:13:26.340 It's very similar, by the way, with kind of woke ideology. On the one hand, you have the people

02:13:31.920 that in theory, the woke ideologues are there to rally against, right? The true racists, the true

02:13:38.840 sexists, the true people who are, you know, think trans people should be killed or something like

02:13:43.840 that. So you have those people and then you have kind of the woke ideologues. And then I think you

02:13:50.260 have most people in the middle that think this is crazy. Why can't there be shades of gray here?

02:13:56.340 Why is this such a bipolar issue with no, as you say, no dialectical synthesis?

02:14:05.840 So this is why a podcast like Rogan's is so popular, because he actually very often espouses

02:14:12.500 a synthesis rationalist position. Even when he entertains kind of people on the show that are

02:14:16.860 really more antithesis or more synthesis, you know, like a Peter McCullough vaccine guy,

02:14:23.520 he is, you know, when you were on the show too, I was watching and going, oh, this is the synthesis

02:14:27.740 position. You're poking fun at all the extremes of this. And there's not very many rational people

02:14:33.540 in the United States who would really want to hurt a trans person or really want to exclude somebody

02:14:39.240 based on their sexual orientation or their race, right? Consciously, they would not want to do that.

02:14:44.060 And I think we could, because we've had progress, we've had decades of progress on this.

02:14:49.340 And so what we see though, is that in order to belong in an atomized world, in a tribe that you

02:14:55.200 can identify with, you take a much more extreme us versus them position. And I think the woke ideologues

02:15:00.620 are in that. And what it does is it diminishes real racism, real inequity. The fact that, you know,

02:15:06.780 we talk about covidiots. Well, are you going to call a African American, you know, like a black

02:15:11.500 person in Baltimore who's afraid because of Tuskegee and a long history of medical abuse of getting a

02:15:16.600 vaccine, you're going to call them a covidiot? What is, how are you going to reconcile that with your

02:15:22.240 apparent wokeness, right? So it just generates a ton of cognitive dissonance until you can see this

02:15:28.200 from a integral perspective that all this stuff has a bit of truth and partiality to it. And you're

02:15:33.940 always trying to synthesize something that's evolving like an organism towards something

02:15:37.840 that's more true, which means you also have to assume in most people good intent, which we have

02:15:42.560 trouble doing because we are tribal creatures that like to villainize out group. And so getting over

02:15:47.900 that, assuming good intent, I think you might've said this on Rogan, man, if we were able to actually

02:15:51.580 get in people's head, maybe Rogan said that and assume, oh, no, they're actually well-intentioned.

02:15:56.660 Well, that already levels the playing ground that now you can have a conversation.

02:15:59.820 I remember that. That was a really great insight from Joe, which was you could totally

02:16:03.640 eliminate racism or at least distill it down to the true racist. If you had mind reading software,

02:16:09.380 once you had mind reading software, this issue of intent mattering, you know, cause we were debating

02:16:14.380 whether or not intent mattered, which of course it does. Right. But yeah, no, that's, that's a fair

02:16:18.860 point. I want to say something else. This is kind of a mea culpa. I feel my tribalism more than I've ever

02:16:24.840 felt it around this. You know, I remember a few months ago, somebody sent me an image of a woman on

02:16:32.920 Twitter. I think she was a pediatrician and she's clearly, uh, we're going to zero COVID philosophy,

02:16:39.200 or at least that's, I shouldn't even say she's, you know, that, that was my inference based on what

02:16:43.580 she had just posted, which was a picture of her and her three kids at a grocery store.

02:16:48.440 They were in masks, face shields, PPE. And this was, this was not in 2020. This was like literally this

02:16:57.440 summer. And you know, her comment, like she was posting this picture very proudly with her and

02:17:02.880 her three kids and making a comment, like, this is how we roll and 95 face shield, this, this, this.

02:17:10.480 I mean, you couldn't see her kids. You literally would have seen more of them if they were girls

02:17:16.600 in Riyadh. That's how little you could see these poor little kids that looked like they were none of

02:17:25.120 them over 10. And I can't tell you why, but I got really pissed. I got so pissed at her. I don't know

02:17:36.720 her. I don't know anything about her. I don't know her story. I mean, I replied on Twitter in some snarky

02:17:43.020 response to the effect of, please tell me your kids are immunocompromised. Like why on earth would

02:17:49.720 you do this to them otherwise? But it's, it's that particular interaction has stayed with me so far

02:17:57.000 because of how much it worries me about what I've become in this. How have I become so angry at both

02:18:05.120 extremes here? First of all, I'm really impressed that you have enough self-awareness to recognize

02:18:09.760 that because most people don't. I'm with you on this. I think what you're expressing is the

02:18:14.240 righteous indignation of the alt middle. It is this like, wait, this is insane. Just like when you see

02:18:19.460 somebody talking about this whole thing's a hoax and you need to take ivermectin BID for the rest of

02:18:23.560 your life, that's insane. And it generates a kind of a moral outrage, right? Based on our own moral

02:18:29.520 palette of what we find valuable. Now, what I, what I'll add one other piece to this is that

02:18:34.460 this has been potentiated by a collective anxiety of a contagion of Marty calls it the pandemic of

02:18:43.340 lunacy. That is, we are social creatures too. So as much as we try to hide from it, we're connected to

02:18:48.480 others. And this general level of anxiety and panic and disruption and social fabric tearing

02:18:54.260 has then, it feeds back on us as individuals because we're also part of a whole. And that

02:18:59.200 generates that. And that's why things like Twitter really weaponize this. Like I try to stay away from

02:19:04.400 Twitter now because I know, I feel it. And you know, who's my, who's my, you know, if you think

02:19:08.840 of this as a nuclear reactor and I'm about to blow, I'm going to go to go Chernobyl and the top's going to

02:19:12.860 blow out. You know, it's going to be fallout all over the country. The person who is my graphite

02:19:17.860 control rod is my wife, because what will happen is I'll see something on Twitter and it'll be like

02:19:22.440 you, Peter. It'll be like a family of people like stay hashtag stay home. And it'll, they got 13

02:19:27.160 pronouns in their description and they've got 14 masks on their avatar and they've put somehow like

02:19:32.640 bend the curve in their name. And I'm so triggered because I'm just outraged by they don't see the

02:19:37.980 other downstream side effects of their approach. And I'll start ranting and raving to my wife and

02:19:42.400 these people are idiots. I bet they're all over Stanford where you work and this and that and the

02:19:46.300 other thing. And she's like, could it be possible that, and what she'll do, she'll go, could it be

02:19:50.020 that that person is going through this and this and this, and they're seeing it this way. And

02:19:52.960 they've been also paralyzed by fear from this and you're demonizing them as a bad person, but they're

02:19:57.560 actually a good person. And you can just see like, she's lowered the control rod and suddenly I have

02:20:01.660 empathy for this person. And suddenly I'm like, okay, all right. Okay. All right. But we're humans.

02:20:06.420 That's just how we react. The thing is we've potentiated it on mass now with technology that hacks

02:20:12.400 our dopamine drive to go in group, out group. So I don't know. I don't know. Marty, what do you think?

02:20:19.600 It's a really good point that you're both raising here. And I think we need to do everything we can

02:20:24.760 to stand against tribalism. I think we, all of us can do that. We can be role models to others. We can

02:20:32.260 listen to others. We can admit when we're wrong. I mean, these are characteristics that are being

02:20:37.860 completely lost in the echo chambers of cable news and hearing what you want to hear. So you're

02:20:45.180 living in an alternate reality because big tech is feeding you news that actually makes the other

02:20:49.780 side look like they're crazy, right? Because that's how the news has framed their position and

02:20:56.900 you can't see it any other way. So I love the Rogan interview with Peter. And I think that's part of

02:21:04.020 what we're not talking about in society that we need to talk about. And we got to fix this because

02:21:08.360 the next pandemic is probably going to be more severe. You know, we've had a number in our lifetime.

02:21:16.060 I mean, beginning with polio, older patients tell me what it was like going through the polio epidemic,

02:21:22.360 H1N1, SARS, MERS, Ebola, Zika. I mean, we've gotten lucky. We've skimmed the trees on a couple of these.

02:21:29.620 But the next pandemic that's going to be a major serious pandemic, maybe antimicrobial resistance,

02:21:37.180 which is increasing each year, maybe an influenza virus. This COVID-19 virus had an overall global

02:21:43.620 case fatality rate or infection fatality rate somewhere around two-tenths of one percent,

02:21:49.260 somewhere in that ballpark, right? Well, what if it's two percent with a strain of influenza?

02:21:54.840 And we've got this polarized echo chamber of hearing news and the politicalization of the

02:22:01.020 human immune system where the BNT cells have joined the Republican Party and the antibodies,

02:22:06.440 you know, non-neutralizing antibodies have joined the Democrat Party. We can't do this in the future.

02:22:11.040 We're going to need diverse opinions, an open form of discussion, honesty, humility. And I'm

02:22:17.460 concerned where we are leaving in terms of our situation at the end of this pandemic here.

02:22:22.820 Yeah. I got to be honest with you. I'm not optimistic. I mean, I'm going to probably focus

02:22:28.780 most of my energy on controlling myself, which the easiest step on that is literally not looking

02:22:34.400 at Twitter. That's the first. And like, I don't, I spend very little time on Twitter. Like, I mean,

02:22:39.700 less than, I mean, I really don't spend much time on it. The problem is like any amount of time on it

02:22:44.680 seems to be annoying. It's like you could spend 30 minutes a week on Twitter and that's,

02:22:49.480 I have to think it's an anti-longevity agent right there. I mean, that's got, there's got to be a

02:22:54.900 study that will demonstrate that, you know, an hour a week on Twitter will shorten your life

02:22:58.920 expectancy by a year. And more importantly, will reduce your happiness all along the way.

02:23:04.120 Cause it just, I mean, I think there were people who were really good at Twitter who just

02:23:08.580 love to be incendiary and it doesn't bug them and nothing bugs them. They just love to carpet bomb

02:23:15.540 for fun. But like, if you actually think you're trying to make a point and engage, which, you know,

02:23:23.580 sometimes I do, I think there's no upside. Yeah, I agree. It's, it's a bad format in general for

02:23:29.280 that. Now you said something that I think is key that I wish more people would say, which is I'm

02:23:33.620 going to focus on me, right? Like so much, especially with guys, you know, we're so bad at dealing with

02:23:39.400 our own internal states, whether it's emotional states, whether it's cognitive states that we

02:23:45.020 repress, deny, and then project everything out into the world. And we create the world that we hate

02:23:50.380 because it's a reflection of our internal state. And, you know, there, there was an Indian sage,

02:23:55.200 Nisargadatta, who said, you know, some dude asked him, you know, it was, it was, the book was like a

02:24:00.140 bunch of like Americans come to him and ask him a bunch of questions of this guru in India. And,

02:24:04.660 and there's one kid asked him, it's in the seventies or whatever. And he's like, man,

02:24:07.800 there's so much war and stuff. We need to like reform the world, man. The world's so broken.

02:24:11.800 You're sitting here in this cave meditating. What's wrong with you? And he's like, listen,

02:24:16.440 buddy. He's like, don't be talking about, I don't know why I'm suddenly doing my dad. Don't be

02:24:22.560 talking about the reforms. Okay. Mind the reformer itself. Look inside. You're creating your own

02:24:29.020 situation until that internal conflict that's generating this unhappiness is pacified. You're

02:24:34.840 never going to see the world that you want to see. And I think there's a lot there, which means

02:24:38.900 we have to be self-aware. Okay. If Twitter is bad for us, if it really hacks our neural circuitry that

02:24:43.600 causes us on discomfort and lack of longevity, which I agree with you, Peter, for me, it does.

02:24:48.340 That's why I just, I, what I do is I dump and run. I do the Rogan. I'll like dump a video there.

02:24:52.540 I'll be like, okay, guys, have fun with this. And I'm out. And then every now and again,

02:24:55.380 I'll be sitting on the pot and I'll open up Twitter. Cause I'm like, Hey, what's going on on Twitter?

02:24:58.600 And I'm like, Oh shit, this went nuts. This is not good. Another thing I want to, maybe this is

02:25:03.880 maybe a better question for you, Marty, but what, what can parents do? Cause that's the demographic

02:25:09.440 I find myself most concerned with right now is this, this group of, you know, what are we going

02:25:15.660 to call alt middle folks who absolutely believe in science, certainly understand the benefits of

02:25:23.000 vaccines, understand why we needed to do what we needed to do 18 months ago. But today, I mean,

02:25:29.760 these are the calls I get a lot of is, Hey, you know, my kids still are wearing masks every day

02:25:36.380 in schools. They're not being permitted to play sports. If they're not vaccinated, these are healthy

02:25:42.020 12 year old kids that are not permitted to play sports unless they get vaccinated. I feel very

02:25:48.860 fortunate, right? I live in a state that doesn't exactly believe in the government controlling you.

02:25:54.840 And therefore from the minute we've, you know, we've been here for 15 months,

02:25:58.920 school's never been shut down for a day. Our kids are not in masks or it's, you know,

02:26:03.200 it's masks optional. So my kids are not in masks, no restriction on sports, you know, that kind of

02:26:07.900 stuff. I feel very fortunate. What do the parents do who don't live in these States? I mean, what you

02:26:14.660 said earlier, Marty, this is only going to change when enough people get pissed about it. And the

02:26:18.720 policymakers basically realize, Oh my God, I'm going to get voted out of office as a result of

02:26:24.640 this. And by the way, how do you do that with health advocates? Cause they're not really on the

02:26:29.820 hook for votes. You have sort of two layers of this here, which makes it a little more complicated,

02:26:34.680 right? Yeah. Well, I think a lot of people are getting fed up right now and, and this country

02:26:41.340 has a democracy and the democracy does work. It can take time, but elections are already showing

02:26:48.160 polling right now that people want a reasonable approach. And for parents, they should demand an

02:26:53.720 endpoint to restrictions in the schools. If there is a policy that they have no control over,

02:26:59.440 they should demand an endpoint. When we put in so many restrictions in schools, be it

02:27:03.620 the plexiglass, which ironically could reduce ventilation and airflow in a classroom. And kids

02:27:11.620 have to cover their faces with a cloth mask, which the study run out of Stanford in Bangladesh showed had

02:27:17.440 really no impact at all on transmission, just it's such a poor quality mask or a vaccine mandate or a

02:27:25.360 booster mandate, which is what, you know, the bandwagon of the lunacy of what colleges are jumping into

02:27:30.760 right now. They should demand endpoints to these things. You know, at what point, watch the pharma

02:27:37.720 industry change the language. And I predict this will happen from a booster to annual boost. Have you

02:27:45.700 gotten your annual booster? It may be then, you know, we get a new variant, they pop up a new booster in

02:27:51.740 a six month interval. The language will change to, are you up to date? Like it's software. And people

02:27:59.720 that are chasing this may be getting boosters, you know, they may look back in 20 years and realize,

02:28:06.680 hey, I just got 15 boosters for what? People should demand an endpoint. They should demand criteria to

02:28:12.680 remove the masks. They were put in place with no criteria to remove them. They should ask their

02:28:18.220 pediatrician about a single dose of the Pfizer vaccine for their child. That's a reasonable option.

02:28:24.680 It can depend on a lot of factors. And maybe they have concerns. Maybe their pediatrician sees a risk

02:28:30.320 factor in the child and thinks one dose would be safer. Spacing out the doses. Ask about natural

02:28:36.680 immunity. There's people with natural immunity should feel good about their immune protection.

02:28:40.360 So I think these are the things people need to talk about and ask about and vote on come election

02:28:48.380 time. I want to ask both you guys this question. Who are the people that you find to be voices of

02:28:55.020 reason in this? Who do you like to read? Who do you like to listen to? Zubin, you work pretty closely

02:29:01.520 with Vinay Prasad. I find him to be just another amazing example of a thoughtful person in the middle

02:29:07.140 who's rational. Any other folks we can point people in the direction of besides the two of you guys?

02:29:13.480 I'm personally a fan of Dr. Monica Gandhi, UCSF infectious disease doctor. She's been a voice of

02:29:18.620 reason, calm. She also has a really beautiful maternal kind of wisdom about her that she gives

02:29:24.160 off that's a good contrast to a lot of the talking has that are guys. And she's very smart about it.

02:29:29.500 And actually, if you talk to her offline, she is very much obsessed with getting us back to

02:29:35.700 living instead of living in fear all the time. And part of the reason she was such a big advocate

02:29:42.020 of even cloth masks in the early days of the pandemic is she felt that, look, if it lowers

02:29:46.360 inoculum a little bit, it'll prevent some severe disease. But the main thing is it'll get people out

02:29:50.420 there, stop these lockdowns, open up our schools, these kinds of things. And so she's a pragmatist,

02:29:55.740 very, very smart and data-driven gal. Marty, who's on your shortlist?

02:30:00.280 There's really just one person, and that's Dr. Anthony Fauci.

02:30:06.000 Now, in all fairness, he is a true gentleman, if you've ever interacted with him. And he's a very

02:30:11.820 nice guy. I just have had different opinions on how to manage the COVID strategy on almost every

02:30:18.100 single aspect of the pandemic. But to answer your question, Monica Gandhi is terrific. She's got a great

02:30:24.420 sort of feed that she puts out. She's got a site and a Twitter feed that's got great information.

02:30:31.260 Amish Adalja from Johns Hopkins. Peter, you've had him on, I think, early in the pandemic. He's as

02:30:38.520 correct as I think anyone. Everyone's been wrong. Every expert's been wrong. Every expert missed India

02:30:44.240 and Delta and so many other things. But he's been as correct, I think. Martin Kulldorff,

02:30:50.400 he's the gentleman from Harvard who's now with Brownstone Institute, puts out great information.

02:30:56.500 And I would say, more importantly, I do not listen to anyone who's a politically appointed physician.

02:31:05.360 Anyone, current, past, or future. If someone trying to become a politically appointed physician or was,

02:31:13.020 I just block them right out. And I go to these go-to people who I trust.

02:31:16.660 Can I add a couple here? So it's interesting, because I agree, Marty. I actually will even take

02:31:22.180 it a step further and go, someone who's very politically angled on social media, who's taking

02:31:27.840 very strong political stances, I don't trust them either, just because they aren't able to

02:31:32.020 disambiguate that tribalism from their recommendations. I actually am a big fan of John

02:31:38.020 Mandrola. He's an EP doc, cardiologist on Twitter. He's done good work in this space and has been very

02:31:44.060 rational. The other person, and I don't know, Peter, if you know this guy or if you guys have

02:31:47.860 had conflict in the past, because he's more of a vegan dude who I used to have a little bit of beef

02:31:53.040 with, but now I'm convinced he's been very rational on this pandemic, is David Katz, actually,

02:31:58.920 out of Yale. And he's really written extensively, very heterodox, like stuff that would get you booted

02:32:04.340 out of the tribe, basically saying, hey, we should look at the big picture here. We need to look at the

02:32:08.000 harms and the benefits to society. And he's been very rational and has written very eloquently

02:32:13.240 an alt-middle synthesis of this pandemic. The only thing I would add to that, guys, is—by the way,

02:32:19.640 I don't even know everybody on the list that you guys have mentioned. That's how little I'm

02:32:22.440 personally paying attention to this, but I'll now start paying attention to some of those folks

02:32:25.780 sporadically. I don't want to—I have no desire to spend too much time on this.

02:32:30.040 As a general principle, I have no trust in people who can't change their opinion.

02:32:38.260 So when I encounter a person who says the exact same thing over and over and over and over and

02:32:44.940 over again, and when you ask them, do you feel differently about this now versus six months ago

02:32:51.980 or a year ago or 18 months ago, the answer is nope, nope, double down, double down, double down,

02:32:57.140 no matter what they're talking about. It doesn't guarantee that they're full of shit,

02:33:02.700 but it is—it increases the pretest probability significantly.

02:33:07.020 Yeah.

02:33:07.320 Yeah. Like school closures last year. If anyone who called for school closures has not come out

02:33:13.000 and said, you know, we got this terribly wrong and it disproportionately affected poor and minority

02:33:18.300 communities, I feel terrible, then I've written them off.

02:33:22.720 Yeah. It's hard to trust them. Actually, what Peter's pointing at, I think, is something that I talk

02:33:26.420 about when I talk about alt-middle, which is you should be able to question every single one of

02:33:31.640 your beliefs because there's really—if you're sticking to one single view, you're probably

02:33:37.660 missing something. The only belief that I think is a little bit beyond question is that you should

02:33:43.040 always question your beliefs. So it's like a meta-belief about belief. I think people who hold

02:33:48.300 that, where they hold their beliefs loosely based on new evidence and persuasion and so on,

02:33:53.160 but they're not wishy-washy. They're not just going where the wind goes. I think those are the

02:33:57.160 people that are the most trustworthy and who are able to call out their own biases and say when

02:34:01.800 they're wrong and also celebrate when they're correct and go, listen, this gives me some

02:34:06.160 credibility. I was right about this and this and this. I was wrong about this for these reasons,

02:34:09.520 and this is how it's changed my thinking.

02:34:11.800 Yeah. The best investors will tell you they have very strong convictions loosely held.

02:34:15.880 Ah.

02:34:16.220 And so I've always loved that mantra, right? Strong convictions loosely held. And what's

02:34:20.920 interesting is I assumed we'd be 50% sort of fact, 50% opinion. I think we're a little more on

02:34:26.580 the opinion side. But what's really interesting is there's nobody who's successfully running a hedge

02:34:32.620 fund on the mantra of I'm always right. Because in the hedge fund space, it kind of doesn't matter

02:34:42.140 what you think. It matters how much money you make. And the dollars always decide. So if you just say,

02:34:51.120 I'm always right, I'm always right, I'm never willing to change my point of view in the presence

02:34:54.780 of new information, you're going to end up losing money eventually. If you can be malleable and say,

02:35:01.740 this is my point of view based on the available data, hey, there's new data, I'm going to change my

02:35:06.200 point of view. There's just no comparison in the long-term success of those two investment

02:35:11.300 strategies. And so it all kind of shakes itself out. It's very interesting that in policy, in

02:35:17.780 medicine even, the system of reward is so uncoupled from the outcome that there's mass confusion around

02:35:26.820 this. And that's why it's very difficult to suss out the really good critical thinkers versus the

02:35:33.880 not so good critical thinkers. Ah. That's a great point, great analogy actually. I think more people

02:35:40.200 would benefit from having some of those endpoints sync with that kind of thinking in medicine.

02:35:46.740 Because you're right, they're disambiguated. They're completely disengaged. In fact, it's even

02:35:50.920 hard to know what outcomes. Like if you're talking about improving a healthcare system, okay, so what

02:35:54.200 are your endpoints? What are you trying to do exactly? Well, we want a lower hemoglobin A1c. Okay,

02:36:00.780 but is that really what you want? Or do you want this 62-year-old Hispanic grandfather to be able to

02:36:06.200 see the graduation of their kid with decent faculty, decent vision? Okay, that's a different

02:36:11.560 endpoint than a hemoglobin A1c. So how are you going to do that? And how are you going to measure

02:36:16.280 that? So it's a complex human system. That's where it becomes so interesting and difficult. But how is it

02:36:21.540 that different than the financial system? The financial system is exceedingly complex. It's just the

02:36:25.500 measurement outcome is dollars. It's much simpler in that sense. The measurement outcome is

02:36:29.460 unambiguous. Yeah. That's right. Yep. It's very binary and it's very unambiguous. And you see it in

02:36:34.940 the style of patient management among physicians in the hospital. I mean, think about being on rounds

02:36:41.320 in the ICU, Peter, when we were doing that together. The doctors who say, you know, I thought this patient

02:36:49.460 was not going to benefit from steroids, but now it looks like they have a nice response. Let's go ahead

02:36:54.880 and continue this therapy. The people who constantly pivoted, re-evaluated, evolved their position

02:37:01.700 based on information. They were the best doctors. The ones who shut down suggestions by a student on

02:37:08.620 the team who says, you know, I read this and they said, ah, it's a dumb idea. That's not going to work.

02:37:13.520 Those were early predictors of not just who was going to be a great physician, but who was going to be a

02:37:18.300 great person down the road. And then the one criticism that irks me that gets thrown at the

02:37:24.480 government, and I've got plenty of criticisms for the government, but the one criticism that I hear

02:37:29.460 that I'm not on board with is when they say, oh, they're flip-flopping. Well, they should. This is,

02:37:36.020 you know, this is not some political philosophy you got to dig in on. They should constantly be

02:37:41.960 changing. I'm glad you said that, Marty, because I completely agree with that. And I think it's a very

02:37:47.860 important distinction to make. To me, it is not a problem when an advocate or a policymaker says,

02:37:55.740 this is the way we're going to do things. Actually, this is not the way we're going to do things.

02:37:59.280 We're going to change. Situations change, right? No new taxes. Guess what? When George H.W. Bush said,

02:38:06.460 no new taxes, there wasn't a recession going on. There was a recession going on. It wasn't a popular

02:38:11.900 thing to do. It got them outvoted. But politicians get hammered when they change their mind, which is

02:38:17.780 why I would never wish being a politician on my worst enemy. But it is a bit of an unfair criticism

02:38:24.040 when we say, in defense of the criticism now, I will say this. It's because it's typically done

02:38:29.320 with a lack of transparency. Yeah. You know, relating to that is an interesting piece of this,

02:38:34.380 is this idea of persuasion. So how are you going to persuade somebody of something you think is

02:38:40.020 important based on the data that you have? If you do not show them that you're flexible in your

02:38:45.440 thinking, but firm in your convictions loosely held, and that new data would change your mind.

02:38:49.740 And I get a lot of emails saying, you're the only person who convinced me to vaccinate.

02:38:53.400 I was so angry with Biden or whoever for mandating this. And they talked to me like I'm stupid. And it

02:38:58.600 seems like they don't recognize myocarditis and all these other things, but you guys talk about it.

02:39:02.380 And yet you still say, okay, I think this is important for people like yourself and so on. And so I get email

02:39:07.440 after email saying, you have convinced me. But then in the same breath, I get the dogmatists

02:39:12.860 saying, hey, you're like some kind of anti-vaxxer. You know, you're holding back the cause. And it's

02:39:18.440 like, well, I wish you could look at my inbox then, right? You do need that flexibility. Now I'm not

02:39:22.420 saying I'm perfect at that. I'm very, there's things I need a lot of work on, but at least it's

02:39:27.740 on the radar, right? And I think Peter thinks this way. That's why we all kind of gravitate to each other,

02:39:32.400 right? Peter and Marty and me, we were like, oh no, no, there's something about,

02:39:35.980 you get the vibe. This is someone who thinks independently and is able to change their mind

02:39:40.380 and is curious and so on. And I think that sets an example for other people that you're mentoring

02:39:45.300 or teaching or whatever. And we see it in the hospital all the time. You know, those attendings,

02:39:49.540 right? Gentlemen, I feel like we could keep talking, but I feel like we've also sort of provided,

02:39:55.760 I think, hopefully some, A, some information for folks with respect to Omicron, a little bit of

02:40:02.020 clarity around what we do and don't know about the utility of vaccines, the potential risks of

02:40:07.200 vaccines. I think we've also shared our biases, right? I think, I guess we haven't explicitly

02:40:12.000 stated it, but I think we're all pretty anti-mandate, at least given the current facts.

02:40:17.880 I love, I don't know, one of you made this, I think it was you, Marty. It might be a reasonable idea

02:40:22.100 to mandate parachutes if people are jumping at 10,000 feet. It might be entirely another thing

02:40:29.000 to not mandate parachutes when people are jumping from 15 feet into the water.

02:40:35.040 So you have to know the situation. You can't just say, we must do this. We must never do that.

02:40:40.820 So I love that analogy. And I think given where we are now, I realize the amount of criticism I face

02:40:47.560 for being against mandates, but I think you got to let your, you got to, your conscience has to speak

02:40:52.780 on this and I think it's wrong. Yeah. We got to treat people like adults.

02:40:55.960 Strong convictions loosely held. Yeah.

02:40:59.000 That's right. Maybe, maybe in the, maybe in the presence of new information,

02:41:01.800 I'll change that conviction. But given the evidence I have today, it's a pretty strong conviction.

02:41:05.860 Yeah. Gents, thank you so much. And I really hope we don't have to do this again.

02:41:10.980 I hope so too. I hope we can just talk about what it was like in the hospital back in the 90s

02:41:15.120 and 2000s. Cause that's funny and, and concerning on many, many levels.

02:41:20.820 And if you do figure out how to get that epididymal taser thing working, you let me know. Cause I

02:41:27.860 really could use that device. Listen, guys, I am the patent holder for the PKG, the prostatocardiogram.

02:41:35.640 I put a couple leads, one on the, on the perineum couple on each testicle and I get a PKG. Sometimes

02:41:41.440 you go into P-fib where your prostate is just fibrillating, at which point you get a high output

02:41:45.740 failure. You know, I haven't fully thought it out, but I'm hoping to get Peter through your

02:41:50.940 connections. I can get an investment in Marty through your political connections. I can get

02:41:55.340 some buy-in from policy, but the PKG, a prostatic defibrillator in every closet, I think is what

02:42:01.420 I'm hoping for policy-wise. You'll mandate it, of course, right? Of course I will. With operative,

02:42:07.420 the word man in there, because it's, it's mostly for men. But again, I want to be gender neutral

02:42:12.560 about this. All right, gentlemen, thank you. Enjoy the remainder of your holiday season.

02:42:20.440 Okay. You too. Good to see you, Peter. Good to see you, Zubin.

02:42:23.180 You too. Happy new year, guys. Thank you for listening to this week's episode of The Drive.

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The Peter Attia Drive - January 03, 2022

#189 - COVID-19： Current state of affairs, Omicron, and a search for the end game

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