The Peter Attia Drive - #192 - COVID Part 2： Masks, long COVID, boosters, mandates, treatments, and more

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

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00:00:41.720 head over to peteratiyahmd.com forward slash subscribe. Now, without further delay, here's

00:00:48.080 today's episode. Welcome to another special episode of the drive. This is a follow-up to

00:00:54.960 our recent COVID-19 podcast with Drs. Marty Macri and Zubin Damania. That episode was released

00:01:00.840 on January 3rd. It was very popular. We received a lot of follow-up questions and requests from

00:01:05.520 listeners to revisit the subject matter. So for this episode, in addition to being joined by Marty

00:01:11.300 and Zubin, we're also joined by Dr. Monica Gandhi. Monica is an infectious disease specialist and

00:01:16.000 professor of medicine at the University of California, San Francisco. She earned her MD from

00:01:20.140 Harvard Medical School, did her internal medicine residency and ID fellowship at UCSF. She also

00:01:24.400 holds an MPH in epidemiology and biostatistics from UC Berkeley. So before getting into kind of

00:01:29.860 the lay of what we discussed, I want to highlight a couple of things. First, along with the previous

00:01:33.540 podcast on this subject matter, this is kind of different from a traditional podcast. It's more

00:01:37.580 of a discussion between the group of us. That format seemed to resonate quite well based on the

00:01:42.240 feedback. So we thought we'd revisit that. Along those lines, we again tried to call out the

00:01:47.500 distinction between fact and opinion. And I think in this episode, we have a pretty healthy mix of

00:01:52.620 both of those things. My hope is that going into this, you're familiar with at least what we spoke

00:01:57.360 about in the previous episode. If not, it might be worth going back to listen to that. This episode was

00:02:02.240 recorded on January 17th, 2022, in an effort to get it out as soon as possible. It's not going to have

00:02:07.540 the most robust set of show notes. And of course, it will be audio only, not video. Now with that

00:02:12.000 preamble, let's talk about the episode itself. The things that we get into in some detail are the

00:02:16.640 newest data on Omicron since our initial conversation. And of course, we have a lot

00:02:20.260 more information on Omicron since that discussion. We talk about how viruses evolve and change over

00:02:24.860 time and how that affects antibodies. Monica gives a great explanation of what B cells and T 0.98

00:02:29.880 cells do and how antibodies work and what the implications of that are for different types of

00:02:34.080 immunity, vaccine and natural. Talk about the ideal timing and the number of vaccines for long-term

00:02:39.500 immunity and how natural immunity plays into this and whether or not you should be boosted

00:02:43.140 depending on those things. We also discuss some of the side effects of current vaccines.

00:02:46.980 We get into the controversial topics of vaccine mandates, masking, Canada's lockdowns, kids in

00:02:53.000 school, Sweden's approach to COVID, Robert Malone's recent podcast on Joe Rogan, where Zubin does a

00:02:59.280 pretty good point-by-point discussion of where he thinks Malone is off the mark and where he's

00:03:05.020 potentially saying something valid. We spend quite a bit of time talking about this sort of fact

00:03:10.220 versus fear approach to discussing COVID. And it's clear that we're still in largely a fear-based

00:03:16.000 approach, although it's not entirely clear to me why that's the case. In fact, this morning,

00:03:19.760 shortly before even recording this intro, it's January 20th today, I just saw an article that

00:03:25.140 talked about how by March, the United States could see an additional 50,000 to 300,000 deaths.

00:03:33.140 And the reality of it is that's simply fear-based thinking. It's very unlikely we're going to see

00:03:39.160 300,000 deaths in the next 40 days. So it's not clear to me why that type of language is being

00:03:46.180 used. And I think we try to do a good job here of bringing this back to facts as opposed to wildly

00:03:52.300 extrapolated models and things like that. We end this conversation again talking a little bit about the

00:03:56.960 future and what the exit strategy looks like here. I think it's very clear to anybody who's paying

00:04:00.980 attention that we are in an endemic. This is no longer a pandemic and therefore we should have

00:04:05.860 strategies geared towards that. So without further delay, I hope you enjoy my follow-up discussion

00:04:10.320 with Marty Zubin and Monica. Hey guys, wonderful to have you all here. Monica, thank you so much for

00:04:23.000 joining the trio and increasing the average IQ of this group by 40 points. We're really looking

00:04:30.680 forward to this. So Monica, as you know, Zubin, Marty, and I sat down a couple of weeks ago,

00:04:36.560 kind of had a relatively informal discussion on the topic. We couched much of what we said as this

00:04:43.160 was opinion, this was fact. The format seemed to resonate a lot with people and the follow-up

00:04:48.140 was surprising. I thought it would be a one and done. I thought it would be this one discussion we

00:04:52.200 would have put to rest as many of the misconceptions as we felt we could. But the reality of it is people

00:04:57.640 appreciated it, but said, look, we have more questions. And so we decided, I guess we should

00:05:02.120 do this again. And we're really grateful that you could join us. So where do we want to start here?

00:05:05.980 There's so much to get into. Marty, you probably spend a lot of time in the last couple of days

00:05:11.840 looking at some of the questions. Is there anything you want to just jump into right out of the gate?

00:05:16.520 Sure. Well, I think it might be worth talking about the new data on Omicron that came out since our

00:05:20.900 last conversation. It is great having Monica here. I deleted my up-to-date app when I got to know

00:05:27.020 Monica because I just call her now and she answers all my questions. That's so funny you say that,

00:05:31.640 Marty. I literally just canceled my up-to-date subscription last week as well. So that's

00:05:36.040 fantastic. The app a lot of doctors use to look things up quickly. Now I just call Monica. 0.97

00:05:42.440 Big study came out on the preprint server from Kaiser Southern California that looked at Omicron

00:05:49.440 specific cases and they found 52,000 cases of Omicron. None required mechanical ventilation. And

00:05:56.640 remember 52,000 documented means there's four or five cases out there in the community for every

00:06:03.480 one that we're picking up with testing. About roughly half may be asymptomatic and a lot of

00:06:08.000 people have tough getting access to testing. So we're really looking at a population of say a

00:06:13.760 quarter million people with Omicron and nobody required a ventilator. Now there was one death in

00:06:21.660 that group, not through the ICU and intubated, but remember the test they use, which is the S gene

00:06:27.540 deletion is not a perfect test for Omicron and it can pick up an occasional rare Delta virus. Plus they

00:06:33.660 didn't have absolute confirmation that anyone hospitalized was hospitalized for the virus as

00:06:40.620 opposed to with the virus. They looked at the presence of symptoms on their record. But regardless,

00:06:46.240 we're looking at a net total of 154 people who were hospitalized out of say a quarter million with

00:06:52.700 Omicron. Now of those hospitalized, 83% were there in the hospital for less than 48 hours.

00:07:00.280 Now, if you remember way back about two months ago, this is exactly what the South African doctors

00:07:06.460 observed early on. They noticed people were in the hospital about two days instead of eight days

00:07:11.400 and they proclaimed to the world, this is a mild infection. There is no need to panic. And we

00:07:19.340 basically did the exact opposite, but this data is pretty compelling right now. Now, the reason it's

00:07:24.160 so important is that 98.3% of new cases of COVID in the United States are Omicron according to the most

00:07:31.220 recent CDC numbers. On December 10th, it hit 73%. Now we're at 98.3%. So we're dealing with a different

00:07:39.740 virus. And I personally wish it had a different name because people know it comes from the lineage

00:07:45.760 of COVID. And we've got the raw memories of the destruction of COVID and the loss of life and how

00:07:52.920 our hospitals were overwhelmed. We think of it in terms of COVID, but it's really functioning and

00:07:57.960 behaving like a different virus. Now you might say, well, look, we're in an Omicron wave. People are

00:08:02.180 still in the hospital. The vast majority are people who came in with Delta, who were infected with Delta,

00:08:07.820 who were unvaccinated and got Delta. And remember, people stay in the hospital a long time, especially

00:08:12.000 right now when it's very difficult to discharge a COVID positive patient to a skilled facility or

00:08:17.040 rehab. So that's inflating the numbers a little bit, but hospitals are truly strained. But it's

00:08:21.380 really those who had Delta. If we look at the future, Omicron promises to be a mild virus based

00:08:28.020 on all of this data. Question for anybody, but Marty, it sounds like you might even know the answer

00:08:32.560 already. Do we have a sense of how many people are in the hospital with Omicron because of Omicron or

00:08:38.860 because that's an incidental finding along the way? So somebody's in there for cancer treatment,

00:08:43.600 but they happen to be testing positive or they are in there because of chest pain that's related to

00:08:49.000 cardiovascular disease. And then of course they're COVID positive along the way.

00:08:53.060 So I just actually looked this up. There's a bunch of hospitals in the country that report this

00:08:56.740 number on a daily basis. NYU, for example, reported 53% are not there for COVID, but they're COVID

00:09:04.740 positive. They're incidental COVID admissions. Jackson Memorial in Florida, 65% are incidental COVID

00:09:12.060 positive cases. So think of it in terms of 50 to 60% are incidental. That latter question also depends

00:09:18.960 on how highly vaccinated the region is. So for example, the numbers are even higher out in California for

00:09:24.980 people with COVID in their noses because we swab everyone. So LA County reported 67%, which was closest

00:09:33.000 to what we saw in South Africa during the Omicron surge, which was 63%. And it wasn't that South Africa

00:09:40.840 was a highly vaccinated region. It was about a 25% vaccinated region. There was a seroprevalence study

00:09:46.240 in SARS-CoV-2 in South Africa that showed 79% of adults had a SARS-CoV-2 antibody. So meaning

00:09:54.320 think of South Africa with between natural immunity and vaccines as having the same degree of immunity

00:10:01.060 likely as California. So I think the higher the vaccinated region, the higher the incidental rate

00:10:07.100 is. I'd like to add just to a couple of your Omicron studies because they just came out yesterday

00:10:12.160 hot off the press, very verifying of what you just said, Marty. One was from South Africa, which was

00:10:17.880 really well documented. What's the contribution of immunity versus the more milder aspect of Omicron

00:10:26.180 contributing to the better outcomes with Omicron. And they tried to tease this out essentially by

00:10:32.260 looking at the fourth wave in South Africa. Hopefully we can post all these links, but in the fourth wave

00:10:37.620 in South Africa compared to the prior three waves. And essentially what this study showed that was just

00:10:44.200 this week was that absolutely immunity is contributing to why in December, 2021, January,

00:10:51.720 2022, we're having a better outcome with the latest variant. It is absolutely the contribution of

00:10:57.420 immunity, both natural immunity and vaccine induced estimated vaccination probably led to a 0.24

00:11:04.900 hazards ratio of a severe outcome. Monica, can you tell folks what that mean who don't live in the

00:11:10.280 hazard ratio world? So there's been a great debate since Thanksgiving, which is when the South African

00:11:16.740 scientists, who are amazing scientists, I thought got treated not very well because they kept going on

00:11:21.880 TV saying, this is more mild. And then people would say, oh, let's wait till the UK or the US says this.

00:11:27.300 So it was, I thought really unfair. And these are my colleagues because I'm an HIV doctor, so I know

00:11:31.900 them, but they kept on saying this fundamental question became, okay, is Omicron more mild because we have

00:11:37.580 so much immunity in the population at this point, January, 2022 now that our T cells and B cells are

00:11:43.920 attacking that SARS-CoV-2 variant takes a while for the B cells to make antibodies. You may not have

00:11:49.320 antibodies right away. Maybe if you just got boosted, you may have antibodies right away if

00:11:53.480 you're older, but say you have the vaccines or you've had natural infection. You have your T cells,

00:11:58.320 your B cells, they produce antibodies. They attack that virus. They bring down the viral load quickly.

00:12:03.600 They make it less infectious and they help you do well with the virus. And so immunity, of course,

00:12:08.680 will help you do well. This is probably what happened in 1918 when we were transitioning from

00:12:13.580 pandemic to endemic, had a lot of immunity in the influenza world in the world. However, the next

00:12:20.940 question is also, is Omicron less variant inherently than the other strains that we've had so far, the

00:12:27.700 other variants we've had so far. And yes, it seems to be not just based on the six laboratory studies,

00:12:34.020 including two in ex vivo lung transplants. So this is human lung tissue, and then also animal studies

00:12:39.420 that show it can't infect lung cells very well, six studies now. But what the South Africa study showed

00:12:44.740 us that I just told you about is that you can distinguish, they did a very good job, it was very

00:12:50.160 good analysis, distinguishing between immunity, making it more mild, and also having fewer,

00:12:56.160 less virulence. And they estimated it's 25% less virulent than Delta above and beyond immunity. So

00:13:03.440 it's not just our increasing immunity in the population that's making Omicron more mild, but

00:13:08.540 it's something to do with the virus itself, likely that it can affect lung cells well. And then another

00:13:13.180 study that would verify what I just said, again, over the weekend was in young children who are less

00:13:17.860 than five, they are all unvaccinated by definition, because we can't vaccinate those less than five,

00:13:23.340 we don't have it in this country. It's a US based study. And also they didn't have prior COVID

00:13:28.280 infections, so they couldn't have had natural immunity. And severe outcomes in that population

00:13:33.100 is already very low. But severe outcomes with Omicron versus Delta, meaning going to the ER,

00:13:39.020 was about two thirds less, meaning going to the ER or hospitalized was about two thirds less. So

00:13:44.180 Omicron seems a third, at least in young children, as virulent as Delta. So putting all these studies

00:13:50.700 together, you've just really made a very big point. I think that Omicron by itself beyond immunity is

00:13:57.120 less virulent. I want to ask you another question about this, Monica, because you're the expert,

00:14:01.600 certainly amongst all of us when it comes to viruses beyond this one. Marty and Zubin and I actually

00:14:07.200 speculated on this, I think in the last episode. So we kind of came up with a teleologic idea around

00:14:12.540 this. Is it likely that as pandemics become endemics, they become milder? The argument we

00:14:20.640 came up with is, look, it's evolutionarily in the best interest of this virus to become less and less

00:14:25.740 virulent as it goes on. And if it wants to coexist with us indefinitely, it probably shouldn't be

00:14:31.920 killing us. You referenced obviously the Spanish flu in 1918, as it went from this deadly pandemic

00:14:38.480 into basically the flu, the thing that we have every year, notwithstanding the genetic drift that

00:14:43.340 comes with it. If you were to look into a crystal ball, do you believe that the SARS-CoV-2 that we

00:14:49.380 will live with indefinitely, which I think there's no question we will be living with SARS-CoV-2 0.99

00:14:53.760 indefinitely, is it going to be a very mild version of this that's going to be somewhere between all

00:14:59.760 the other coronaviruses and influenza? It makes sense. And that's been the pattern in history. And it

00:15:06.160 makes sense evolutionarily. It's exactly what you said. Ebola is a really dumb virus because it kills

00:15:11.720 its host and a virus that makes more copies of itself, but doesn't kill its host. That's more 0.99

00:15:17.320 evolutionary advantageous, just like the organisms want more children. On the other hand, I would say

00:15:23.460 this, and I think this is a very key point because now, because this Omicron is less virulent, there's

00:15:28.960 now been a lot of fear that, well, we're going to get a more virulent variant later. If you have

00:15:34.500 immunity to the entire virus, then even if you do get a more virulent variant that arises not

00:15:44.240 in humans, but from an animal reservoir, you have a more virulent variant. If you have immunity across

00:15:53.140 the entire virus, like B cells, T cells, antibodies, which will come down with time, that's okay,

00:15:58.380 that's what they do. But B cells and T cells formed across the whole virus, a lot of people have seen

00:16:03.620 Omicron. Probably 50% of people in Europe, it's estimated, a quarter of Americans probably more have

00:16:09.440 seen Omicron. Then you have the T cells and B cells to fight that new variant in the future, even if it's

00:16:18.420 more virulent. I think that's a really key point. People are really, they're not taking comfort for

00:16:23.460 Omicron being more, less virulent. There's a lot of anxiety right now. Well, okay, then what's going

00:16:27.660 to be the next thing? But if you have immunity across the whole virus, then you can fight

00:16:31.640 Zeta that comes out later, if you've seen the virus. And what Omicron did is it made a lot of

00:16:37.740 us see the virus. I mean, both the FDA chief and the NIH chief, NIA chief have said we're all going to

00:16:42.700 see Omicron. Sorry, Monica, I just want to keep asking you questions before and turn this more into

00:16:47.500 an interview of you. I apologize, but we'll get back to a discussion. Is the implication then that

00:16:53.120 the immunity acquired naturally by being infected by Omicron, whether you've either been vaccinated

00:17:00.200 or not vaccinated, but you're getting some additional immunity, how would you qualitatively

00:17:04.540 or quantitatively assess that relative to a person who has been vaccinated, but has not seen Omicron?

00:17:11.700 A very important study, and there's been multiple ones of these, shows us that if you get natural

00:17:17.320 Omicron infection on top of your vaccines, you form broadly neutralizing antibodies against all the

00:17:22.380 variants. Totally makes sense. Alpha, beta, gamma, delta. But importantly, you form T cells and B

00:17:28.980 cells across all the variants. I mean, again, that totally makes sense. You've just seen the whole

00:17:33.120 virus. It is qualitatively true, I would say, that if you see Omicron on top of your vaccine,

00:17:39.540 that you have a more in-depth and in-depth immune response against the whole virus, because

00:17:44.340 remember, the vaccines we have in this country only expose us to the spike protein of the virus,

00:17:50.040 so just one piece of the virus, as opposed to the whole virus. Now, then people would say, hey,

00:17:54.480 I want nothing to do with Omicron. I am going to stay in my house right now, and I won't see

00:17:58.500 Omicron. One thing I've been really thinking about lately is why we don't have Covaxin in this country,

00:18:03.980 but we, I don't want to go off on too much of a tangent, but Covaxin is a whole inactivated

00:18:08.140 virion made in India, and it's a more traditional vaccine. It may have increased our uptake.

00:18:13.100 Like, Covaxin filed for an EUA 73 days ago with the FDA. You get to see the whole virus. So if you

00:18:20.500 never wanted to see the virus, Omicron, which again, it's not like people are going out and

00:18:25.140 getting Omicron, but just living right now, a lot of people are exposed. But if you don't see

00:18:29.480 Omicron, I wish the booster could be Covaxin. My new thing is pushing Covaxin and seeing why the

00:18:35.160 FDA isn't approving it. But I don't want to go into too much of a tangent, but I do think that would

00:18:38.960 have increased our uptake in our country because mRNA vaccines got a reputation.

00:18:44.360 Can I ask a question, a follow-up on this that I don't know we know the answer to, but

00:18:47.260 you have the whole virus exposure, Covaxin, vaccinated whole virus exposure, natural infection,

00:18:53.300 Omicron exposure versus a pure spike protein deltoid exposure from a mRNA vaccine. Is there a

00:19:00.580 difference in mucosal antibody immunity between those mechanisms? Because now we have a mucosal virus

00:19:07.980 that replicates rapidly in the mucosa and viremia is not a major part of its pathogenesis until

00:19:13.880 later. And so that's why we prevent severe disease with bloodborne antibodies, but we might

00:19:19.140 be able to actually make a dent in transmission and infection in the first place if we had more

00:19:23.460 mucosal defense. So I'm curious your thoughts. What happens is when we're exposed to the virus,

00:19:29.040 we do develop IgA antibodies in our nose, and then those go down with time. Or if even we're exposed

00:19:35.480 to the vaccine, we develop IgA antibodies in our nose, and those go with time. So like you just

00:19:40.540 said, there's a great interest in mucosal nasal vaccines to help decrease transmission. But it is

00:19:46.780 true that if you get Covaxin or you get exposure to the actual virus, you develop IgA against multiple

00:19:54.340 parts of the virus. It's just, it's what it is. You're just developing IgA against the spike protein

00:19:59.480 if you get an mRNA vaccine, because by definition, the mRNA vaccines and the adenovirus DNA vaccines

00:20:05.540 only give you exposure to the spike protein of SARS-CoV-2. And you know, Monica, this makes me

00:20:10.980 think back to, gosh, early days of vaccine, call it March of a year ago. Was Moderna first out of

00:20:18.040 the gate or Pfizer? I can't remember. They basically came out within weeks of each other. And then J&J...

00:20:23.020 Pfizer was November 9th, and then Moderna was November 16th. It was literally a week later.

00:20:27.900 That's right. And then J&J and AstraZeneca followed shortly thereafter, a single dose.

00:20:33.720 One of the things I recall that didn't get enough attention, and it was difficult to figure this out

00:20:39.300 reading headlines and abstracts, you had to go through the raw data, was the absolute risk

00:20:45.420 reduction was greater with J&J than both Pfizer and Moderna. Now again, this was in the original

00:20:51.180 strain, not Delta. And that got easily missed. It makes me wonder if based on what you're saying,

00:20:56.840 that's not surprising, because the J&J vaccine would have provided a more robust picture to the

00:21:03.140 immune system of the virus than Moderna or Pfizer, correct? Well, it's interesting. Both Johnson &

00:21:08.460 Johnson and AstraZeneca are adenovirus DNA vector vaccines. They show you a different part of the

00:21:15.600 spike protein, which is why mixing them give you more of the spike protein. You see antigens across a

00:21:21.980 longer piece of the spike protein. But actually, I think what happened with the DNA adenoviral vectors

00:21:26.940 is they produced a more robust T cell response than the mRNA vaccines. And T cells are your long

00:21:34.080 lasting friends. Remember, those who've got survived SARS-CoV, the first one SARS from 2003,

00:21:41.520 late 2002, early 2003, there are people 17 years later that they have strong T cell immunity against

00:21:47.480 SARS-CoV. So your T cells are your long lasting arm of the immune system. Antibodies always come

00:21:52.860 down. If I had antibodies for every cold I've ever had in my body, I couldn't move because I'd be so

00:21:58.640 thick. So antibodies will always come down, but T cells are enduring and AstraZeneca seems to produce

00:22:04.080 and Johnson & Johnson's stronger T cell response. I think it's maybe worth actually spending a minute

00:22:09.100 on this because I think we can easily take for granted here because of our familiarity with B cells and

00:22:14.400 T cells and how antibodies work, MHC class works. Is there a way that you can maybe explain to folks

00:22:22.160 the difference between a B cell and a T cell and how they work in response to viruses specifically?

00:22:28.060 Because this is going to become interesting. Marty has spoken at length about the idea that if we're

00:22:34.020 going to get into a mindset where your antibody levels are determining the value of your worth in

00:22:41.320 society, we're in for a really rough slog. It's going to be weekly boosters, maybe monthly boosters

00:22:47.300 if we're being generous. So why is that the wrong metric if you were to exclusively focus on it as

00:22:54.500 opposed to understanding how the T cells work? What's happening in your bone marrow? There's no

00:23:00.740 reasonable person to my knowledge that doesn't agree that SARS-CoV-2 is never going away. So anything

00:23:08.200 we're talking about should be in the context of eternity here. So why does this matter? What's

00:23:12.780 the difference between these B cells and T cells and how they actually kill viruses?

00:23:17.600 I'll explain it really fast and simply, I hope, which is T cells are actually the main arm of the

00:23:24.120 immune system that fight viruses. So for example, I'm an HIV doctor. So as T cells go down, people are

00:23:30.500 susceptible to very severe viral infections. Their cells, they last for a long time. They're called

00:23:36.100 cellular memory. And then what B cells do is they become the recipe book or the template to produce

00:23:43.440 more antibodies, but they have to be aided by T cells to do so. And so your antibodies, which are

00:23:50.300 pieces of protein, they will come down with time. They will come down even after a booster, say 10 weeks

00:23:56.260 or so. But what your B cells do, and we know you develop B cells to the vaccines because they've

00:24:02.580 biopsied bone marrows from people who've had natural infection, lymph nodes from people who've

00:24:06.540 had the RNA vaccines, and you produce strong B cells in these, what are called terminal centers.

00:24:12.160 The B cells will, if they see the virus again, aided by your T cells, will produce antibodies directed

00:24:19.700 against that SARS-CoV-2 when they see it in the future. And not only will they produce antibodies,

00:24:25.720 but they will actually adapt those antibodies to the variant they see. If they see Delta,

00:24:31.820 they'll make Delta-specific antibodies. Omicron, Omicron-specific antibodies. Zeta,

00:24:36.080 Zeta-specific antibodies, because that's what adaptive immunity is. It's like they vary the recipe

00:24:41.040 based on the conditions. That's what adaptive immunity means. So B cells will produce antibodies

00:24:47.500 against the variant they see aided by T cells. And then T cells line the whole virus and directly kill

00:24:53.620 the virus itself. So your T cells and B cells, which are formed by the vaccines and natural

00:24:59.100 immunity, will last a long time and will enable us to have ongoing immunity to the virus in the future,

00:25:06.380 even different variants. If that's lost, if that very simple fact is lost, then we can be very anxious

00:25:13.040 when new variants emerge instead of feeling calm about it and knowing that adaptive immunity works.

00:25:18.560 B cells could last 90 years. There's people who've gotten influenza in 1918, and then they found these

00:25:24.740 90-year-old, 100-year-old people. They looked at their B cells and they said, oh, you actually can

00:25:30.280 produce antibodies directed against the influenza strain from 1918, 90 years later. B cells lost a

00:25:35.680 long time. Marty, just give me a quick approval status on all vaccines at the moment. So the Covaxin

00:25:41.540 is interesting. I want to also hear a little bit about Novavax, but the exact status of Moderna and Pfizer,

00:25:47.260 they're off EUA, correct? Those are fully approved today, or are they still under emergency use

00:25:51.520 authorization? Actually, just Pfizer though, right? I think they're still waiting for the final Moderna

00:25:56.440 approval. Pfizer fully approved. Moderna is still under emergency use authorization. J&J, what is the

00:26:02.040 status of J&J in the US? It seems to be persona non grata. Is that official or unofficial? Even CDC

00:26:08.860 has sort of given a preferential guidance saying they prefer the mRNA vaccines to J&J, and Paul Offit and

00:26:14.880 others have speculated that J&J really always should have been a two-dose vaccine. As a single

00:26:20.160 dose, it had a lot of promise initially, but it's looking more like it should have been a double-dose

00:26:24.440 vaccine. And then you have the vaccine-induced thrombotic thrombocytopenia issue, which seems to

00:26:28.520 be a class effect with the adenovirus vector vaccines because AstraZeneca has it as well. And so

00:26:34.180 for those reasons, CDC has given that preferential guidance. And I think it's still under EUA,

00:26:39.060 right, Monica?

00:26:39.480 Yeah. And you're totally right. Sputnik V, also another adenovirus DNA vector, they all have this

00:26:44.960 rare side effect. So it got dead, even though I think that's interesting because it's still really

00:26:49.280 rare.

00:26:50.120 Why is it that that side effect, which is incredibly rare, basically led to a complete halting of the

00:26:57.960 use of that vaccine? Whereas the myocarditis that's seen in young men, specifically under 25,

00:27:05.780 specifically with Moderna, doesn't seem to warrant the same level of consideration,

00:27:12.380 though by my math, it's more prevalent a concern.

00:27:16.400 I would speculate that it's a question of severity. So the outcomes of people who get

00:27:20.840 vaccine-induced thrombotic thrombocytopenia can be very bad to fatal. It's very rare,

00:27:26.220 but it is catastrophic if it happens. Whereas with myocarditis, at least from the early series that we

00:27:32.000 have generally reversible, although requiring hospitalization, still terrifying for parents

00:27:37.340 and children, but less of a catastrophic issue. And then there's that whole controversy of which

00:27:42.900 maybe Marty and Monica can speak to of, well, what's worse for generating myocarditis, natural

00:27:48.400 coronavirus infection, or the vaccine? And this is where data sets seem to disagree and how you

00:27:54.260 interpret them.

00:27:55.480 Who wants to take that one? Maybe I'm just looking at the wrong data, but I'm looking at nature. I'm

00:27:59.380 looking at circulation. This doesn't seem ambiguous to me. Can someone explain that?

00:28:04.700 That's right. Those studies pretty well did a head-to-head comparison and found that the rates

00:28:09.880 of myocarditis after vaccination were higher, particularly with Moderna. And if you go to

00:28:16.840 Europe, parts of Europe, they basically restricted Moderna in anyone under age 30, something we haven't

00:28:22.540 really talked about much in the United States. There's also this interesting idea. The myocarditis

00:28:27.280 from vaccination may be different than the myocarditis from the infection itself. There

00:28:33.560 may be more delayed contrast uptake in the heart that they're noticing in the studies of the

00:28:41.520 myocarditis from vaccination. So there's a feeling among cardiologists that it's not the exact same

00:28:46.440 apples-to-apples myocarditis. Have you guys heard that as well?

00:28:49.300 Yeah. And I will say, as you know, the Moderna is a hundred micrograms, Pfizer's 30 micrograms.

00:28:55.900 So that dose difference probably explains why it could be more seen with a Moderna vaccine. It's

00:29:03.940 just literally a higher dose, which is why, like you said, not used under 30 in so many countries.

00:29:09.660 And I think the best study on this is from Canada that showed that the risk of myocarditis after the

00:29:15.640 second dose is more with a higher dose, Moderna, and also more if you have a shorter period between

00:29:23.360 your two doses, which is why spacing the doses has been such a strategy in Canada of eight weeks

00:29:29.820 or even longer between doses. We speculated on this during the last episode, Monica,

00:29:35.320 but I'm curious if you have an immunologic rationale for why the mRNA vaccines were dosed at four weeks

00:29:42.380 apart. Is there a clear rationale for why that would have been the way to do it?

00:29:46.520 I think it was just expediency because the trials wanted to hurry. I mean, we're in the middle of a

00:29:50.980 pandemic, so they gave Pfizer three weeks apart, Moderna four weeks apart. But I think Dr. Stanley

00:29:56.960 Plotkin wrote a clinical infectious disease article in January, and he's our Infectious Disease Society

00:30:03.440 of America. We name our vaccine lecture after him. He really knows vaccines. He was saying we need to

00:30:08.760 face them out longer for two reasons. One was to save more lives, because if you get T cell immunity,

00:30:14.780 you can, if you have limited supply, you want to save more lives by giving people just one dose while

00:30:19.460 you're, and then give them the second dose later. And then the second was, he said that in any field

00:30:24.640 of vaccinology, and now this has been shown in a cell paper, if you give longer time between doses,

00:30:30.360 you get a better response, not just antibody responses, increased antibody responses, but fundamentally what

00:30:36.460 we were talking about is we want to develop cellular memory, and there's better T cell responses if you

00:30:41.440 space them out, the doses by eight weeks or so. This was a cell paper. So Canada has always spaced

00:30:47.520 out doses, especially for the young. I knew a doctor, a Hopkins surgeon, a brown skin guy, Marty

00:30:54.100 something, I don't remember his last name, but he was making this point about trying to get everybody

00:31:01.100 the first shot before people got their seconds. And boy, he really got hammered for that. I mean,

00:31:06.640 he was, by the way, this is both fact and opinion. Monica, going back to that point, if you were playing

00:31:12.820 the long game, so not the antibody game, I kind of think of antibodies as like a vanity metric. Like

00:31:18.640 you can brag about how high your antibodies are. It's a cool vanity thing. But if you're playing the

00:31:23.100 really long game, what would be the ideal time to give a booster to somebody who has had two shots

00:31:30.520 of Moderna or Pfizer? And I guess almost nobody would be one year out from their second shot now

00:31:37.340 because these things only kind of came on board in about January and healthcare workers and high-risk

00:31:41.700 people were first. So most people listening to this will not even have been fully vaccinated a year

00:31:47.660 ago. And yet many people are boosted, suggesting that giving a booster in less than a year is the optimal

00:31:54.480 way to boost long-term immunity. But is that true based on what we know about the immune system?

00:31:59.540 Would we be better off boosting less frequently? How would we think about that?

00:32:03.320 We had to extrapolate on the three-dose vaccines from hepatitis B vaccine, human papillomavirus vaccine,

00:32:10.400 and the longer between the second and third doses, the better. I mean, Dr. Plotkin talks about this in

00:32:15.520 the CID article. I think what happened here with the booster is that we had a lot of high transmission

00:32:21.660 with Omicron. And then the idea was, oh, if we give the booster, maybe we can bring transmission

00:32:26.740 down. And that's actually all I can see is why there were widespread booster recommendations as

00:32:31.660 opposed to more selected booster recommendations for those who were more at risk for severe disease.

00:32:37.260 So I think it was an attempt to increase antibodies to bring transmission down. I'm trying to think of

00:32:42.520 the reason. What's the efficacy of that? Do we have data on how the vaccine reduces transmission?

00:32:49.000 It will increase your antibodies, and it could. There was an Omicron paper that in households,

00:32:54.760 giving a booster did decrease transmission in the household setting. However, I will say that in

00:33:00.280 any risk versus benefit analysis, and I know you spoke about this last time, what you do is you decide

00:33:05.440 about the boosters based usually on what it does for the patient. If the patient benefits from a booster

00:33:12.480 to reduce severe disease, then that's when you would give a booster in how we usually do infectious

00:33:19.100 disease, not for this purpose of transmission. Because later, say we get a different variant and

00:33:25.180 virus goes up in the community, we probably won't give booster to try to decrease transmission. I don't

00:33:30.960 think. How long does that affect last? The UK study, Marty and Zubin, 10 weeks. The booster made the

00:33:37.820 antibodies go up and then right back down after 10 weeks. It's just never been done that we give

00:33:43.660 boosters to decrease transmission. We usually give boosters in a risk versus benefit analysis for the

00:33:49.600 patients. We want to make sure it's safe for the patient, and then also want to make sure that it

00:33:53.700 does something beneficial for the patient, which in this case would be keeping them out of the

00:33:58.760 hospital. So older people, immunocompromised people, people who have medical conditions, 0.99

00:34:04.360 maybe everyone over 40, something that's helpful for the patient.

00:34:08.960 So if we were to speculate, I won't single out any of my favorite universities, but if we were to

00:34:13.360 speculate based on the policies that are in place of providing boosters to healthy college kids in an

00:34:19.500 effort to prevent transmission, the only logically consistent thing to do would be to make sure college

00:34:25.840 kids get boosters every 10 weeks for the rest of their lives. Because at least that way, we might have

00:34:31.860 some ability to reduce the transmission from college kids who would be unharmed by this virus to

00:34:39.460 potentially anybody in their orbit who could be. And of course, that ignores what you said before,

00:34:44.580 which is this would be a first in class episode of putting somebody outside of the patient ahead of

00:34:51.060 the patient or in whom you're putting the booster. Is that a fair assessment? I just like being

00:34:56.220 logically consistent. I mean, I think that's one of my pet peeves in life, right? Is like when we say

00:35:00.760 things that are illogical, if we're going to live in a world where we're going to make college kids

00:35:05.320 get booster shots, they're going to have to get them every 10 weeks.

00:35:09.100 Of course, that would never happen because we can't do that. We do have to focus in on the patient.

00:35:14.700 But wait, wait, wait, why can't we do that, Monica? I mean, says who can't we do that? We're doing it now.

00:35:18.840 Like you said, it wouldn't be logically consistent. And also, I think it ignores. And I think actually

00:35:25.000 everything that's been going on over the last couple of months, especially since Omicron got

00:35:29.540 declared, ignores how well the vaccines work for the individual. So the staff member, the older adult

00:35:36.360 who's teaching the student, I think this is profoundly not recognized is how well the vaccines work for

00:35:43.880 them, even two doses, certainly three doses if they're older. Marty and Zubin, you'll have to

00:35:48.800 tell me if I think the healthcare worker study in the New England Journal from Israel showed anyone

00:35:53.100 over 50 really benefits from a third dose, even in reducing severe disease. So say you have a staff

00:35:59.520 member, say you have the teacher. What the CDC showed us just in a study two weeks ago is that

00:36:05.420 even the two-dose vaccines, your risk of a severe outcome from COVID with just a two-dose vaccine

00:36:11.260 across the entire swath of the population, your chance of dying from COVID was 0.0003. Please

00:36:18.600 remember that I said four zeros and then three. And then there were specific risk groups that were

00:36:24.780 at risk for severe outcomes. They were older people over 75 with multiple comorbidities, four

00:36:30.300 comorbidities. Not only should those patients be boosted, maybe even get a fourth booster, but they

00:36:34.880 should certainly be one-way masking for themselves to help protect themselves. All of that putting

00:36:40.880 together means that we have underestimated that those college students, if they're around vaccinated

00:36:46.660 staff members and teachers, those vaccinated staff members and teachers are doing great. These

00:36:52.440 vaccines work so well for them against what we're so scared of, which was COVID, severe disease. So I

00:36:59.220 think we are underplaying the vaccines when you just put that to the logical conclusion for everyone

00:37:04.520 around those college students. Can I ask a question? Because I think relating to this, this Peter's

00:37:08.540 proposing is this hypothetical Q10-week booster that bumps up our antibodies. And WHO and EMA,

00:37:15.520 the European Medicines Agency, just recently said this is probably a bad idea from an immune system

00:37:20.580 standpoint, but they did not elaborate. So are we talking about immune tolerance from giving the same

00:37:26.100 antigen again and again and again? Like what's the rationale against doing that?

00:37:30.320 They term it original antigenic sin, but it means that you see, you keep on seeing the same

00:37:36.320 piece of protein that you make the same spike protein to the ancestral strain again and again.

00:37:42.460 But what adaptive immunity does is allow you to produce trained immunity, adapted immunity to

00:37:49.300 whatever virus you see in front of them. And they don't want to train the immune system to respond to

00:37:53.880 the ancestral strain. Well, it is interesting what you said, Zubin, that the European CDC basically

00:37:59.080 said specifically that repeated boosters could cause, quote-unquote, problems with the immune system.

00:38:06.540 And they clearly have some concerns there, right? Even if they're not, well, how can you study something

00:38:11.860 that we have not yet done? I mean, we're in uncharted territory. We have anecdotally, colleagues of mine

00:38:18.940 and I've seen cases that are just raised questions like new onset autoimmune diseases, either immediately

00:38:27.520 after the second dose or after a mild, very mild infection in somebody fully vaccinated. So maybe

00:38:34.820 that immune system was revved up, caused juvenile diabetes in an adult. How often do you see that

00:38:40.380 on day two of a very mild infection? Well, maybe that immune system was all revved up. Now the risk

00:38:46.720 benefit still favors vaccination. This is not an argument to say, hold off on vaccines because

00:38:52.200 there's concern. This is an argument to say, only give boosters if there's a clinical benefit.

00:38:58.240 And the frustrating thing is, as you alluded to, Peter, if we would have spaced out these doses,

00:39:04.020 we might not even be talking about boosters. To put a number behind what Monica is referring to,

00:39:09.640 this University of Birmingham study, Birmingham, UK, not Alabama, found that the immune response was

00:39:16.120 3.5 times greater when the doses were spaced out three months versus three weeks. And that was in

00:39:24.340 175 patients over age 80. So they developed a weak immune response in general to vaccines. So it's

00:39:30.760 going to be even further magnified in young people. That's why I got my two Pfizer doses three months

00:39:35.880 apart. And the most frustrating question I get is, I'm fully vaccinated. I just got COVID.

00:39:42.020 When do I get my booster? Or it's like, I get those questions. You got your booster. Yeah,

00:39:48.080 exactly. You just got the best booster of all because what that study showed us, especially with

00:39:53.340 Omicron, but it would be true of any natural infection is that you develop profound TB and T cell,

00:40:01.100 B cell, and broad neutralizing antibodies across the whole virus. So that is the best booster of all,

00:40:06.760 unless you've got a covax and booster. So when these B cells are re-triggered,

00:40:11.820 you get another process of what they call somatic hypermutation, right? So the B cells are constantly

00:40:17.220 undergoing a mutational process to diversify. And so it's almost like if you have natural exposure

00:40:23.980 to vaccine and vaccine, and maybe the two doses plus or minus a booster, at that point, you have a

00:40:29.680 diversity of antibody response that should cover a lot of potential variant options, correct?

00:40:35.280 Yes. I mean, there's now actually four papers that show this, but the most recent is in Journal of

00:40:41.160 Infectious Disease, but the best one I think was in Science that again, if you see a variant in the

00:40:46.780 future, say right now, we only know about the variants are mostly across the spike protein.

00:40:51.800 Of course, the Omicron has 50 mutations across its entire genome. There's 32 are in the spike protein

00:40:57.400 that you produce antibodies directly. They evolve. The word adaptive truly means you adapt

00:41:03.160 your own immune system to what you see. I'm going to switch gears for a second and continue down the

00:41:08.240 path of vaccines. But again, talk about it through a very polarizing discussion, which is that of

00:41:12.760 mandates. And again, I'll sort of ask everybody this question, but what is the best argument in

00:41:19.520 favor of mandates? I'm going to be the odd man out.

00:41:23.240 I'm looking for a diversity and I'm looking for arguments in favor and arguments against. So

00:41:28.040 tell me what the best argument is to mandate vaccination.

00:41:31.880 Okay. Cause Zubin and I had this discussion the last time we spoke and I favored vaccine mandates

00:41:36.940 and he did not. And I know that one argument is that the vaccines reduce transmission and that argument

00:41:46.280 with each successive variant has been lessened, not just because the variants evade, at least Omicron

00:41:53.520 evades antibodies more, even though T cells and B cells are intact, but because just with time from

00:41:59.420 your vaccine, your antibodies decrease, the transmission argument has become weaker. However, the reason I did

00:42:05.880 support vaccine mandates is because I work in a hospital and there is no doubt that the people in the ICU

00:42:13.400 and the people who are sick are unvaccinated adults. And if our entire purpose of a lot of what we did

00:42:22.160 throughout this pandemic was to save hospitals, then not having hospitals have unvaccinated people when

00:42:29.680 they could have gotten the vaccine allows us to work on other aspects of hospitalization. I recognize

00:42:34.660 this is not a popular opinion, but that was my opinion until the Supreme Court.

00:42:39.380 I'm not convinced it's an unpopular opinion. I seem to think that has anyone ever done a straw man

00:42:44.380 poll? Is there a Gallup poll on what percentage of Americans favor vaccine mandates versus not?

00:42:49.140 I don't actually know the answer to this remotely.

00:42:51.400 I think the vaccinated are more concerned about thinking that their vaccines don't work than the

00:42:56.400 unvaccinated, which is a very interesting poll that was recent. Those who are vaccinated are more

00:43:00.720 concerned about COVID than those who are unvaccinated. People are more fearful. They don't trust the

00:43:05.280 vaccines in a way if they're vaccinated. I think it's a failure of public health messaging.

00:43:09.000 That reminds me of an interesting anecdote. I had to negotiate or mediate is probably a better word,

00:43:14.840 mediate a familial turmoil, conflict about an unvaccinated member of a family. So there's a

00:43:22.420 member of the family. So it was the son of the family. So someone in his 30s, healthy,

00:43:27.140 did not want to get vaccinated. The parents, of course, were vaccinated. And they kind of brought me

00:43:32.300 in to mediate the discussion. Why could I not talk their idiotic son into getting vaccinated? 1.00

00:43:37.720 I don't have any mediating skills, but I had an insight as I was listening to the debate between 1.00

00:43:44.360 them. And I decided to ask a very simple question of the father who was particularly distressed

00:43:51.960 at the fact that his son was not getting vaccinated. And I said to him, I said, what do you believe

00:43:59.440 is the risk that your son will be hospitalized or die if he contracts COVID in an unvaccinated state?

00:44:07.980 I want you to remember his son was in his late 30s and is very healthy. I'd like each of you to take

00:44:14.080 a guess at what his response was, meaning what he believed the risk of hospitalization or death could

00:44:21.180 be to his unvaccinated 38-ish year old son. I suspect he overestimated it at something like

00:44:28.300 50% or something higher. Yeah. Any other guesses? I think I saw a survey when they looked at this,

00:44:35.100 that something like a quarter of people from one particular vantage point felt that the

00:44:40.140 hospitalization rate was over 40%. Yeah. Do you have a guess, Monica, what he thought

00:44:44.600 was his son's fate? Yeah. I mean, even if he said 10%, it would be way too high.

00:44:50.860 He said 50%. He said 50%. So good guesses, guys. I win. I win. And then I said, well, look,

00:44:59.540 and it's really funny. This was one of the few times when I actually had some emotional intelligence

00:45:03.420 because I don't feel like I have a very high EQ. And I think my knee-jerk reaction would have been to

00:45:08.500 be, you idiot. How could you possibly think that? Don't you know the data? Instead, I flipped it and I was 1.00

00:45:13.100 like, oh my God, I now understand why you are so torn up about this. If I thought my child was making

00:45:22.520 a decision that was turning their risk of death into 50%, I would turn everything on its head to

00:45:29.860 prevent it. And then I said, well, let's look at the data. This is actually his risk of hospitalization

00:45:34.980 or death without the vaccine. And this is his risk of hospitalization or death with the vaccine. And

00:45:39.620 there was about a 10-fold difference, right? It was a log difference. But it was the difference

00:45:43.540 between 0.001 and 0.001. I mean, it was incredibly small. But that feeds to your point, Monica, I think,

00:45:50.580 which is I really wonder how many people who are emotionally full of anxiety need a little bit of

00:46:00.600 a, maybe like a prep course on this stuff. Let's just do the facts again about how deadly this thing

00:46:06.320 is. What's your risk going to the hospital? What's your risk of X, Y, and Z? You'd think

00:46:10.160 that we would know that by now, but I don't think that's the case, at least based on this one anecdote,

00:46:14.340 right? You're so right that all that data is available, how much lower risk you are when you're

00:46:19.760 younger. And it's a very interesting and different virus in the sense that young children are very low

00:46:26.020 risk for severe disease, which isn't true of, for example, influenza, which affects young children in

00:46:31.000 the extremes of age. And it has to do with receptors in noses of young children and also

00:46:36.740 their innate immune system and how our innate immune system probably mediates pathophysiology.

00:46:41.880 But you're right that somehow people are so not aware of the epidemiology. And I will blame

00:46:47.400 public health officials also for not clearly laying it out how much more at risk you are when you're

00:46:53.660 older. I still blame public health officials for not even putting out this data of how vaccines

00:46:58.260 really make you almost immune to the severe outcomes, even two dose of COVID, unless you're

00:47:03.880 in specific risk groups, in which case those specific risk groups really must be protected

00:47:07.820 and they're vulnerable. I think it's a failure of messaging.

00:47:10.280 One interesting thing, I think Peter kind of put his finger on it here is emotion. So emotion and

00:47:15.280 morality and our moral sort of taste buds. So when Monica says, listen, as doctors, we see it's clear

00:47:21.360 it's unvaccinated people that are suffering the most in the hospital and anything we can do 1.00

00:47:25.560 from a care versus harm standpoint to ensure that people get vaccinated would be a good thing.

00:47:30.760 And actually, so this is my personal take looking at the emotions of this for mandates. If I could

00:47:36.040 wave a magic wand magically and have every single person in this country that's eligible to be

00:47:40.860 vaccinated, vaccinated at a minimal level that prevents severe disease, I would do it. I would

00:47:44.920 do it in an instant because I know the net area under the curve of suffering would be much,

00:47:49.620 much less. Where Monica and I have a different emotional spin on mandates would be, I see the

00:47:56.420 emotional reactance, the psychological reactance to a government that nobody trusts and a public

00:48:02.880 health apparatus that people don't trust mandating something, which then generates a response of,

00:48:08.040 you're not going to tell me to do this because I don't trust you, which then damages our ability

00:48:12.540 to vaccinate in the future or with future pandemics. And that's why I am always nervous about the public

00:48:17.780 health policy tool of mandates being spun around because I worry that it will backfire in a longer

00:48:23.680 emotional way with a segment of the population that we could reach otherwise with education like

00:48:29.440 the Swedes. They don't have to mandate anything. They trust their government. They've built distrust

00:48:33.600 over years and the vast majority of them are vaccinated. So I think we both agree that we want

00:48:38.840 the best thing for the most people. And then it's just a question of how to wield the policy to make it

00:48:42.620 happen. And I think there's something else to dig a bit deeper into that. Now, obviously we're well out of

00:48:46.820 fact and now into opinion-based thought, but I just can't think of too many case studies in my life.

00:48:52.400 And this again goes back to things I learned in the hospital. Marty, think about all the times,

00:48:56.760 I mean, all of us have had these discussions with patients when family members are on life support

00:49:02.760 and they're brain dead and you're having these discussions about withdrawing care. And if you go in

00:49:08.580 there in a condescending way, using guilt and shame and brute force, the outcome is always a disaster.

00:49:18.020 I saw a quote somewhere. It wasn't even talking about this. It was about something else. And it

00:49:21.500 said like, never in the history of civilization has shame and fear forced someone to do the right thing.

00:49:28.840 It was a little more profound than that. It was more nuanced than that, but that was the gist of it.

00:49:32.860 And I think that's, what's interesting to me is there's something about the mandate that feels

00:49:38.100 very shaming and very fear-based. And I'm not convinced that that strategy works. And I agree

00:49:45.120 with you, Zubin. I think that if we could take every person who would be protected by this and

00:49:50.300 get them vaccinated, you would absolutely reduce the suffering to both the individuals and to society,

00:49:55.700 right? To the healthcare system and all these other things. But I don't know, maybe I'm just naive.

00:49:59.240 I really wish it could be done with honest information and not with fear. I pulled this

00:50:03.720 analysis together yesterday. I actually asked one of my analysts to pull these data and then I wanted

00:50:09.560 to make some graphs and we'll show them to folks. But I want to show you guys this. I was sort of

00:50:15.020 surprised at the magnitude of this. So can you guys see my screen? I know the listener will have to look

00:50:19.100 at this in the show notes, but so I had them pull up mortality data for people in the US under the age

00:50:26.280 of 35. And I just wanted to look at four categories besides COVID. So motor vehicle accidents, suicides,

00:50:32.420 homicides, and drug overdoses. And I looked at the data and I thought, okay, well, what's the easiest

00:50:36.480 way to represent this? And it turned out that just by dividing every one of those by COVID mortality,

00:50:42.720 so you would make COVID mortality unity. Then you could look at what the relative mortality was. So if

00:50:48.760 you look at this graph here, what I'm basically showing you is by age groups of the under five-year-olds,

00:50:55.440 the five to 14-year-olds, the 15 to 25-year-olds, the 25 to 35-year-olds. And the y-axis is showing

00:51:00.900 you how much greater that cause of death is than COVID for that individual. So for example,

00:51:07.020 when you're looking at motor vehicle in the under five-year-olds, it's like 11 times greater.

00:51:12.380 Homicide is almost 10 times greater. And drug overdose, which seems hard to imagine,

00:51:17.840 you know, they're probably accidentally taking Tylenol or something, is two times greater. Fortunately,

00:51:22.140 there are no suicides in that bin. As you go higher, as you look at now five to 14-year-olds,

00:51:27.700 motor vehicle accidents, more than 10 times greater mortality than COVID. Suicide, this is the most

00:51:33.900 tragic to me. In five to 14-year-olds, the risk of suicide is six and a half times greater than that

00:51:39.960 of COVID. The risk of homicide is five times greater. And the risk of a drug overdose is the exact same as

00:51:47.440 that of COVID. And now you look at 15 to 24-year-olds, it's basically across the board,

00:51:52.500 nine to 10 times greater risk of death in the United States due to motor vehicle accidents,

00:51:58.840 suicides, homicides, and drug overdoses. And even in the 25 to 35-year-olds where we're now seeing,

00:52:05.000 hey, I think the adjusted number is 6.9 deaths per 100,000, you're still seeing a drug overdose

00:52:13.040 that is six and a half times higher than that. And then when you look at motor vehicle accidents,

00:52:19.100 suicide, homicide, they're more than two times that. I guess I'm keep coming back to this thing

00:52:23.940 about people are so phosphorylated about young people not being vaccinated. And this comes back

00:52:29.720 to my point about being logically inconsistent. If we're going to be this phosphorylated about a 30-year-old

00:52:35.760 not being vaccinated, that's fine. But then I expect you to be seven times more phosphorylated

00:52:41.880 about how many of them are being killed by their own hands, by the hands of somebody else,

00:52:47.000 by drug overdose, or in a motor vehicle crash. Isn't that the right thing to do if we're going to get

00:52:51.880 so phosphorylated about a 30-year-old not having a vaccine, especially when we've already established

00:52:57.740 with this variant and the variants that are to come, it doesn't necessarily prevent transmission

00:53:03.160 all that much. So we're really talking about the risk to the individual. I just think we need to

00:53:07.960 get very upset about a lot of other things. Gosh, that's so compelling, Peter. I mean,

00:53:13.140 what you're showing is basically that motor vehicle accidents independently, each separately,

00:53:18.600 suicide, homicide, drug overdoses, compared to COVID, just blow COVID out of the water, not even close.

00:53:25.960 These are the major public health threats facing young people. That doesn't mean that COVID's not a 1.00

00:53:31.320 concern. It just shows how we have had massive blind spots during this entire pandemic. People

00:53:38.520 don't just die of COVID. They die of depression and poverty and hopelessness and alcohol and stress

00:53:46.160 and deferred cancer care and drug abuse. And that is the broader perspective. That's the context that I

00:53:52.380 think we've lost. And if you remember when Joe Rogan had Sanjay Gupta, I'm going to joke around and say

00:53:59.120 on the witness stand, but it was on his podcast. And he pressed Sanjay Gupta and he said, do you feel

00:54:04.460 good that you're immune about your immunity and your vaccination status? Do you do stuff? And he

00:54:09.020 started parading around, yeah, I think people should feel good about their immunity. And I'm 50 or so,

00:54:14.860 I'm healthy, I'm vaccinated, I feel good. And he said, well, so you're not concerned about COVID.

00:54:21.040 He basically said, you know, I'm not concerned because I'm vaccinated. And then Rogan points out the data

00:54:25.440 that a young unvaccinated healthy child, and that's an important stratification because

00:54:30.420 the death and hospitalizations are significantly clustered in kids with comorbid conditions.

00:54:35.700 And those are the ones that should be priority for vaccination. But for a healthy child, the risk

00:54:40.040 stratification is different. And he said, do you understand how your risk is still greater than that

00:54:46.580 of a young child unvaccinated? And he's not suggesting we don't vaccinate kids, but he's saying,

00:54:52.660 do you understand how parents are not that concerned, just like you're not concerned?

00:54:58.720 And I think he was trying to elicit this sort of perspective that there's a lot of threats

00:55:03.360 out there. Let's put them in context. And I don't know who the parent was that asked you,

00:55:10.100 that thought there was a 50% risk of their 30-year-old healthy child getting vaccinated.

00:55:15.180 Getting COVID.

00:55:16.140 For getting COVID. Was it Sonia Sotomayor by any chance?

00:55:18.960 I can't disclose my patience. Sorry, Marty.

00:55:21.200 Okay. Whether it was her or somebody else, the risk from COVID net from the CDC's website

00:55:27.460 is the risk of all people in the United States unvaccinated getting hospitalized is 65.9 per

00:55:36.440 hundred thousand per week. And that was roughly at the peak of Delta. That ended up being about one

00:55:42.760 in 1,500 people in the population. Now, that one person is not a young, healthy 30-year-old in

00:55:50.980 general. They tend to be the profile that Monica was suggesting. In other words, older.

00:55:56.160 So we've never really talked about stratifying by comorbid condition. And to answer your question,

00:56:02.260 I think immunity requirements make sense, I think, in healthcare for those who are patient-facing.

00:56:09.880 I don't think it's the same calculus for an accountant who's working by home for the hospital.

00:56:14.520 We've been sitting stagnant at 85 to 86 percent of the adult population in the United States

00:56:20.980 vaccinated for a long time. And what I think happened is all these discussions of the mandates

00:56:25.980 hardened a lot of people. And a lot of these immunity requirements do not account for natural

00:56:31.160 immunity. So you have a hospital system in Washington state. They're in Tacoma and Olympus.

00:56:37.420 It's called multi-care. And multi-care laid off 55 staff for not being vaccinated. And that's on top

00:56:45.140 of the people who left before the vaccine requirement took into account. So a lot of these people had

00:56:50.400 natural immunity. Healthcare workers, as you know, especially at risk and more likely to have natural

00:56:54.780 immunity. So they were working on a real skeleton crew. And then what happened is they got more

00:57:00.820 patients as you always do in the winter viral season. A lot of them with COVID. This skeleton crew

00:57:07.020 was so short-staffed. The hospital asked people who called in sick with COVID to come in back and

00:57:14.180 work in the hospital. And this is a memo. This is reporting from Jason Rantz, where the memo is online.

00:57:20.300 I tweeted it the other day. And it says, basically, even if you have symptoms, if you've tested positive,

00:57:25.560 come back unless the symptom is fever. Then they told the managers, hey, when you assign these workers,

00:57:32.140 try not to assign them to people immunosuppressed. If anything, try to assign them to

00:57:36.600 patients who have COVID. The COVID staff take care of COVID patients. I mean, this is the insanity of

00:57:42.980 blanket policies, hardening people, requirements that do not account for natural immunity.

00:57:49.340 Ironically, the state had this harsh, few exception, no exception vaccine mandate in Washington state.

00:57:56.100 Well, a lot of the snowplow workers, they work alone, they drive a snow truck, and they were fired.

00:58:02.320 One of the main highways in Washington state then got snowed. It was undrivable. So the county,

00:58:09.600 Kinetus County, offers to then plow this road for the state. The state should be plowing it,

00:58:15.020 but they don't have enough driver snowplowers. So they offer to plow it. The state says, no,

00:58:19.900 you're not allowed to because your snowplow workers do not have the vaccine mandate. They're not under

00:58:25.700 the vaccine mandate. This is the lunacy of the hardening of the positions around this mandate talk.

00:58:30.560 So Monica, I want to bring it back to you because I really do want you to help me

00:58:35.120 accept vaccine mandates. I respect you so much, but as you can see, my bias is that they're not

00:58:41.400 logically consistent and they're bad policy. So in light of Marty's story, what's the case for why

00:58:48.640 we should be mandating a vaccine? It's fair. And I learned from everyone as I hear what I just heard.

00:58:54.920 I mean, I definitely think recovery or having had natural infection has to always be taken into

00:59:01.600 account always. And so, for example, there's a study soon to be published. They already actually

00:59:07.180 published this in the med archives. So I won't say anything that we don't know that healthcare workers

00:59:12.640 were equally as likely to be reinfected if they'd been vaccinated versus had natural immunity and

00:59:19.380 severe disease was equally as protected. So recovery immunity always has to be taken into account

00:59:24.200 for any mandate. I think that our country is unable to have nuance about COVID. What you just did

00:59:34.640 and showed us the differential risk of COVID in the young and the old was so powerful. And yet

00:59:42.040 our country more than any other country has kept schools closed in only certain political legions

00:59:47.920 have in a way restricted the young more than the old in this very strange backwards way in a way that 0.95

00:59:55.000 Europe didn't do. Without that lack of nuance, maybe I was saying vaccine mandates because we seem to have

01:00:02.400 unable to have non-shaming nuanced conversations in this country. We will have a lot to do after this to

01:00:08.260 figure out why we allowed healthcare workers to not drive the conversation about COVID. And we allowed people

01:00:16.460 who don't have a lot of expertise in a way to drive the conversation. Maybe that's because of social media

01:00:21.440 or maybe it's politicians or political, but I just know that I lived through HIV and I continued to

01:00:27.320 because I'm an HIV doctor and never did someone with few credentials could drive the whole conversation.

01:00:34.780 So I think it's a very complex topic. It's done. The Supreme Court has only said for healthcare workers.

01:00:40.020 So I feel like they absolutely made a decision together that vaccine mandates aren't going to

01:00:46.260 be. Although the reality of it is the mandates are still happening. I have a previous podcast guest

01:00:50.380 and this person will remain nameless because I've spoke with them last week and they said that they

01:00:54.940 would prefer I not tell their story with attribution. They're fine with me telling their story,

01:01:00.500 but not with attribution. This is a person who is a professor at an Ivy League university who does

01:01:06.940 really remarkable work. I'm not just saying that because I interviewed them on the podcast. I

01:01:10.960 interviewed them because they do really remarkable work. This individual was fired from the Ivy League

01:01:18.080 university for not getting vaccinated. The point being is the university could have its own mandate

01:01:23.620 program absent the federal government. This person was fired in November of last year in 2021.

01:01:29.500 I read an article today, I believe said, I don't want to get the number right. This is a conservative.

01:01:35.460 I think it was 150 of the fortune 500 companies in the U S are going to continue with mandates even in

01:01:44.880 the context of what the Supreme court said. So in other words, I don't think this issue is over

01:01:47.700 because of the Supreme court. It sounds like States may choose to do this. I mean, certainly the

01:01:52.520 States like California and New York may be still deciding, Hey, we're going to create our own mandate.

01:01:58.560 So I don't think this issue goes away. I would do want to ask you about something that I've never

01:02:02.140 heard a straight answer to. Marty Zubin and I discussed this. So I don't know if you guys,

01:02:06.160 Marty Zubin have thoughts since we last spoke about it, or Monica, you have thoughts to interject.

01:02:10.080 Natural immunity seems to be this taboo word. If you say the words natural and immunity

01:02:15.360 juxtaposed, it's like you're not on the COVID team. You're on the, what do we call ourselves?

01:02:22.140 The COVIDiots. You're a COVIDiot as opposed to a branch COVIDian. Is there a technical challenge 1.00

01:02:27.160 in determining if someone is naturally immune? Again, there's no other example I can think of

01:02:32.760 in the entire world of virology when natural immunity isn't a good thing. Why is it with COVID

01:02:38.600 we've decided it's irrelevant? It's as though it doesn't occur. Is there an operational reason for

01:02:45.060 that, that it's too hard to measure or that somehow the antibodies when you're naturally immune

01:02:51.020 are not amenable to our test kits? Like I know that that's not the case, but I'm trying to come

01:02:57.600 up with some reason why we've decided natural immunity does not count. But no other place does

01:03:05.520 this. So it's a US thing. Europe, almost every single country, natural immunity is taken into

01:03:11.260 account and passports and whatnot. So I think we have to cut this short and say something political

01:03:17.260 in the US, but it doesn't happen. Can I speculate one thing that's been speculated before? And I'm

01:03:21.180 going to use a word that you would think wouldn't apply to science, but it's called religion. So

01:03:26.400 in a way, what we've done is we've created a God-shaped hole in our society over multiple

01:03:31.760 years of secularization, which is, that's all fine. But what's happened now is you have a situation

01:03:36.080 that polarizes people almost the way a religion would. So look at the natural immunity versus 0.50

01:03:41.800 vaccine immunity. It is a sanctity versus degradation issue for people, a purity issue. So if you're

01:03:47.000 a COVIDian and you're in the thesis camp and you're like, no, vaccines are the answer. We

01:03:51.640 get through this through vaccine-related immunity, you are unclean, unpure, undesirable, and unwelcome

01:03:58.320 if you are not vaccinated. If you've gotten the disease previously, you already have a strike

01:04:04.200 because you didn't mask up, you didn't distance, and you are unclean. So I think people will never

01:04:09.480 say that, but they will feel that innately, especially when it's reinforced by mass media and culture

01:04:16.140 at work and so on and so forth. Now on the other side, there's an equal religious fervor,

01:04:21.000 and that is the holy sacraments of hydroxychloroquine and ivermectin and the conspiracy end times

01:04:27.780 revelation aspect of these guys are trying to hide something from us, poisoning us by injecting our 1.00

01:04:33.360 holy temples, our bodies with vaccines. So both of the sides on this that are polarized have a religious

01:04:39.640 aspect to it, I think. And that's why it's been so hard to understand why this is going on.

01:04:44.200 First of all, that is a really interesting insight about the shame of having got COVID

01:04:49.020 early in the days, right? Because if you're riding natural immunity from 2020, I mean,

01:04:54.880 you must be a filthy person, right? You are of low moral character if you dare had COVID. 0.94

01:05:02.780 I mean, I actually know somebody, my brother, I'm ashamed to admit this, my brother had COVID

01:05:08.300 in Q1 of 2020. Can you believe what it is? Oh, shame, Peter.

01:05:13.440 Yeah, he is a filthy human being for having let himself come in contact with someone who went to 0.99

01:05:20.720 Florida in 2020. Anyway, it's just, you know what? He is still my brother and I still, I still talk to 0.97

01:05:28.100 him. Yeah, I think I love him. I would go so far as to say that.

01:05:30.980 I think Omicron is actually de-stigmatizing though, and that's good. In a way, a very highly

01:05:36.260 transmissible respiratory variant, it can't be eradicated. And like you just said at the beginning,

01:05:41.620 Peter, this is now being recognized now by almost everyone, I don't think. And it's not shame.

01:05:47.480 It's not that we weren't good enough. It's not that we weren't masky enough. It's a highly

01:05:51.900 transmissible respiratory variant with animal reservoirs, a pre-symptomatic period, a long

01:05:56.760 infectious period and non-sterilizing immunity to the vaccines. All of that means it cannot be

01:06:01.200 eradicated, but it can be made endemic. It can be controlled. And since everyone's realized that now,

01:06:07.800 and now we're in this phase where people are converging and saying the same thing when they

01:06:12.000 used to say different things, it is the time where the shame of getting a pathogen is being

01:06:17.520 de-stigmatized. I think being in the HIV world, I really revolt against giving shame and stigma to

01:06:24.280 getting a infection. We used to hate people who did that in HIV in the early eighties. And now those

01:06:29.660 same people are stigmatizing and shaming people who get a virus, but it's okay because everything is

01:06:35.000 changing now. And I think there's a convergence of thought.

01:06:38.860 So I want to talk a little bit about masks, because again, I think what's nice about this

01:06:42.000 group is we have different views on things. And Monica, I know that you're going to make a good

01:06:45.980 case for why people should be wearing masks. So let's just start with the facts. What do we know

01:06:51.900 today about the efficacy, both at preventing transmission and preventing the receipt of the virus,

01:07:00.600 whatever the right way to describe that is, right? Protecting you versus protecting others.

01:07:04.340 When it comes to the following groups of masks, N95 and KN95. And if there's a difference between

01:07:11.100 them, please tell us. Secondly, a surgical mask. Third, a cloth mask. Can you comment on those three

01:07:17.160 categories of masks and in the two domains, which is giving versus receiving virus?

01:07:23.420 So actually, I've had a very consistent position on masks. My first podcast with Zubin was that cloth

01:07:28.680 masks seem to reduce the severity of illness. And then there were some NIH studies that showed that

01:07:35.540 actually it's probably the humidification of air when you're wearing a cloth mask that reduces the

01:07:41.000 severity of symptoms. However, we're in 2022. The best way to reduce the severity of symptoms

01:07:46.420 is to get vaccinated. Which one would I rather do? Wear a cloth mask my whole life or get vaccinated?

01:07:53.120 That has gone out the window because that was a very specific utility for cloth masks for the

01:07:59.980 individual that's gone out the window now that we have vaccines. So this is how I feel about masks now.

01:08:05.160 I have a very clear opinion. There are certain masks that seem to work best for the individual.

01:08:11.800 We cannot be mandating mask mandates for the whole population anymore because transmission doesn't seem

01:08:19.240 to be reduced by cloth masks. It doesn't seem to be reduced by even surgical masks unless you really

01:08:25.080 tuck them in and double loop them and so forth. That's how people use them. So the Bangladesh randomized 0.99

01:08:29.360 controlled study of masks was reanalyzed by a group at Berkeley and cloth masks and surgical masks did

01:08:36.180 little for the population level. But what a mask does is it one way protects you. And so what I would do

01:08:43.220 if I were the CDC is I would say the right masks, which are N95s, KN95s, KF94s, FFP2s, double masks,

01:08:49.860 or even tucked in surgical masks, put them on their website, which they did the other day,

01:08:53.800 and say, hey, population, anyone who's worried about an exposure, please wear these types of masks.

01:08:59.920 There are some people who want no exposure to Omicron. There are some people who really feel

01:09:04.600 protected by their vaccine. And even if they have mild symptoms, they feel okay about that.

01:09:09.140 There are some people who have no risk tolerance. There are some people who have high risk tolerance.

01:09:14.320 You can't mandate for the whole population. I want my father to wear an N95 because he happens 1.00

01:09:19.060 to be getting chemotherapy right now and he's 87. I want my child who's low risk and fully vaccinated,

01:09:24.900 I don't have risk tolerance for him. So it can no longer be mandated. But if you tell people the

01:09:30.140 right type of mask and one way masking works, then a teacher in a classroom can wear the right type of

01:09:35.540 mask. And the students in the classroom, if a parent feels concerned, they can put that mask

01:09:40.500 on their student, on their child. And if a parent is not concerned after they've been vaccinated or

01:09:45.180 even not vaccinated, then they don't have to wear that mask. So that's where I think we are with

01:09:49.020 masks, one-way masking. So just to be clear, is the implication of what you just said, Monica,

01:09:53.560 that the masks don't prevent you from transmitting the virus to someone else?

01:09:58.280 My interest in cloth masks and my interest in masking were for the individual

01:10:01.240 for reducing severe disease. And I think we do have that data now from the NIH with humidification

01:10:07.720 of air. However, the Bangladesh RCT mask study, which was published in Science, has now been

01:10:13.360 corrected because the raw data got put out. And so three groups looked at the raw data and it didn't

01:10:18.960 look like cloth masks reduced transmission. And even surgical masks actually was much less than

01:10:25.300 originally said in the interpretation of the Bangladesh RCT in villages. Probably if you may be like

01:10:31.160 tucked it in and double looped it and like really sucked it to your face, you could make surgical

01:10:35.260 masks work better because they're polypropylene material. But at this point, we are this far into

01:10:40.640 the pandemic. We have vaccines. There are some people who want to wear masks and never have a

01:10:45.860 risk. There are some people who don't and are okay with having a mild infection or getting exposed

01:10:50.920 because they feel secure about their vaccines. And I think the entire equation has changed with masks.

01:10:56.720 I have no tolerance for my father getting exposed because he's getting chemotherapy.

01:11:00.240 Just to be clear, Monica, when you go and visit your father, you're going to wear a mask as well,

01:11:05.680 I assume. I mean, I can understand why he should be in the KN95 or N95. 0.51

01:11:10.020 Yeah.

01:11:10.660 Do you wear one then to go and see him?

01:11:12.880 I haven't seen him since he's gotten his third dose of chemo. But when I see him,

01:11:17.020 I will see him in a couple of weeks. I'll either test and make sure that I'm negative before I hug him

01:11:21.880 or I'll wear a good mask while I'm waiting for the test. Of course, I can't expose.

01:11:26.180 He is in that category where he can have a severe breakthrough. Yeah.

01:11:29.240 So the implication is that the mask, he wears a mask to protect him and you will wear a mask to

01:11:35.980 protect him. I will do that. But the point is that in where we are with vaccines, that may be

01:11:43.460 my choice, but it is a difference between a mandate. And I'm telling you, I'm in a state

01:11:48.900 that mandates masks. So I'm really saying this very clearly. If we can tell people the right type

01:11:54.780 of mask to protect themselves, actually his mask will protect himself. I may not need to wear

01:12:00.080 something because his N95 protects him just fine. It's why he is right now wearing N95s when he goes

01:12:06.240 out to a grocery store. His masks protect him. If you tell people the right type of mask,

01:12:12.720 there are going to be people for the next three years who wear those right type of masks for

01:12:16.960 themselves everywhere they go. I don't need to wear a mask to protect him.

01:12:21.720 I'm really pushing on this because on the last podcast, I was very vocal about my personal

01:12:26.520 choice, which is I don't wear a mask. I never wear a mask. Luckily, I live in a state that is,

01:12:32.340 what can I say without offending people, free. And so we don't have to wear masks anywhere.

01:12:37.520 And very few of us choose to. Kids don't wear masks in schools. It's just, it's a free for all

01:12:43.600 here in Texas. And the amount of hate mail I got for that statement was, boy, I was surprised by that

01:12:52.200 in a cute way. I couldn't believe how many people got so angry at me for not wearing a mask. They

01:12:58.660 must be aware of data I'm not aware of. No, no. The data is very clear now at this point because

01:13:04.400 we've had two years of data on masks and I have been a huge mass proponent until the vaccines came

01:13:10.360 out. So I was really, really in the mass. It's like all people would interview me about. I was hoping

01:13:14.900 you were going to smack me silly for not wearing a mask because I want to hear the case, right? I want

01:13:18.980 to understand. No, no. At this point, I would actually advise people to look at Joseph Allen's

01:13:23.560 work, Shira Donna's work. One way masking works, we have vaccines. Anyone who wants to wear a mask

01:13:31.040 should. Anyone who wants no exposure should. And it should be specific type of mask, those six that

01:13:36.920 I just said. And that can be for a child. That can be for an adult. Can we recite those again?

01:13:42.600 Yes. N95s, KN95s, FFP2s, KF94s, a double mask with cloth and surgical, or the final option is actually

01:13:52.740 a cloth mask with a surgical filter inside, a filter inside that's polypropylene material. That's probably the

01:14:00.720 most comfortable option. So a cloth mask with a filter inside. Those have all been studied very

01:14:05.020 well. They all protect the individual. And if I want no exposure, I can wear one of those masks.

01:14:10.740 I want my father to have no exposure. He can wear one of those masks. But if I am comfortable with

01:14:15.800 having some exposure because I'm fully vaccinated, then I don't have to wear that mask. And that's

01:14:20.380 where we should go to in this country. And again, I will refer everyone to Joseph Allen's work because

01:14:24.780 he has been working on COVID mitigation for this entire time and he wants one way masking now and so do I.

01:14:29.700 So what's the group consensus on how long people will need to wear masks on airplanes and in airports

01:14:36.460 and in federal buildings and in places like California?

01:14:40.860 California, I think they're going to start unmasking in 2054, General.

01:14:48.040 I will say I live here. Everything's changing. There is the acceptance of endemicity is now being

01:14:55.580 talked about at very high levels. So the Biden administration task force advisors wrote a piece

01:15:02.340 in JAMA just two weeks ago that was similar to a piece I'd written in time that said, you have to

01:15:07.800 accept that we have to live with COVID. And so I think there's going to be four things that happen that

01:15:12.180 are different now than before what used to happen in the world. We have to protect ourselves from

01:15:17.820 respiratory pathogens as a whole. We're probably going to always vaccinate. We need better treatments

01:15:22.580 and we need more of those treatments. The third thing is probably there's going to be more attention

01:15:26.440 paid to ventilation for all respiratory pathogens. And then finally, there will be people and there

01:15:32.160 will be recommendations by the CDC that anyone who wants to mask can wear those six type of masks

01:15:36.420 from now on. But I don't think it can be mandated. And I don't think it'll be mandated in California

01:15:40.740 after February 15th, nor do I think it will be mandated in travel after March or whatever date

01:15:45.960 Biden has said. That is fantastic news to hear.

01:15:49.980 One May masking works. It's like your vaccine protects yourself. Your mask protects yourself

01:15:54.280 too. And for those who are very concerned, I'm so happy for them that we now have such good data

01:15:58.920 on which mask they should wear, including my father.

01:16:01.740 I was doing some video work last week for a documentary that I'm doing and everybody has to

01:16:08.400 get a COVID test right before and everyone has to be negative. So you've got a whole group of people

01:16:12.180 that just had a PCR test that demonstrates their negative. We're all on this very small intimate

01:16:16.660 set. And it's one of these things where I have to talk directly to a camera, which I can't do.

01:16:20.640 I have a real block when it comes to talking directly to a camera. So the only time I can

01:16:24.660 talk to a camera is when I have this thing called an Interatron, which allows me to look at a person's

01:16:29.840 face who happens to be sitting next to the camera. So everybody on the set is in a mask, except me.

01:16:35.320 I say to the woman who's in the Interatron, who I'm supposed to be looking at,

01:16:39.100 can you please take your mask off? Because the whole purpose of me being able to look at your

01:16:42.900 face is to be able to read your facial expression so that I can be speaking to you properly. And she

01:16:47.500 said, well, I don't think the rules allow me to take the mask off. And I was like, but everybody

01:16:52.060 just had a negative PCR test. I think everybody's vaccinated here as well for what it's worth.

01:16:57.040 Why are we wearing masks? Oh, and by the way, you're about six feet away from me.

01:17:00.460 It was just like part of the rules of how this thing had to be done. You sort of now know a little

01:17:04.680 bit about my personality, which is just how logically inconsistent things really are a

01:17:11.040 challenge for my endothelial function via my blood pressure. Zubin, you brought up the idea of

01:17:16.400 religion. I mean, you brought up the idea of secularization in a society leading to almost

01:17:22.640 semi-religious beliefs around different topics. And masks have become one of those in this country,

01:17:28.460 but the data is super clear. Yeah, I think you nailed it. So Peter,

01:17:31.820 you are an impurator. There's again, a dirty sanctity issue that comes up where people who 0.82

01:17:38.020 are very conditioned about masks, who don't see it logically, feel it emotionally. And they see

01:17:42.840 someone without a mask and they feel like this is a dirty person coming to invade the sanctity of

01:17:46.820 their body. And this is how we've conditioned people, unfortunately. Like the way Monica talks 1.00

01:17:51.220 about masks is how I feel about masks. It's now an individual choice and it's great. Like for my

01:17:55.620 parents who are elderly with multiple comorbidities, absolutely. But logical inconsistency,

01:18:00.040 you know, I have people in my studio. We're now four feet, three feet across from each other

01:18:03.960 talking very loudly. We're all vaccinated. We're all comfortable with our risk, even in the setting

01:18:08.200 of Omicron, where again, the great shaming mechanism has been leveled. And so hopefully some

01:18:13.060 of the religiosity starts to dissipate, but I wouldn't hold my breath. I think it's going to

01:18:16.240 take some time. Marty, do you have any sense of how many children in the United States are still

01:18:21.520 being mandated to wear masks at school? Is it the majority or minority at this point?

01:18:25.560 I would say it's the majority. I mean, it's up to local school districts in many states,

01:18:30.240 but I would say it's the majority. And unfortunately, a lot of them are wearing the

01:18:33.640 cloth masks. They're getting all the downside of hiding their faces, not learning how to read

01:18:38.820 facial expressions, all those other things, and none of the supposed upside.

01:18:42.600 None of the benefit.

01:18:43.620 We talked about that Brown University study that talked about significant cognitive and motor delays

01:18:48.700 in children that can only be ascribed to the loss of the human connection. When you look at the

01:18:55.380 risk stratification in kids, it's just a whole different ballpark as we've talked about. And

01:18:59.540 honestly, we are now using policies designed around beta and delta in an era of Omicron,

01:19:06.680 which is behaving very differently. So what happens when Omicron is essentially gone,

01:19:13.540 and now we've got a wave a year from now, but it's parainfluenza, or we have a rhinovirus wave,

01:19:20.320 which we have every year. Then what? Are we going to cover their faces again? So they're

01:19:25.040 basically covered K through 12. And then, of course, when they hit universities, they're going

01:19:29.220 to have to wear a space suit or something. There is a study that just came out since we chatted last

01:19:34.500 time. Maybe, Monica, you referred to this, but the Proceedings of the National Academy of the Sciences

01:19:39.100 on masks that looked at N95s with a nosepiece, N95s without a nosepiece, and a surgical mask.

01:19:46.620 They didn't even study cloth masks, I think because they recognized there's no value in it.

01:19:52.080 So what they found is that if you have an infected person with direct contact with somebody else

01:19:56.920 for 20 minutes, the risk of transmission with surgical masks was 10.4%. With an N95 without a

01:20:06.560 nosepiece, it was 4.2%. And an N95 with a nosepiece, in other words, a good seal, 0.14%. So that tells us a

01:20:15.040 lot. That tells us that not only if you're infected and around somebody, you can significantly reduce

01:20:20.760 the risk of transmitting, but it also tells us that the quality of the mask matters. Now,

01:20:25.680 why are we learning this two years into the pandemic? From a public policy standpoint, which

01:20:30.220 is the perspective I've come from, and I've had to dive deep into the immunology of it, but really,

01:20:37.340 public policy has always been my interest. And what we're seeing here is a complete absence

01:20:42.860 of fulfilling the role of providing data to the public by the NIH and CDC. So for two years,

01:20:50.080 with their gigantic budgets, they couldn't do this basic study on masks. We're learning it on the very

01:20:56.020 tail end of the Omicron wave. I mean, this is why we have so many political arguments about it.

01:21:02.080 And I think given where we are, we need to, and I would encourage people, respect people with their

01:21:08.520 opinion on masks. If you see somebody wearing a mask, don't make fun of them. We need to respect

01:21:12.600 each other. I saw someone playing golf by themselves with two masks on. My immediate reaction was that

01:21:19.000 person lives with a lot of anxiety, but you know what? Let them be. We got to get away. We don't

01:21:24.400 want kids bullying each other. We want- In a way that anxiety has, I mean, it's so deep in our society

01:21:31.180 right now because of how we messaged about COVID that I feel a great deal of compassion for people

01:21:37.020 who feel that degree of anxiety because facts isn't going to change their mind. And we have done

01:21:44.620 a fear, not facts messaging instead of a facts, not fear. And I feel great compassion for people who

01:21:50.380 are so scared right now. So Monica, I know that we've only got you for about another 10 minutes.

01:21:56.120 Luckily, the rest of us here can keep going because there's so many other topics that people have

01:21:59.780 asked about. One of the things that people did ask about that I know you are an expert in, and in

01:22:04.840 fact, your institution is now doing a clinical trial that actually tried to get somebody into,

01:22:09.040 I want to talk about long COVID. So can you tell folks technically how we define long COVID and give

01:22:15.700 us any other insights you have as to what it's about, what the incidence is, what the potential for

01:22:20.580 treatments are, and anything else that you think is germane? So you're right. Our institution,

01:22:24.880 I'm not in that study, but our UCSF has a great study on post-acute SARS-CoV-2 sequelae. And

01:22:32.620 essentially, actually, it's true of any severe viral infection. If you have severe viral infections,

01:22:38.520 you can get lingering symptoms, influenza included. And the pathophysiology seems to be twofold.

01:22:47.000 One is that if you have no immunity to the virus, it can go multiple places. It won't stay in your body

01:22:52.720 long-term like HIV, but it can go multiple places. That's one mechanism. And then the second

01:22:58.000 is that your innate immune response, if you have no immunity to the virus, can lead to inflammation

01:23:04.860 that lingers. Luckily, after vaccination, two things happen, or after immunity, after you've had

01:23:11.520 the infection before, you get adaptive immune responses. So quickly, when you get the virus in

01:23:17.700 your system, like you're having a mild breakthrough infection, your immune response swoops in. There

01:23:22.780 are actually T-cell islands in the nose, despite the antibodies going down their T-cell islands in

01:23:27.580 the nose. Your immune response actually swoops in, makes that virus not go everywhere. It's usually

01:23:33.240 why the breakthrough infections are mild and up in the upper respiratory tract. So you've just lost

01:23:38.180 one pathophysiologic mechanism by being vaccinated or immune because it doesn't go everywhere. And then

01:23:43.260 the second is it's not your innate immune response that reacts. It's your adaptive immune response. So

01:23:48.780 you don't have that kind of massive inflammation that can occur before your immunity. So there was

01:23:53.260 just a study this morning in Israel that those who are vaccinated don't get long COVID symptoms after

01:23:59.460 having a mild breakthrough. In fact, they have long COVID symptoms at the same rate as people who've

01:24:04.860 never had COVID at all. There's people who have had a lot of anxiety and depression during this time,

01:24:09.560 understandably, and that can be mistaken for long COVID symptoms.

01:24:13.260 I don't think I was aware of that, Monica. You're saying that there are people who are being

01:24:16.100 quote unquote diagnosed with long COVID who have never had COVID and it's really just a

01:24:20.540 manifestation of anxiety? There are some studies that what's going on in the world right now and

01:24:25.640 how miserable everyone is, is making people have less cognitive function because it's just a miserable

01:24:31.440 time. But this very good study just from this morning and essentially shows us that if you've had two

01:24:38.720 vaccine doses that you have fewer long COVID symptoms than people who have never had COVID.

01:24:47.440 So basically vaccination both brings your long COVID symptoms in check. So getting vaccinated for

01:24:53.720 long COVID is one way to treat long COVID. And then also those who have mild symptomatic breakthroughs

01:25:02.040 who have been vaccinated don't seem to get long COVID symptoms. There's basically three studies

01:25:08.920 that show this now, including one from Israel this morning. So putting that all together, the biggest fear

01:25:14.820 of the fact that this virus is endemic and not going to be able to be eradicated among people who are getting

01:25:21.700 mild infections are could they get long COVID symptoms? And there hasn't been any evidence of that.

01:25:27.580 And we have had a lot of breakthrough infections through Delta and now through Omicron. And these

01:25:33.140 are very good studies that shows our adaptive immunity prevents us from getting these longer

01:25:38.440 symptoms. So I think that's very good news for long COVID. Do we have a sense of what the incidence is

01:25:45.020 of long COVID in presumably the unvaccinated, which is the majority of the people that it's being seen in?

01:25:51.220 It depended on if you had severe disease or mild disease. So those who had severe disease,

01:25:56.780 this is a very good nature study. You're more likely to get longer symptoms after that. And it

01:26:01.560 was about 30%. If you had mild disease, it was very low. So it really depends on your severity of

01:26:06.380 initial infection. However, at this point, we have so many people who've been vaccinated and we have so

01:26:12.000 much natural immunity that our long COVID population is going down and we're still treating, because I

01:26:17.540 know this from the clinic, people who had initial severe infection before the vaccines were available.

01:26:22.260 And the reason I'm interested in this question is, as we've all noted, there's still a substantial

01:26:28.280 portion of the young population that's not vaccinated. So Marty, you said about what 15%

01:26:33.800 of Americans are unvaccinated. Is that right? 15% of Americans over five years old are unvaccinated?

01:26:38.680 Over 18 and about 20% over age 12.

01:26:41.520 Okay. So we could do the math on that and reverse engineer what fraction of people aged 20 to 40 are

01:26:47.240 unvaccinated. Really, to me, that might be one of the more potentially compelling reasons to be 1.00

01:26:54.080 vaccinated if you're otherwise young and healthy is to mitigate the risk and the downside of long

01:26:59.920 COVID. Is that a fair assessment? I agree. I mean, not only does vaccination

01:27:05.260 help you not get long COVID if you get COVID, but also it seems to be able to treat long COVID

01:27:11.120 because your more dysregulated immunity goes into a more adaptive and organized immunity. So again,

01:27:18.340 I think it's profoundly important to say vaccination helps long COVID either after the fact or before

01:27:25.460 the fact. So adaptive immunity seems to be the way to get to all roads lead to where we need to get to

01:27:33.580 with this virus, which is having a lot of immunity to the virus. It's why before in 2020, we didn't have

01:27:38.840 any immunity to the virus and we were much more nervous. Now in this stage of the pandemic,

01:27:43.780 we have so much more immunity to the virus. Again, 79% of people in South Africa, even though

01:27:47.820 it's a 25% vaccination rate, there's a lot more immunity in the world. And then that relates to

01:27:52.840 schools, I think. Say a little bit more about that. Again, this is kind of facts, not fear versus

01:27:58.240 fear, not facts messaging. You really went over for us how much lower the risk is among the young,

01:28:05.580 especially children for severe COVID. And it has to do with, there's clear mechanisms by why children

01:28:12.400 are less likely to get severe COVID with ACE2 receptors and their innate immune response.

01:28:17.740 And that's true of long COVID as well. So all of that put together, we have to refocus our ideas now

01:28:24.480 on schools, not being a place of fear, because I think what Marty just said was really significant to

01:28:31.120 me that there will be para-influenza, rhinovirus, influenza, there'll be other viruses that cause

01:28:38.080 infections from now on. And we have to think of children's holistically as the place where they

01:28:45.220 need to learn. I think that ill effects of school closures, I think there are very few people now who

01:28:50.940 deny them two years into the pandemic. The ill effects include mental illness, anxiety, depression,

01:28:57.000 eating disorders, and learning loss. And all of that put together means if I were in charge of the

01:29:02.360 nation, I would put my emphasis on schools because children are most, I mean, any societies from the

01:29:09.920 beginning of history is the most precious resource. So we put a lot of fear. We ask children to shoulder

01:29:16.940 a burden for older adults and we have the vaccines and we've had the vaccines now for a year. We need to

01:29:23.160 now move towards normality for children in schools. You see it, like Harvard just said, they're not

01:29:28.580 going to do asymptomatic testing or contact tracing starting in the spring semester. They're going to

01:29:32.720 have normal college. Johns Hopkins is still not having normal college. Some colleges are going normal,

01:29:38.260 some aren't. Harvard being Ivy League, hopefully we'll have an emphasis on others. Maybe Joseph Allen

01:29:43.560 being there is helpful for the one-way masking argument. If you want no exposure, wear your good mask.

01:29:48.660 So you're seeing things change. Will they still be requiring boosters?

01:29:53.200 They just announced over this weekend that they're going to have normal school in spring semester.

01:29:57.220 I'll need to see the fine print on that because I still, as you can tell, it's a real bone to pick

01:30:01.440 with me that we're mandating vaccines in anybody, but boy, especially in college kids and then to

01:30:06.060 mandate boosters. I'm struggling. Yeah. Yeah. So fair enough. I will say that the idea that college

01:30:15.080 students, I mean, Marty wrote a really poignant piece on this, but the college students would be more

01:30:19.500 restricted than all those adults in the restaurants and bars and sporting events. And it would be the

01:30:25.120 college students that would be most restricted. It was a very poignant article. And Harvard of all

01:30:29.760 places saying they're going to have normal school in the spring semester and accepting that we can't

01:30:34.180 eradicate a virus for me was very hopeful this weekend.

01:30:37.760 Well, Monica, I really appreciate it. Thank you for making time today. I know you have to run

01:30:43.260 Zubin and Marty and I will have a lot to continue talking about and we'll try not to talk about you

01:30:48.040 too much. And you're crazy. 0.99

01:30:49.020 Actually, I will tell you that everything that we just talked about this entire podcast was based 0.96

01:30:56.220 on data. And I think it's good. We don't use a fear not facts approach, but data is the only way

01:31:01.400 to get through this pandemic. We knew this in medical school the whole time, but it hasn't

01:31:06.760 been data driven in a lot of cases. It's been fear driven. So I hope we can change people's minds

01:31:11.900 with the data.

01:31:13.080 Likewise. Thank you, Monica.

01:31:14.440 Thank you very much. It was great to talk to all of you.

01:31:16.600 Thanks, Monica.

01:31:17.800 Great to see you.

01:31:18.980 Thank you.

01:31:20.220 So guys, one thing I want to build on that Monica indirectly alluded to, right, which was the

01:31:24.980 importance of keeping kids in school. It kind of reminded me of, we're going on the way back

01:31:29.800 machine now, but do you remember in spring, summer of 2020 when Sweden didn't lock down

01:31:36.760 and everybody looked at Sweden as though it was crazy? I have not gone back and looked

01:31:43.720 at Swedish outcomes. Do either of you guys know anything about how the situation shook

01:31:48.600 down?

01:31:49.580 I think Marty has more data and I have more anecdote. So maybe I'll start with the anecdote

01:31:53.420 and then Marty can fill in the blanks. So I get a lot of messages from Swedes. Recently

01:31:58.000 got a really good detailed one of somebody who's not in healthcare, but who studies this

01:32:02.720 stuff in general and said, remember, I think a lot of this that we're talking about, we

01:32:06.860 have as people failed to see context where context is absolutely crucial. And so putting

01:32:13.600 Sweden in context, you have a Nordic country that actually over years has developed a relationship

01:32:19.060 between its population and its government that is trusting. And it took a lot of different

01:32:23.180 approaches to do that. Their healthcare systems a certain way, their public welfare systems

01:32:27.540 a certain way, and they have a certain type of population, a lot of whom live in single

01:32:31.360 homes. It's easier a little bit to distance, things like that. So that all being said, they

01:32:35.660 took a tack that said, okay, large events, large gatherings, there were rules about that.

01:32:40.700 So it wasn't just like let her rip in the early days, but their public health officials

01:32:44.680 like Anders Tegnell and these guys were saying, listen, in those days, they did not know

01:32:50.560 when a vaccine was coming. It could have been years. So they said, we need to design a public

01:32:53.980 health approach that's going to be a long game approach, thinking years. So they said,

01:32:59.100 we cannot shut down schools. And they did not, if anything, for like a period of a couple of

01:33:02.980 weeks, it was never months there. Early on, what they found was they did have a higher mortality

01:33:08.280 per capita rate than their neighbors, largely because the one big mistake that was made early

01:33:13.280 on is failing to protect nursing home patients who are the highest mortality, highest risk in the

01:33:18.680 early days. After that, though, so 2020, in 2021, it seemed the data shifted to where actually,

01:33:25.100 no, their excess mortality was not higher than their neighbors. And they actually did quite well.

01:33:30.200 They continue to have trust, although there was a little bit of controversy. And overall,

01:33:34.660 they've stayed mostly open. They had some businesses that suffered that the government

01:33:39.180 directly stepped in and paid salaries and things like that. So there was more of a social support

01:33:43.460 network, but they really were playing the long game. And it seems like so far,

01:33:47.020 they've done quite well. So Marty, what are your data points on this?

01:33:51.100 Yeah. So Sweden is a fascinating case study because they took a radically different approach.

01:33:55.720 And while there was early criticism of their strategy, nobody talks about them since that time.

01:34:00.720 And it turns out that their data are very impressive. So the total population rate of the

01:34:07.780 mortality per capita in Sweden, all in all cumulative, this entire pandemic has been 1 in 663. Now,

01:34:16.980 by comparison, in the United States, it's 1 in 387. We're talking about a radically different

01:34:24.280 confirmed deaths per capita rate. Now, that's according to Statistica. And if you look at where

01:34:31.800 Sweden falls, it's around the middle. But remember, most of the countries in the bottom half

01:34:36.320 are not reporting reliably. Burundi is one of the lowest mortality rates in the world. They're

01:34:43.400 obviously just not capturing a lot of cases. So it's a fascinating example of what happens if you

01:34:50.600 do a selective protect vulnerable people strategy and then figure out a way to continue living life.

01:34:56.960 Now, the real question is, what is their excess mortality from non-COVID deaths? In the United States,

01:35:02.900 there's a suggestion that excess mortality, you may have seen this report come out,

01:35:07.000 is somewhere in the range of 20% higher than the COVID mortality rate. So there's been something like

01:35:12.920 last year, 385,000 COVID deaths in 2020. But the total excess deaths that year were about 430,000 or

01:35:23.780 something like that. So there's some explaining to do there. And no one's taken a deep dive yet. We know

01:35:28.640 about some very broad statistics on opioid or substance abuse deaths. But if you go to the CDC's

01:35:35.080 websites, and this is where the politics may be playing in or just government incompetence,

01:35:39.980 good luck finding numbers on suicide during the pandemic. Good luck finding numbers on substance

01:35:44.560 abuse. They're very crude. They're broad and they're early. They're more delayed than they need to be.

01:35:48.740 One thing, guys, that this guy mentioned too, is that their degree of vaccine uptake in 2021

01:35:54.660 is quite stunning. They did a very good job because they already have innate levels of trust in public

01:35:59.820 health officials. It was public health officials like Anders who were doing the messaging. It was

01:36:04.720 not politicians during much of COVID. So they did very well in 2021, probably partially because they

01:36:10.780 got to vaccine. They've never focused on masks and they did focus on protecting vulnerable. Although

01:36:16.180 there was an unspoken sort of idea among their leadership. It's felt that they were willing to

01:36:21.980 sacrifice some old and vulnerable early on to keep society as a whole running and younger people

01:36:27.040 functioning and the economy going. And they never said this publicly because obviously that's a

01:36:31.220 poisonous message, but that was the feeling. So they made these compromises that were really quite

01:36:36.300 interesting. And then in the long run, the area under the curve of excess mortalities may well have

01:36:40.740 been impacted positively by what they've done. Although I think it's going to take some years to really

01:36:45.240 unwind what's going on everywhere.

01:36:46.880 Many of us sort of found it morally offensive that you would take a let it rip strategy. But those who

01:36:53.500 defend what Sweden did will actually tell you it was not really a let it rip strategy. What they did is

01:36:59.500 they tried to evolve the strategy based on the data. And early on, there was a very focused attempt to

01:37:05.220 protect the elderly and the vulnerable. If you went to a restaurant early on in the pandemic in the semi-open

01:37:12.420 society in Sweden, they were distancing. They were still using some mitigation. So it was not a truly

01:37:17.500 let it rip strategy. And I think to their benefit, I mean, the kids have been in school throughout

01:37:22.720 and they've not been masked. European CDC recommends against masking people in primary school.

01:37:28.980 Looking back, there's, I think, some lessons there. And the people who advocated for us to do what

01:37:33.760 Sweden has done, I mean, they are impartially vindicated now with some of this data.

01:37:38.600 The last thing, I think it's worth reading a line from what this guy sent me. He says,

01:37:41.400 my 15-year-old daughter spends a lot of time on YouTube. And when I asked her if there's anything

01:37:44.960 she wants to add to what I'm telling you, she immediately said that she cannot relate to the

01:37:49.560 COVID experience many talk about online. Her life is basically continued as before. And I don't see

01:37:55.500 any long-term effects in terms of distrust and fear. That Sweden is held together in a way that's

01:38:00.560 very encouraging. There haven't been big draconian measures or big demonstrations of discontent and

01:38:05.040 families and friends torn apart due to different views. So that's really quite interesting. That social

01:38:09.720 fabric has held together. And that's important. It's like we ignore that at our peril. Again,

01:38:14.280 the context of the whole thing, rather than just the little fragments that people tend to focus on,

01:38:18.920 what's the overall context?

01:38:20.720 Again, just sort of digressing into anecdote, I have very close friends in Canada, and a number of

01:38:28.020 them are very seriously considering doing something I would have never imagined possible a year ago,

01:38:35.480 two years ago, any point in time, which is moving to the US. Canadians are a very proud people. They

01:38:40.000 tend to have this superiority complex over Americans, the swaggering, arrogant Americans and 0.99

01:38:47.000 stuff like that. But when you look at the truly draconian measures in my home province, where I grew

01:38:53.740 up, Ontario, I grew up in Toronto, there are people that have basically said, look, we've historically

01:38:58.280 loved Canada, but enough is enough. They're really looking to move to US states that have been far

01:39:05.660 more open. And it's really extreme. So to give you some perspective, referring to a friend who had

01:39:11.340 COVID, didn't get vaccinated, kids are not vaccinated. As a result of the fact that the parents had COVID

01:39:17.880 but are not vaccinated and the kids are not vaccinated, the kids can't play sports. They're not

01:39:22.980 permitted to play sports. You have to think about that for a second. So like, what is the implication

01:39:27.720 when you take kids age 12, 13, 6, 7, 8, and you say, sorry, your parents aren't vaccinated. You

01:39:35.900 haven't been vaccinated. You don't get to play organized sports. And of course, you're wearing

01:39:41.140 masks in school and all these other things. And I'm sure people have heard that the province of

01:39:45.320 Quebec is now trying to tax the unvaccinated. It's a sin tax now. Think about that for a moment. 0.86

01:39:51.680 Again, if we're going to be logically consistent, if we're going to say we're going to tax the

01:39:55.500 unvaccinated, boy, we are going to be taxing a lot of people, right? I mean, if your BMI is over 25, 0.96

01:40:02.100 we should probably be taxing you too. If you're clumsy and you're doing high risk sports, I mean,

01:40:08.280 you should probably be taxed for that because you're more likely to end up in the hospital.

01:40:13.600 Anyway, and going back to this example of a friend of mine, do you realize that an unvaccinated person 1.00

01:40:18.880 in Canada cannot travel in Canada? So they can't get on an airplane. They can't get on a bus.

01:40:27.760 They're only permitted to drive themselves and they still won't be allowed to cross the border.

01:40:33.920 You know, there are countries that do stuff like this. It's called Sharia law,

01:40:38.040 very aggressive sort of fundamentalist countries that do this kind of thing based on religious belief

01:40:42.640 in a way, because I'm not sure we'd find data to support these activities. This is now,

01:40:47.780 again, I'll reiterate, falling into the vestiges of religion. And the question is-

01:40:52.060 I want to say something even more provocative, Zubin, which is, isn't that almost now as radical

01:40:58.440 as the most radical form at the opposite end of the spectrum, which is the most radical form of

01:41:03.480 fascism, right? I mean, think about what was going on in Poland in the 1930s. So it's the totally

01:41:09.560 opposite end of that spectrum, but you couldn't leave that country. You would have needed to escape

01:41:14.300 that country for your safety. I'm not trying for a moment to compare this to Nazism. I'm simply saying

01:41:21.260 at some point, these completely opposite ideologic things meet in terms of how restrictive they are.

01:41:28.300 Yeah. Actually, you really think about that. You're in a country that can effectively be landlocked

01:41:33.040 and you cannot escape. You cannot leave Canada. It sounds like a great movie, Escape from Canada,

01:41:38.520 and Toronto is a post-apocalyptic flaming wreck. But I could see Marty starring in that,

01:41:44.840 the first Brown-like leading actor. I think we need that.

01:41:49.540 As I remember the dean of the Harvard School of Public Health said,

01:41:52.600 a Canadian is essentially an unarmed American with health insurance.

01:42:00.640 Here's where the argument falls apart, Peter, with data. What happens if that same individual that

01:42:06.680 you're describing is infected with influenza or peri-influenza? Then what? Oh, that's okay,

01:42:13.160 I guess, right? Even though the case of fatality- Yeah, presumably they're allowed to get on an

01:42:17.080 airplane and they could probably even get on a bus or a train and maybe even- They can kill people.

01:42:22.320 They can kill people with influenza very easily. I mean, this is that influenza kills so many people

01:42:27.000 per year. You know, another thing that doesn't get a lot of attention,

01:42:29.720 we have so many remarkable antiviral treatments for COVID now. I don't know about you guys. Have

01:42:36.660 you guys ever had influenza, the actual real deal OG flu? Yeah. Yeah, I've had it twice in my life.

01:42:43.380 It sucks. It's the worst. That is a bad virus. And we don't really have anything too good. Remember 0.99

01:42:50.580 Tamiflu, how useless that turned out to be? People were stockpiling Tamiflu. Like it did nothing.

01:42:56.900 Influenza, which is about as bad as Omicron. Marty, correct me if I'm wrong.

01:43:02.880 Oh, worse. Influenza is worse than Omicron.

01:43:05.020 I mean, you're talking about the study of 52,000 people, one death. I mean-

01:43:09.580 I haven't got Omicron yet. I've been trying. Actually, super annoyed that I don't have it yet

01:43:13.520 because I feel like I'm missing out on a booster shot or something. But when I look at all of my

01:43:17.940 patients and friends who have had Omicron, yeah, I would say it certainly anecdotally appears far less

01:43:22.740 severe than influenza. And yet when you get influenza, you don't have a drug that you could

01:43:28.700 take if it gets really bad. The way we have fluvoxamine and the other more recent Pfizer and

01:43:34.040 Merck drugs. So that's another thing that doesn't really seem to get in the spirit of what can you

01:43:38.360 do as an individual to protect yourself? Well, step one, get vaccinated. Step two, have access to

01:43:44.640 therapeutics. Step three, have access to a healthcare system that has literally just spent the last two

01:43:52.240 years doing a fellowship on how to treat this disease. I think one of you said it earlier,

01:43:57.040 right? We're operating under assumptions that are two years old.

01:44:01.360 An infection fatality rate of a prior virus. Omicron needs a PR firm because as long as it's

01:44:09.280 COVID, people think they're using all the COVID historical data. And when you add population

01:44:15.240 immunity and a more mild virus, it does change the calculus. It doesn't mean people don't get sick.

01:44:19.200 Doesn't mean that any of us would ever wish anyone become infected and deal with this virus. Nobody

01:44:25.820 would want that. But I'll tell you, I just talked to doctors in Egypt there this morning. They've had

01:44:31.180 a real tough time getting people vaccinated. They've tried everything. They're very thankful to God

01:44:36.460 that Omicron is what it is because it is going to confer large, broad population immunity. And

01:44:43.060 otherwise, there were just no other strategies to get there. The question is, how did we become so

01:44:48.320 dependent on the CDC to adjudicate on every aspect of American life? And we know typically

01:44:55.080 they draw on data from their MMWR reports that's historical. Everybody is so upset at the CDC over

01:45:02.100 so-called messaging in terms of, I've done my five-day quarantine. Do I get one test or two tests? Do I get

01:45:09.140 antigen tests or PCR tests? Stop. Let's ask the bigger question. Why are we even quarantining immune

01:45:17.720 people who are low risk from other immune people? Would we ever do this for parainfluenza or

01:45:24.220 rhinovirus? This is where we've just sort of developed this intense dependency. And as long

01:45:29.660 as we're waiting for the CDC to tell us whether or not we get one or two antigen tests because

01:45:33.480 the sensitivity in the pre-symptomatic phase or asymptomatic phase is below 50 percent. So after

01:45:39.080 you've done your five days of quarantine, you're still not getting the definitive answer. So why

01:45:43.600 are we having these arguments when we need to just get back to common sense? Which means if you've been

01:45:48.920 exposed, then wear a mask. Doesn't matter what virus. If you are around someone vulnerable, be careful.

01:45:55.320 Maybe stay your distance. And if you're sick, stay home. That is a pan-viral strategy that we need to

01:46:02.280 adopt for general public health hygiene that gets us away from these crazy deliberations that we're

01:46:07.520 having right now. It requires a culture shift too, right? Because people have to understand that going

01:46:11.920 into work sick without a mask, say, is really a taboo. That should become a social taboo. It's not

01:46:17.920 something that you do. It's not where we are or where we were certainly pre-pandemic. One interesting

01:46:22.500 thing too is this context issue. There are a lot of doctors on, say, in the coastal cities that have

01:46:27.420 been victimized. I call it victimized because I'm biased, right? I'm going to say biased now. This is

01:46:31.160 editorializing. Mask mandates, kids' mask mandates, vaccine mandates, all of this. And they see a

01:46:37.860 society that's actually a pretty highly vaccinated group and they're like, come on, guys, let's stop

01:46:42.360 this. We need to open up. Why are we doing this? And people like, say, maybe you and me, Marty, have

01:46:46.180 been messaging this more balanced message of, hey, some of these restrictions don't make sense. Now,

01:46:50.680 where I get pushback, which I think is interesting, is from doctors, say, in the Midwest or in parts of

01:46:56.300 Texas or rural parts of the country who say, listen, these doctors skew more liberal, say,

01:47:02.460 they're in very conservative areas and they're seeing maskless people, lots of morbidity in the 0.96

01:47:07.260 ICU. And their response is, no, their messaging is the opposite. We need mask mandates. We need to

01:47:12.880 do vaccine mandates and we need to be very monolithic in a public health messaging. So where

01:47:17.520 you are even determines kind of how your mindset is and how you communicate and how you might see

01:47:22.300 somebody like, say, a Marty McCary who's saying these things, they may see that as dangerous in

01:47:27.360 a setting like that. Whereas someone like me may go, say it louder, Marty. It's interesting.

01:47:32.480 I was reflecting on an extension of that theme, again, thinking about how we were going to be

01:47:36.580 talking about this stuff today and sort of getting into some of the philosophy of it. But

01:47:40.100 since the last podcast came out, which is a couple of weeks ago, I've obviously been a little more

01:47:45.760 attentive to all things related to COVID in the news, in the literature, et cetera.

01:47:51.280 And truthfully, it hasn't been good for me. So my blood pressure has been running about 10

01:47:56.200 millimeters of mercury higher. Unfortunately, most of that is just social media. And again,

01:48:01.060 part of it is just I have this anaphylactic reaction to things that are logically inconsistent,

01:48:06.060 but it serves no purpose other than to hurt me. But I got thinking, why is that? We all have an

01:48:12.680 agenda and I've been really trying to understand my agenda because I have an agenda. You have an agenda.

01:48:18.720 Everybody has an agenda. And I wish we could all wear t-shirts that said, this is my agenda.

01:48:24.800 So if I'm talking to you, I see your agenda and I can use that to help me interpret what you're

01:48:31.880 saying. I think I understand my agenda really well, right? My agenda, because I'm not a contrarian,

01:48:36.920 like I'm not the guy who wants to disagree with the mainstream view just to be different.

01:48:42.100 Sometimes I disagree. Sometimes I agree. I think my agenda here, we talked about this a little bit

01:48:46.500 before is I'm worried about the integrity of the profession and the broader discipline of science.

01:48:53.860 I really have concern for the integrity of this. And I have many friends and some patients who have

01:49:02.760 completely lost faith in this profession. That's my ax. That's the thing I'm grinding. I am very upset

01:49:11.160 about what the implications of this are down the line. And I think that's what's coloring for better

01:49:17.220 and worse, how I feel about the situation that we're in today. Do you guys have a sense of your

01:49:23.340 agendas? Absolutely. By the way, this is the kind of self-reflection that every single person should

01:49:28.980 do when they think about this, because it then frames the whole conversation very differently.

01:49:33.460 And it involves a degree. You said you have no emotional intelligence. Actually, you just showed that

01:49:37.120 you do. Because I'll tell you the same thing. Since we did the show another couple of weeks ago,

01:49:41.640 and honestly, I've been weaning off talking about COVID prior to that. And you kind of reignited me

01:49:46.560 thinking about this stuff. And it's been nothing but suffering for me ever since. There is a feeling

01:49:52.380 of like, first of all, now you're interested in seeing what people say about it. And it becomes this

01:49:57.300 agenda versus agenda. And it's an unconscious sort of thing. So my agenda with this from the early days

01:50:04.020 has been somewhat shared with yours, somewhat shared with Marty, somewhat shared with Monica's,

01:50:07.460 which is trying to find a synthesis of what is the best policy versus science thing for the most

01:50:13.780 people and trying to bridge across this divide of misunderstanding and division and to try to

01:50:19.300 understand all these positions. I call it alt-middle. I've started to think of it as like a corpus

01:50:23.360 callosum that binds the left and right hemispheres. Like, how do we build those fibers that connect

01:50:28.740 these things together and help us think rationally? And my bias has always been that. Now,

01:50:33.140 the way I'm criticized for that bias. So it's good. So you put it on your T-shirt. I'm alt-middle

01:50:37.080 Z-dog MD. I want to be the corpus callosum in the conversation. People will attack directly and say,

01:50:41.900 there is no middle ground here. It's mask or don't mask or it's this or it's that. And that's fine.

01:50:46.380 But at least then we know where our agendas are and where our biases are, whose hive mind has captured

01:50:51.080 us. That's important to understand because otherwise you'll never be able to bridge these different

01:50:56.540 gaps and have some sanity. And what about you, Marty? What would your T-shirt say? What's your deep,

01:51:01.680 dark agenda here? I want us to be as open as we can about this.

01:51:06.180 I would say to end tribalism because that is the most offensive thing. It's not a different

01:51:11.680 opinion. I'll hear somebody articulate a different perspective and they'll come out entirely

01:51:16.520 differently on what we should be doing or should be recommending. That is okay in the context of

01:51:23.660 civility in my mind. And my thought is, you know, let's show the data on both sides to the best of our

01:51:29.500 ability and let people make a decision. One of the few things that will be morally offensive is the

01:51:36.100 automatic tribalism, the dismissal of people because of something that they thought early on.

01:51:42.920 And nothing captures that better than how Jay Bhattacharya was dismissed early on. And

01:51:47.320 now you see like, hey, the data is playing out just as he said. I also feel that we made a tremendous

01:51:54.280 sacrifice as a country. We're living like grizzly atoms. I mean, I was at risk of growing a ponytail.

01:52:02.440 We come out of this thing and you have people that are saying that was absolutely the right thing to

01:52:08.580 do. And we need to go back into the cave because of speculation of a more dangerous virus coming out

01:52:13.020 of South Africa. And you want to say, stop, let's look at the data. That sort of retreat, I think,

01:52:18.480 many times is scientifically dishonest. When I see the universities who ironically are supposed to be

01:52:23.260 champions of data and scientific reason, revert to these sort of primitive practices that are

01:52:29.800 almost barbaric, they're definitely cruel on students. You want to say, I remember in college,

01:52:35.500 they would insist that everybody at a liberal arts college take a science course so that you

01:52:40.640 understand the scientific method and process, right? They would force these philosophy majors to

01:52:46.020 memorize rocks in geology class, thinking, why do they have to memorize the names of rocks for their

01:52:51.860 future? Well, it's to understand the scientific mind and the scientific process. And then they do

01:52:57.520 this complete rejection of any open scientific debate and cancel people with different opinions.

01:53:04.240 To me, it's the tribalism that bothers me. And it's just sad to see it play out.

01:53:10.160 I'll say one last thing on this, and then we'll get back to what people care about,

01:53:12.780 which is not our griping, but it's more the fact stuff. But I was actually really surprised at some

01:53:18.520 of the hate mail I got after the last podcast. Now, I haven't gone back and listened to it,

01:53:22.740 guys. I got to be honest with you. I don't really have the time to go back and listen to podcasts I

01:53:26.420 record. So, I mean, I guess it's possible I came across as a racist homophobe, but I don't think I

01:53:33.300 did because I'm not actually racist or homophobic. But some of the hate mail I got was, you are a racist 0.94

01:53:41.680 homophobic piece of shit who lives in Texas. How can you say the things that you are saying about 1.00

01:53:49.540 COVID? First of all, I'm like a brown guy. Like, am I racist against white? I mean, like, just tell

01:53:56.420 me, help me understand more where my racism is coming from. These were people that just went off.

01:54:03.440 Like, they went completely off. Somehow, my not wearing a mask and moving from California to Texas,

01:54:13.280 which technically happened before COVID, but that's another story, is really all a sign of,

01:54:20.120 I don't know, misogyny, racism, homophobic behavior. Like, sometimes I get upset when I get

01:54:26.160 nasty comments. This couldn't even upset me because I couldn't even understand. I was like,

01:54:30.120 literally interested in this. I was like, wow. I'm looking at the grammar of the person who wrote

01:54:34.060 it. Like, were they sane? Is this a person who is having, you know, kind of a mental break?

01:54:38.580 Yeah, like China. Yeah, like. Anyway, I'm sure you guys experienced the same thing, right?

01:54:45.280 Marty, unless you wanted to say something, I have some thoughts on this. And this actually relates to,

01:54:49.540 say, the Robert Malone interview on Rogan. We're going to talk about this because I want to make sure

01:54:53.700 we spend some good time on this. We all get asked a lot about it, so. Absolutely. And actually,

01:54:58.200 this is an epiphenomenon of that interview in my mind, because he talked about mass formation

01:55:02.980 psychosis in that interview. And this is a garbage term that he kind of made up from some crazy guy 0.95

01:55:08.300 in Europe. But here's what's actually happening, in my opinion, and why you see what you're seeing, 0.84

01:55:12.500 Peter, and we're all seeing it. Everybody's seeing it. And I don't know if I said this in our last

01:55:16.400 podcast, so if I have you just stop me and say you already talked about this. But this is what I think

01:55:19.960 is happening. And others, I've been talking about this in the sense-making community online, people who are

01:55:24.300 focused on trying to figure out how do we make sense of the world in a fractured information

01:55:27.820 economy and so on. So David Fuller at Rebel Wisdom and other people like that, BJ Campbell.

01:55:32.740 There's an idea that individual humans actually do instantiate these higher elements of thinking.

01:55:39.740 We call them different things, groupthink, hivemind. He actually calls them egregores,

01:55:44.380 which is a demon that emerges from groups of people and their thinking. And it used to be in the old

01:55:50.080 days, you would share information in very slow and uniform ways, like whether it was mass media,

01:55:55.280 just a few channels, or whether it's money as a way to exchange information because they're economic

01:55:59.880 incentives, like you build a city on a river because it's easy access to ports and so on.

01:56:03.920 But now with social media, you effectively have turned every human with a smartphone into an

01:56:11.340 addicted machine that behaves like a neuron. And its neurotransmitters are likes, dislikes,

01:56:17.660 comments, shares. So each of us is part of a network of people that acts, again, we're neurons,

01:56:23.220 and we instantiate through these instant connections, these hivemind groupthink tribes

01:56:30.360 that Marty said, hey, we're trying to reduce tribalism. So this is why they even exist,

01:56:34.160 because instantly you can be a part of this and then be controlled by it without even knowing it.

01:56:40.160 And it's lubricated by social media because now the neurotransmitters, like we get our

01:56:43.960 dendrite receives the information from social media, we process it, we make a decision, we send it out.

01:56:48.380 And what happens is whatever hivemind you're in has certain rules, and it is competing against other

01:56:55.040 hiveminds in a way that we're not even able to access. And so when you say something, Peter,

01:57:00.560 like you say, you know what, I don't think we should wear masks and I don't wear masks,

01:57:04.100 that particular hivemind that says, you know what, masks are important, we're liberal in our political

01:57:10.240 ideology, and these are the rules of that, will say, okay, we recognize here an impuritor who left to

01:57:16.500 go to Texas, which is a sign of disloyalty to this particular hive, and he's not saying the right

01:57:21.400 things about masks. Therefore, he is absolutely evil, outsider, must be stopped. And the people 0.99

01:57:28.800 who are acting as the neuron in that network don't even know they're doing it. They actually believe

01:57:34.340 this, but until they really introspect or they talk to you in person or something happens that

01:57:37.940 breaks the spell. But I think that's what's happening. So the Malones of the world are captured by 1.00

01:57:42.840 the antithesis groupthink hivemind. The, say, Fauci's, Eric Topol's of the world are more

01:57:48.680 captured by the thesis hivemind. And who are we in this middle corpus callosum hivemind? We're hated

01:57:55.100 by everyone. That's my thinking on it. Well, I will say this. Some of the messages that meant the most

01:58:00.600 to me were, I have been morally opposed and opposed in every manner to getting vaccinated until I heard

01:58:09.640 this podcast, I actually think I might get vaccinated now. That's worth all the hate mail

01:58:15.100 in the world. And by the way, I don't think the purpose of these podcasts is to, hey, let's make sure

01:58:19.420 we figure out a way to get everybody vaccinated, right? It's, how about we give people the information

01:58:23.160 so they can make the best decision in their best interest? But when someone says, a buddy of mine

01:58:26.880 who's the most anti-vax human being in the history of civilization just got vaccinated because of that 0.95

01:58:30.860 podcast, I think, wow, that's fantastic. There is hope that information can trump fear.

01:58:35.540 I get the same thing. And I'll say this, that I get a lot of criticism from

01:58:39.420 hardcore vaccine absolutists in my messaging saying it opens the door. You and Marty McCary and Vinay

01:58:45.200 Prasad and Peter Atiyah and Monica Gandhi opened the door for people not to vaccinate. It's criminal

01:58:50.460 and you shouldn't do it. And making videos that say vaccinate and chill is irresponsible in the

01:58:54.820 setting of Omicron that's killing so many people and so on and so forth. And again, I just feel that

01:58:59.060 hivemind's rejection. Whereas we're seeing the outcome, which is people are actually making reasonable

01:59:04.840 decisions based on information that's non-judgy and non-shamey.

01:59:08.520 Why I think you were effective in convincing that person to get vaccinated or the discussion was.

01:59:13.820 I don't think it was me. I think it was just the podcast, to be clear. It wasn't anything I did per

01:59:17.300 se. I think it's the honesty. I think people are starving out there for honesty on this topic.

01:59:24.720 That's not tribal. It's not an allegiance to a party line on what we have handed down to us as an

01:59:32.460 edict. I think it's this very genuine humility around the data and a virus that changes and

01:59:38.620 evolves and we have to change our thinking in real time. So I personally think people are starving

01:59:44.100 for honesty out there in data. And I also get millions of comments and emails and most of them

01:59:51.740 are, you know, thank you. But like all of you, I can't keep up. And we've had these conversations

01:59:55.960 offline. But the one email or the one inquiry that I will actually carve time out of my day

02:00:02.160 to have a conversation with is somebody who is on the fence about getting vaccinated,

02:00:07.780 spending time and just explaining things with a non-judgmental approach. By the way,

02:00:11.800 we've been doing this as physicians our whole careers. We don't mandate somebody does dressing

02:00:17.900 changes. That's right. We don't mandate Whipple procedures for patients with pancreatic cancer.

02:00:22.620 It's like, yeah, look, I mean, if you don't operate, the odds of it killing you are X. And

02:00:28.600 if you operate, the odds are Y, which are lower than X. But in the short term, there's this risk. I

02:00:34.420 mean, yeah, it's like physicians are very good at having naturally Bayesian discussions.

02:00:41.500 Can you imagine if you don't have this Whipple procedure, you won't be able to travel because

02:00:46.760 they'll catch you at the TSA and you will lose your job. And they'll treat you like crap when you 0.99

02:00:52.860 come to the emergency room next time because you're unwippalized. If your A1C goes above seven, 0.90

02:00:59.400 you're not allowed to work here anymore because it demonstrates you're eating too much and not

02:01:03.440 exercising enough. And we can't have you in this place of work. I'm sorry. You just can't do it.

02:01:09.340 Your potential future diabetes and diabetes related complications could overwhelm the healthcare

02:01:13.880 system. We want their A1C to be lower, right? But it's the approach. Is it a judgmental or a loving

02:01:19.660 approach? That's right. You can't shame somebody into lowering their hemoglobin A1C.

02:01:24.860 You know what shames people into that? The fact that they attract ants when they urinate.

02:01:29.140 That's enough. Spilling that much sugar in your urine. We got to talk about those things.

02:01:33.480 All joking aside, this is exactly what Monica's entire career has been based on. How do you message to

02:01:39.900 say people at high risk for HIV? You don't shame them. You don't mandate they wear condoms. You

02:01:44.500 don't mandate abstinence. It doesn't work. You have conversations that are by nature Bayesian.

02:01:49.720 Here's the risks and here's our priors and how you think about it.

02:01:53.300 So let's get back to some fact-based insight for people. Where are we, Marty, on monoclonal antibodies

02:02:00.020 as a therapeutic option? So let's come back to early 2022. Everybody's getting Omicron. Some people

02:02:07.400 are getting a bad case of it. Are monoclonal antibodies effective? If so, which ones?

02:02:12.380 So two out of the three only work on the Delta variant. And by the way, the people over the last

02:02:18.400 few weeks who have been showing up in the hospital in deep trouble medically tend to be heavily skewed

02:02:24.060 towards the remaining Delta variant. Now, if the CDC estimates are correct, Delta is 1.7% of new cases

02:02:31.120 as of January 14th or so. That tells us that the influx, that sort of the ongoing damage that this

02:02:39.740 is causing in terms of severe illness is really letting up right now just by the dominance of

02:02:45.660 Omicron. So we only have one monoclonal that really works well, Sotiramab. It's a GSK,

02:02:52.100 Vir biopharmaceutical product. It's a monoclonal called Sotiramab. And that's the only one that really

02:02:58.320 works well on Omicron. But if Omicron is as mild as we're seeing, that tells us we should be using

02:03:02.920 it selectively in high-risk individuals. We don't do a good job of that in healthcare. We can barely

02:03:09.840 hold back throwing the kitchen sink at people even when it's excessive. I mean, it's just a general

02:03:15.080 pattern. And so what you're seeing is these industrial strength big guns like Pax Livid and

02:03:23.180 Sotiramab are being used in very low-risk people, sometimes people with wealth and power and access

02:03:29.900 that tend to get. And that's where we need to say, hey, wait a minute, we have all these tools in the

02:03:34.260 toolbox. Let's use them selectively and wisely based on somebody's individual risk.

02:03:40.760 And any emerging data on the efficacy of fluvoxamine against Omicron specifically,

02:03:46.780 because obviously the Lancet trial, the JAMA trial were all in Delta. Anecdotally,

02:03:52.080 do we know anything or has there been any way to update that insight?

02:03:54.880 The only thing new is some new data on lunacy at the NIH because they wrote a summary of

02:04:04.380 fluvoxamine where they described its benefit and impact on reducing hospitalizations and survival

02:04:10.420 and concluded at the end of it that there was insufficient data to recommend it, which was

02:04:15.060 a conclusion that should not have been derived from that summary. So unfortunately, now you have

02:04:20.980 this sort of militaristic, everyone just falls in line mentality in medicine by some physicians.

02:04:26.980 Now, many of them are creative and smart enough and they're like, hey, I read the studies. The

02:04:31.740 reduction is dramatic just because there's not an official authorization around it at the FDA.

02:04:38.460 I'm going to use it for my patients. Those are the doctors we hear from. Those are the doctors saying

02:04:42.300 thank you. And that's, by the way, a lot of doctors, maybe most. And then there's some that just say,

02:04:46.520 well, the CDC doesn't say it for me to use it. Or they say the NIH is not officially endorsing it.

02:04:52.820 So they're up against that. Now, the people who did that study have told Zubin and I that they're

02:04:57.580 close to what they believe might be some good news at the FDA around an authorization. That's just a

02:05:03.060 gestalt and it's not insider information. But unfortunately, this is a drug that has reduced

02:05:08.760 mortality among people compliant by 91% in high-risk COVID patients. And we still have very little

02:05:14.940 awareness around it. As a matter of fact, there was a paper that just came out on the preprint that

02:05:18.780 showed, it was a survey of doctors saying, basically, when you get somebody with COVID,

02:05:22.720 what do you recommend to them? What they said was kind of pathetic or sad. It was vitamin D, 0.97

02:05:28.900 vitamin C, zinc, and something else that has no evidence really behind it. Now,

02:05:33.480 maybe there's some value to vitamin D, who knows? But I mean, that's it. I mean,

02:05:37.700 no discussion of convalescent plasma, which now in concentrated form reduces hospitalizations

02:05:42.800 by 50%. That's been around, by the way, for two years. No mention of fluvoxamine.

02:05:47.580 Let's tell people about that. So convalescent plasma was talked about immensely in March and April of

02:05:54.880 2020 when we truly had nothing on the horizon. And then it kind of went away. And I don't know if it

02:06:02.180 went away because it didn't have efficacy and it was demonstrated or because we finally got

02:06:08.760 monoclonal antibodies later that year. First of all, tell people what convalescent plasma is

02:06:13.840 and talk a little bit about it as a therapeutic. So I'm just close to it because the authors of

02:06:19.580 that study on convalescent plasma early on put a piece in MedPage today and I remember talking to

02:06:25.680 them. So this was an exciting development. Convalescent plasma is the plasma from someone who

02:06:32.820 recovered from COVID illness. That's what convalescent means. It means they've recovered

02:06:38.500 and so the plasma is not the red cells. It's not red in color. It's other fluid that the red cells

02:06:45.340 circulated in your blood system and that plasma contains antibodies. So basically what you're

02:06:50.060 getting is you're getting infused a partially intact immune system. That is, you're getting

02:06:54.760 infused real antibodies. And essentially monoclonal antibodies that pharma companies make is the same

02:07:01.220 thing. They're just antibodies made in a laboratory and they tend to be all one type, hence monoclonal as

02:07:07.980 opposed to polyclonal antibodies. So in the convalescent plasma, you're getting a more diverse

02:07:11.860 antibody profile. Arguably that's better for the reasons Monica just laid out. So there was a lot 0.98

02:07:17.460 of enthusiasm around it. It's been used by the way for a century. I mean, there's stories from people

02:07:22.720 getting infections from gunshot wounds in war, getting convalescent plasma. And so there's a lot

02:07:28.160 of experience with it. That was one of the first levers the medical community reached for when COVID hit

02:07:34.080 us. And so people were getting it and there was a benefit, but the benefit was small. I think it was

02:07:38.980 a reduced hospital stays from like 13% to 9% or something like that. So what you had was an

02:07:46.260 announcement by Trump administration officials that had a lot of enthusiasm and they used the term,

02:07:52.880 head of the FDA at the time said there was an absolute risk reduction. And the technically proper

02:07:57.740 term is a relative risk reduction. So people who may just hate the administration or hate anything,

02:08:03.860 that comes out of it just pounced, including in the medical community. They pounced and this is an

02:08:08.700 unfair representation of the data and they just went. So there was this sort of backlash was in

02:08:14.240 part, in my opinion, politically driven. So then you didn't get a lot of attention around it. There was

02:08:19.780 sort of this confusion and the head of the NIH, Francis Collins, was asked to weigh in on convalescent

02:08:25.000 plasma. And he said, we need a randomized controlled trial, which is, in my opinion, kind of a cop-out.

02:08:31.380 Here we had strong data in a non-randomized fashion because they were telling people,

02:08:36.980 hey, we've got this. Do you want to try this on a trial?

02:08:39.700 By the way, in his defense, I think that's a totally reasonable answer,

02:08:42.840 even if done in parallel, right? It's like, we should have an RCT of this stuff.

02:08:46.900 Yep, we should. But what he did is he threw water on any sort of interest in using it clinically.

02:08:53.620 A lot of it was in sort of a news media distorted, but I agree.

02:08:58.700 So then you had pharma companies basically saying, hey, we're making antibodies. Why use

02:09:03.680 convalescent antibodies? But there just wasn't enough to go around and convalescent plasma fell

02:09:08.240 to the wayside. Now, the authors of that study had told me, hey, we're not using this therapy. It's

02:09:13.980 only 40 bucks. No pharma executive gets rich off of donated plasma. We need to start talking about

02:09:20.980 this more. Well, around that time, another study critical came out and said, it doesn't really work

02:09:27.900 hardly as well as the original trial showed. Now, I reached out to the study authors of the first

02:09:34.480 trial that showed a benefit in the New England Journal, and they said that study was flawed.

02:09:37.620 The design was flawed. We need more research and trust us, it's coming. And they were very frustrated.

02:09:43.220 So they eventually published a study that came out very recently that looked at concentrated

02:09:48.800 convalescent plasma. Concentrated suggesting you're getting more antibodies in that infusion.

02:09:54.900 And it showed a dramatic reduction in hospitalization, a reduction by 50%. Well done study.

02:10:01.100 Still, nobody talks about it. You don't hear about it much. It's, oh my gosh, can you believe there's

02:10:06.060 not enough monoclonal antibodies from Regeneron? Well, here's another therapy. It's not getting

02:10:12.080 attention, the attention it deserves. Is it safe to say that convalescent plasma

02:10:17.220 presumably has a greater diversity of antibodies than a monoclonal antibody?

02:10:23.960 Sure. Yes.

02:10:24.920 But we don't yet know how effective convalescent plasma will be against Omicron. But we know,

02:10:32.220 obviously, for understandable reasons, that at least two of the three monoclonals are not effective

02:10:37.000 because presumably they're no longer binding to epitopes that are sufficient to kill the virus.

02:10:43.740 That's right. In general, when you are exposed to a virus, you get a more diverse antibody response

02:10:49.720 or profile than you do with just a monoclonal infusion. There's two reasons why people think

02:10:54.800 natural immunity is stronger and more effective than vaccinated immunity. One is you get a more

02:11:00.380 diverse antibody portfolio in the response. And the other is the reason Monica alluded to,

02:11:05.720 and that is natural immunity is based in the mucosa. It's more mucosal based immunity. So it's more on

02:11:10.620 the front lines of defense. Okay. So therapeutics, do we want to talk a little bit about Robert Malone?

02:11:19.780 Tell folks who he is, Zubin, and why his name is on the lips of many, both disciples and

02:11:29.100 non-disciples or those who want to banish him from the universe.

02:11:33.520 Yes. Robert Malone is an interesting epiphenomenon, I think, of our division around this into these

02:11:40.540 two churches of COVIDian and COVIDiat. And he's an interesting guy. He's definitely a scientist who

02:11:47.660 was involved early on in some of the work on the mRNA technology in general. And in particular,

02:11:54.880 wrapping that mRNA molecule in a lipid particle and a fat particle that allows it to be taken up by

02:12:01.040 cells. In that case, it was mouse cells looking at an HIV protein expression to work on a HIV vaccine,

02:12:08.020 which it turned out didn't quite work out because it didn't generate an immune response,

02:12:11.560 but the technology was there. So he was one contributor in a vast chain of contribution

02:12:16.920 that actually led ultimately to where we are now. But his particular contributions and patents that he

02:12:23.520 had had expired a while ago. He'd given up looking at that and had moved on into different

02:12:27.680 directions on DNA vaccines and things like that. So he bills himself as the inventor of mRNA technology

02:12:33.560 based on what I just said, where he is a small piece of this puzzle. But using that credibility

02:12:39.180 and also the credibility of working as a consultant in different government entities and things like

02:12:44.040 that, he makes a series of claims about vaccine safety that ultimately got him banned from Twitter,

02:12:50.500 which got Joe Rogan's attention. And Rogan then gave him his platform to say,

02:12:55.780 okay, if you're banned on Twitter, what are you saying here? And so there are multiple claims

02:13:00.440 that he's made. And I'll start by saying this. I think some of the things that he said that were

02:13:05.500 correct are things like, A, you don't just give infinite boosters to people because that's not

02:13:11.580 a good idea. That we already talked about earlier. He does question the financial incentives of pharma

02:13:17.500 and different entities within healthcare to focus on vaccines. And I think that's not unreasonable.

02:13:23.260 I think he downplays the point that there's lots of money in therapeutics too. Those are the main

02:13:29.660 things that I think establish his credentials as a heterodox thinker. Now that's all. And then every

02:13:36.980 major point that he makes is fundamentally flawed, if not a parroting of an extreme anti-vaccine position

02:13:45.460 on these things. And we can go through some of them unless you want to stop me.

02:13:49.580 And I'd like to go through some of them specifically. So maybe take them in kind of

02:13:53.900 a point counterpoint fashion, if you will.

02:13:56.140 Yeah. So one of the things he says is that PCR is overestimating the number of COVID cases and that

02:14:03.100 it's not accurate. The truth is it is quite accurate. It's very sensitive and it's quite specific.

02:14:09.460 So that's just not quite right. And his point is, you know, we're over counting cases and so on.

02:14:14.280 Does he provide an estimate of the magnitude by which it's being overcounted?

02:14:17.760 I don't remember if he did, but I don't recall him saying specifically. He does make other magnitude

02:14:23.160 estimates. For example, he says, if we had just provided early treatments in the form of

02:14:29.140 hydroxychloroquine, ivermectin, monoclonals, et cetera, it is a fact that we would have saved

02:14:34.480 500,000 U.S. lives. And he provides no data to actually support this. That's, I think, an unsupportable

02:14:40.940 claim based on information that we have, especially since there's not evidence that hydroxychloroquine

02:14:46.100 and ivermectin actually do anything. That's compelling. That's still being studied with

02:14:50.240 ivermectin, but with hydroxychloroquine, it was quite clear. He said that hydroxychloroquine was

02:14:55.500 shown to be active against the original SARS, but this is a bit misleading. The original SARS

02:15:00.900 in vitro, they used chloroquine and it inhibited the virus in vitro. But there are millions of

02:15:07.880 compounds that will do that. It was never shown to be anything beyond that. So that's a misleading

02:15:12.480 statement. He then discusses that the spike protein that is used in current vaccines by

02:15:19.500 Pfizer, Moderna, et cetera, was never tested for safety. Their spike protein was never tested for

02:15:24.580 safety. But he then either is deliberately misleading or misunderstands the scientific

02:15:29.520 process with this because that's what the clinical trials with tens of thousands of people

02:15:34.520 were doing was showing, oh, the spike protein that we've coded for with this mRNA is safe and

02:15:40.520 effective in a human population. So that's just not true. The other thing he says that's abjectly

02:15:45.660 untrue is that there were no preclinical or animal studies on these particular vaccines or mRNA

02:15:50.940 constructs and that those are findable. They're all there. So that's just simply not true. Let me see

02:15:56.400 here. There's a lot. He made so many claims, pulling up some of them here. He made the claim that

02:16:03.040 hospitals in particular are mischaracterizing COVID cases. Now, this is a claim that actually has some

02:16:11.180 validity in the sense. Hospitals are paid more for COVID patients. This is true. So there is some

02:16:17.160 incentive to code in a medical billing situation. Upcode, this is COVID, even though it may be like

02:16:23.100 pneumonia or something else going on, MI, but he also has COVID. In the early days, they've kind of

02:16:28.460 looked at this and it's not clear that that was happening because to some degree, there's a fraudulent

02:16:32.600 component there. That's just straight up fraud. So he specifically said there are gunshot victims

02:16:37.500 being coded as COVID patients. And by the way, that could be true if a gunshot wound patient has COVID

02:16:44.580 and if there's a greater financial incentive to take care of a COVID patient, you could do that.

02:16:51.920 It would be unethical. I think it would be against the spirit of how one is to code. And I guess you

02:16:57.000 could argue it could verge on fraud if the billing entities are rigorous enough to say,

02:17:03.980 why was he admitted to the hospital and ask that question, right?

02:17:07.260 Yes, that's exactly right. You nailed it. So it's fully within the realm of the possible,

02:17:11.580 but I don't think in practice that it happens at a level where it would explain anything that would

02:17:17.400 move the needle on the pandemic. And actually, you can just look at excess mortality figures in the

02:17:21.120 US to know that something is up. It's a combination of COVID and the peri-COVID phenomenon

02:17:26.140 of our response to COVID and other things that COVID does.

02:17:30.120 By the way, what was the excess mortality in 2020? And do we have 2021 data yet? Absolute

02:17:35.120 lives lost above and beyond 2019. I don't remember the excess mortality at the end of 2020 because

02:17:41.880 I'd done a show on this in the mid-2020s. I looked at it in 2021 and I actually have the exact number,

02:17:48.120 so I almost don't want to say because I'm sure I'm going to bastardize it. I want to say it was

02:17:52.540 close to 250,000 excess deaths in 2020 relative to 2019. But anyway-

02:17:58.660 Got it. Sorry, I've got the numbers here.

02:18:00.320 Okay, perfect.

02:18:02.020 477,000 excess deaths from March 1st to December 21st, 2020. So basically the 2020 number is 477,000.

02:18:10.680 And 74% of them were due to COVID, that is match up with the COVID mortality.

02:18:14.920 So it was 400,300 of which are COVID.

02:18:19.280 385,000 were COVID, 477,000 total.

02:18:23.440 Oh, okay. So half a million excess deaths. So you can't explain this with coding,

02:18:27.600 if that's part of the argument. Yeah.

02:18:29.040 Well beyond coding. Now, some of it may be ancillary effects of lockdowns and so on,

02:18:33.140 but some of it may be even undercounting of COVID cases, people just dying at home and not being

02:18:37.180 diagnosed. So there's lots of different potential explanations.

02:18:40.340 This sort of begs a question, which is, were the people who disproportionately died people who

02:18:46.840 were going to die within the next two to three years? And does that imply that there may be

02:18:51.800 a reduction of death in 2022, 2023, when a lot of the people who were going to die of natural causes

02:19:00.160 of heart disease, cancer, and things like that, the most vulnerable people who died in 2020 and 2021,

02:19:05.800 basically died ahead of schedule. Their lives were shortened by a year or two.

02:19:09.640 And you'll see fewer people dying in 22 and 2023. Does that matter? No. But it's just kind of a

02:19:15.480 curious epidemiologic phenomenon, right? This has been discussed actually quite a bit,

02:19:19.960 particularly in online circles. It's this dry Tinder theory that you took out people that were

02:19:24.640 going to, they had a life expectancy, like you said, that was quite short. And all this did was

02:19:28.520 knock them over. And we see this every winter in the hospital, like flu. That's why they say

02:19:33.060 pneumonia is the old man's friend, right? Like it's the final thing that in a very medically frail 1.00

02:19:37.080 person. So again, what's the ramifications of it? I actually think it has this ramification in the

02:19:41.680 sense that how much of the overall suffering under the curve was just expedited by a year versus how

02:19:46.900 much is cutting off five years, 10 years of quality adjusted life years that's quite high. That then

02:19:51.720 would justify or de-justify certain social policies that we put in place. So it's a good question.

02:19:57.240 And I think relating to this, he, Malone, asserts that we don't have good vaccine monitoring at all,

02:20:03.880 and asserts that there are lots of vaccine injuries and damage that we are not counting.

02:20:10.540 And he talks about VAERS, which is really a hypothesis generating system where anybody can

02:20:16.980 report and so on. But he does not talk about PRISM or V-SAFE or the VSD, the vaccine safety data link.

02:20:24.120 These are very robust vaccine monitoring systems that actually help to catch things like very rare

02:20:30.080 events, like the vaccine-induced thrombotic thrombocytopenia of the Johnson & Johnson

02:20:33.840 AstraZeneca vaccine. So I think that's quite misleading to say that. It's good that he's

02:20:38.100 asking these questions. And I think people should ask questions about vaccine safety, but he's a

02:20:42.380 little misleading here. Now, where he's directly misleading is he makes the assertion that the

02:20:47.160 lipid nanoparticles from the mRNA vaccines concentrate in tissues such as ovaries, explaining things like

02:20:55.080 infertility and menstrual cycle abnormalities in women. And the truth is, the data he's citing is

02:21:00.560 a rat study out of, I think, I forget where, where they pounded these rats with supernormal levels of

02:21:06.460 this lipid nanoparticle mRNA. And they saw accumulations in various tissues, but no tissue

02:21:12.740 damage actually. And this has not been seen in humans. There are menstrual cycle abnormalities. So

02:21:18.720 that's where he is correct. And NIH has actually funded studies on this. And what they're seeing is

02:21:23.620 what women have reported, if we'd actually listened to women, that their menstrual cycles are abnormal

02:21:28.700 for a cycle or two, either heavier, lighter, they skip a period. An Oregon study that I think was

02:21:33.460 preliminarily released with this funding actually showed that, yeah, this may be true at least for

02:21:37.040 a period or two, but then reverts back. We have not seen widespread effects on fertility.

02:21:42.620 On that topic, Zubin, I remember the first one of my female patients to tell me this. She's an 0.98

02:21:47.680 especially funny woman. And she said, she said, we were actually, you know, it was actually in a

02:21:52.640 social setting as well. So we weren't like in the office having this discussion. She said, you know,

02:21:57.440 it's really funny. It seems like I was stabbed in the vagina. Is that possible? And I was like, 1.00

02:22:02.880 wow, say more. And she's like, yeah, she's like, look, I've never had so much bleeding in my life.

02:22:09.640 And that lasted for two cycles for her.

02:22:11.780 Interesting. The speculation on why this may be has been rampant. Some of it is just with any

02:22:17.960 infection with an immune response, there can be abnormalities in menstrual cycles. And it's that

02:22:23.100 whole hypothalamic ovarian axis thing that I wish I understood better, Peter. I've never understood

02:22:29.160 the lady parts. I'm going to be fully honest. My wife will confirm this. But I think the fact that we

02:22:34.420 take it seriously is important. So I'm glad at least Malone mentions it. He just mentions it in

02:22:40.120 combination with just the wrong thinking. He mentions other things about ivermectin that

02:22:45.380 are incorrect, like Japan recommending ivermectin for treatment of COVID. They did not. He says that

02:22:51.020 the Chinese were using hydroxychloroquine to great effect early on and use that as an example of reason 1.00

02:22:56.800 of why we should be using it. Simply not true. So things like that along those lines.

02:23:01.640 And those are the types of claims that are difficult because you can't counter a negative. In other

02:23:06.920 words, if someone says, look, I mean, it's been well known that the so-and-so hospital in China

02:23:12.180 pioneered a study that then led to the mass adoption of this therapy. Well, you can't search

02:23:18.760 the anti-truth to that. Like it's just, you can say, well, show me the data. But when someone's

02:23:25.860 rapid fire giving you stat after stat after stat, it's very difficult to counter that.

02:23:30.380 Then this is why I think many people will not, they constantly want to debate. So Malone and others

02:23:35.920 will say, well, we'll debate anybody. But of course we want our friend, Steve Kirsch with us,

02:23:39.700 who's funding some of this stuff. And Steve is known to do this. He will just throw out,

02:23:44.240 well, what about this study? What about this? What about this data out of Uttar Pradesh?

02:23:47.420 When you actually have days to look at the data, you realize, wow, that's total bullshit. 0.97

02:23:51.120 But I could never have responded to that in real time. 0.95

02:23:55.020 Yeah. I've often thought that the only way to do a debate like that is to do it the way a court

02:24:01.160 interacts, which is using a discovery, right? So you can't present evidence in court without the

02:24:07.660 opposite side, seeing the data in discovery, seeing the evidence in discovery so that you don't get

02:24:12.620 the surprises. You can surprise somebody with your interpretation or a question you're going to ask.

02:24:17.720 There can't be any gotcha moments with new data. And I've often thought the only way you could have

02:24:22.160 an honest debate in any format, whether it's an awkward style debate or otherwise, is to have

02:24:26.740 everybody say, this is the only data we're going to debate. Everybody can get as familiar with it

02:24:32.400 as they want. And now let's talk about the opposing views and the opposing ways that we might interpret

02:24:37.460 this. To me, that would be a much more honest way. That's a correct way to do it. Exactly. And you

02:24:41.400 want debate. You want conversations. Stifling that is a terrible... The fact that Malone was

02:24:46.080 deplatformed on these other platforms is why he's on Rogan. So it actually gives people like this that...

02:24:52.480 And I have no idea what his motivations are, right? I mean, you can speculate,

02:24:55.180 but that's all ad hominem stuff and I'm not going to do it today. But the one interesting thing,

02:24:59.640 other thing I'll say about Malone is it's important actually when you're judging the veracity of

02:25:04.380 somebody or the credibility of somebody, it's important to see who they cite to, right? So

02:25:09.640 at one point he says, listen, Peter Duisberg, you guys remember Peter Duisberg? He's a legendary

02:25:15.420 guy in science because he was an esteemed virologist based out of UC Berkeley, my alma mater. He taught a

02:25:22.300 course that I took actually. And he was known for denying that HIV, the virus, caused AIDS to the

02:25:28.300 point where he questioned that HIV didn't fulfill Koch's postulates of infectious agent. And his

02:25:33.240 proposal was it's gay behavior, IV drug use, nitrate poppers, basically sin that was causing 0.91

02:25:41.020 the immunosuppression and that AZT and the drugs we were giving were making it worse. He would say 0.71

02:25:45.880 things in his German accent like AZT is AIDS by prescription. He got famous for this because he 0.97

02:25:51.580 went to South Africa and actually convinced the president of South Africa that this might be true.

02:25:55.620 And it may well have cost lots of people their lives because they were slow to uptake protease

02:26:00.640 inhibitors, et cetera. So Malone actually cites Duisberg as the esteemed virologist who was canceled

02:26:05.820 by Fauci in the early days. This is not true. Actually, Duisberg continued to teach at Berkeley

02:26:11.660 where I took his class, where he presented his ideas and we got to debate them. And he was since

02:26:16.260 proved remarkably wrong. And in the same breath, he actually associates with Robert F. Kennedy Jr.,

02:26:21.500 who is a known sort of anti-vaccine activist, not a physician. So he's kind of aligned with that camp.

02:26:27.300 And right after Rogan, he went on Infowars with Alex Jones and started talking about the Great Reset,

02:26:32.640 various conspiracies along those lines.

02:26:35.300 That's the deep end, Alex Jones.

02:26:37.300 Yeah, yeah.

02:26:37.820 One of the other things I want to ask you about is the only term that I keep hearing from that,

02:26:42.260 because I have not seen that podcast, is the mass formation psychosis term. Can you say more about

02:26:48.300 what that is? Because I literally have no idea.

02:26:50.960 So the way Malone describes mass formation psychosis, and again, I earlier in this podcast

02:26:55.960 talked about what I think is actually happening with groupthink and these neuronal networks. And the

02:27:02.340 fact that it's important to understand this, any human now can create information and put it out in

02:27:07.180 the world and form a hive mind around it. It's easy to do. You don't need a mainstream position

02:27:12.280 to do it. Now, what Malone is saying is the mainstream, which does control major media like

02:27:18.340 CNN, MSNBC, a lot of the scientific community through funding, things like that, big pharmaceutical

02:27:24.540 companies, has created what he terms, based on the work of a European psychologist, I think. I forget the guy's name. He has created a mass formation psychosis. And he parallels it to what happened with Nazi Germany, which again, if you're resorting to the Nazis, you've kind of already lost the discussion.

02:27:42.640 I just sort of did something like that, tried to caveat it so that it wouldn't be as idiotic. But I kind of made the point a moment ago that when you prevent people from traveling within or outside of their country, it's within the hemisphere of the most extreme fascist threats, right? 0.91

02:28:01.480 Yes. And you immunize yourself by wrapping it in reason. And I think Malone actually did that too, where he was talking here, because this is what he said. I think he's correct in this sense. He said, the rules for having a mass formation psychosis where the population is, this is what his words, hypnotized into believing something to the detriment of actual truth is the following. You need an isolated population where there's been isolation and dissatisfaction.

02:28:27.880 And again, going back to Nazi Germany pre-war, you need a sense of economic destabilization and crisis. You need to kind of silo people off. I forget all the things he listed, but one of them is then you need an entity in authority to say, we have the solution and it is one solution and that's it. 0.56

02:28:45.700 And so his argument is, he says, then really good people, the German people who are hyper-educated go and do crazy things. And he said, now we're in a situation where the mainstream has created this mass formation psychosis where the only way out, we're like, we're in this dangerous situation.

02:28:59.980 You have to lock down, you have to close schools, you have to shut down your way of life and wear masks. And the solution is just this, vaccines, forget about therapeutics, forget about ivermectin, forget about monoclonals.

02:29:10.440 It's just this, and this is the only way out. And people start to believe it because they're so destabilized from all the other stuff happening. And so they go along with the mass formation.

02:29:20.180 Where I think he's correct is that we are all victims of groupthink. What he ignores is that so is he. And he's part of the reactionary tribe mind that says, no, I'm not comfortable with this and here are all the crazy things we believe.

02:29:32.620 So that's what mass formation psychosis is from his angle.

02:29:37.080 I really appreciate that, by the way. That was a remarkable tour de force. Do you recommend that people go and watch the podcast so they can hear his arguments out in full and contrast that with what you're saying?

02:29:47.600 Or just as you did with Peter McCullough, where you put out a really nice podcast where you completely unemotionally went through all of his arguments and stated where you thought they were reasonable and unreasonable.

02:29:58.980 Have you done the same thing for this podcast?

02:30:00.800 Man, I knew you were going to ask that. People have been asking me to do it. And I'm just honestly, I'm so resistant because it's so exhausting to do, but I might just do it.

02:30:10.000 I know Vinay is writing an article on it. He was asked to write a piece on it. So he's going to be addressing the points point by point. At some point, I probably will have to do that.

02:30:18.000 There's a guy who did one online, but he is such a thesis guy. Like he's so hardcore COVIDian. It's so biased that you can't really take some of the points seriously.

02:30:27.940 And I think people who would believe Malone will never believe this guy.

02:30:31.720 That's right. It actually forces people to kind of dig their heels in on that.

02:30:34.920 Yes, agree.

02:30:35.540 So if you guys have some time, there's still a few other things I want to talk about. And one of them is what is the exit strategy? We talked about this a couple of weeks ago, which is it's always a good idea to have your exit in mind, whether you're talking about war, whether you're talking about an investment in a company, whatever it is you're doing, a vacation, you should always have an exit in mind.

02:30:56.640 You should always have a plan for when you're going to change this thing back to the new norm.

02:31:02.980 So what's your reflection on that? I mean, I take some comfort in what Monica presented to us, which was that, hey, it might be the case that in the spring, colleges are going to say you don't have to wear masks to sit in class anymore.

02:31:16.780 That would be fantastic for young people, for every person. If airplanes, if the TSA and airlines say you no longer have to wear masks, who's mandating that we have to wear masks in airports? I don't even know who that is.

02:31:29.280 FAA.

02:31:29.600 FAA.

02:31:30.400 Yeah, fair enough. TSA. They're doing enough to it.

02:31:34.860 So, okay, like, do you guys think that in three months there will be no more mandatory masking anywhere in the country?

02:31:41.100 I think in a matter of a month or two, you're going to have very low levels of Omicron around. Almost nobody left who's not already had it or strong immunity. And I think people are going to be so giddy to move on that the fatigue is just going to hit all time highs and people are going to turn the page. And I think you're going to see a sentiment really flip in most of the country.

02:32:07.480 Now, if you remember, the opioid epidemic was nightly news every night, and we all were sort of in touch with it. And then overnight, in one day, the media shifted their attention, and it was almost as if within 24 hours, people forgot we even had an opioid epidemic.

02:32:25.080 And I think there's going to be an even bigger flip pretty soon. It may be something distracting. It may be other news. It may be a concert in Central Park where people just finally feel liberated. It may be a landmark event, but I do think people are going to shift their attention very soon when we get to very low levels of Omicron, which the UK and South Africa would suggest in a preview that that's about a month or two away.

02:32:49.840 Just to push back on that, Marty, we're going to either have Omicron come back next winter or we're going to have Epsilon show up next winter. And presumably case rates will be high again and mortality and hospitalizations will be relatively low. But what will prevent us from backsliding into the state of panic?

02:33:11.520 Well, I think part of it's going to be geography. I've really enjoyed my time in Florida during the pandemic. I feel like I'm just enjoying life. I'm a million times happier here. I don't have to get a colonoscopy to go into a restaurant in New York or anything like that.

02:33:26.900 Think about all those missed polyps, though, Marty. I mean, there's a downside.

02:33:31.940 That's not very good public health messaging.

02:33:33.780 So I think it's going to be regional. I do think there's going to be a big part of the country that's going to say, hey, wait a minute. We could be looking at a new variant in the fall. There's going to be respiratory pathogens circulating this fall for sure.

02:33:49.020 10 to 25% of the public is going to get some respiratory infection almost every year in perpetuity. That's the way respiratory pathogens work.

02:33:57.220 So are we going to put up a serious guard and have this sort of anxiety that we've had with the new variant of the fall or the following fall?

02:34:06.460 But we're definitely going to see more variants. Or are we going to realize what Monica was describing?

02:34:11.980 And that is the beautiful, amazing, gorgeous immune system of the human body where adaptive immunity will increase our protection against future variants, regardless of what they are.

02:34:23.480 And I think there might be some anxiety, but at some point people are just going to say, I believe in the adaptive immunity.

02:34:29.440 So then what are the implications then for vaccine mandates? Where do we see this going?

02:34:34.700 Let's put federal aside. So there's not going to be a federal mandate, but states and employers, universities.

02:34:40.980 Where is that going to go? And look, he's become a bit of a meme, but let's look at Djokovic right now.

02:34:46.360 I mean, the guy just got kicked out of Australia, does not get to defend his title in the Australian Open.

02:34:52.200 I think there's two ways people are talking about this. One is the rules are the rules. You're not exempt.

02:34:56.760 And I think that's a fair statement, right? If Australia has this rule and it applies to everyone, then it should also apply to the best tennis player in the world.

02:35:05.000 Maybe the more important question is, is that a good rule to have? Period.

02:35:07.920 Period. But I read a story today that said, look, he's not going to be allowed in France, so he's not going to get to defend his title at the French Open.

02:35:14.600 And if he's not going to get to defend there, I mean, is he not going to get to defend his title at Wimbledon?

02:35:18.260 I mean, is Djokovic never going to play another major because he's not vaccinated?

02:35:22.720 To me, until this question gets resolved, there's no exit strategy. Where do we see this going?

02:35:29.200 See, this is why we need to have these discussions, because what is the incremental value now of mandating vaccines?

02:35:37.520 And Vinay talks about this a lot, Vinay Prasad. He says, how many people are actually at risk of high complications?

02:35:43.060 And of those, how many are unvaccinated? And of those, how many will mandates actually reach them?

02:35:49.600 And the answer is probably much less than you think. So instead, there are these sort of shotgun mandates that affect a lot of people that really it matters much less.

02:35:58.340 You have these epiphenomenon like Djokovic who now can't play, and we're polarizing society more along these like peri-religious lines.

02:36:06.220 So at some point, we just have to say what I think we've all been saying a little bit, and Monica is effectively saying, which is it's now an individual choice.

02:36:14.800 You can vaccinate, you can wear a mask or not, and you can take the precautions that you need to, and Omicron will be the great equalizer that immunizes a lot of people and will then be on the other side of this, where we don't need mandates and policy stuff.

02:36:28.080 We have to have those conversations, but even opening your mouth about it is taboo within certain hive mind states.

02:36:35.660 I think it also requires a degree of thick skin. Peter, you and I both have attested to being, it's a state of suffering having to even deal with this stuff because of the amount of craziness that we see.

02:36:46.880 So we have to just thicken our skin and say, no, but we're going to keep talking about it because what's the end point? What's the exit strategy?

02:36:52.100 I don't know why I find myself, we talked about this last time, having much more empathy for people who don't see eye to eye with me on vaccines, who are anti-vax.

02:37:03.540 And even though I don't agree with them scientifically, and I don't agree with the facts that they cite in some circumstances, if not most circumstances, I'm curious as to what it says about me as a person, good, bad, or indifferent, that I can't imagine that you would force somebody to get a vaccine in this situation.

02:37:20.280 I reserve the right to say maybe one day a pathogen will come along that is so deadly, for which there is no treatment, for which transmission is eliminated by a vaccine, and for which the vaccine is so incredibly safe, where I might change my mind. 0.89

02:37:38.080 I might reserve the right to say, you know what, we're going to have to mandate this shit, but I can't say it with this fact set. 0.72

02:37:43.560 What you just did, where you said, this is what would convince me to do something, is a key thing. 0.95

02:37:48.960 Because I think what separates your thinking, which is nuanced from, say, a hardcore anti-vax person who's just that condition, say, or even a pro-vax person, is there is no situation.

02:38:00.140 Like if you ask Robert F. Kennedy Jr., is there any example that you have of a vaccine that's done some good?

02:38:05.700 And I was part of this documentary that he was involved, so I've seen this, it's not been released.

02:38:09.420 He says something to the effect of, I don't know if I can even point to anything.

02:38:13.160 It's like, well, so there's nothing that would convince you.

02:38:15.780 There's no status.

02:38:17.560 That's tough.

02:38:18.420 Then you're talking about a real belief-based thing instead of a, like you said before, Peter, strong convictions loosely held.

02:38:25.140 Like what would dislodge that conviction?

02:38:26.720 I think when you know how the sausage is made, when you see the decision-making at, say, a state government level that is requiring a 25-year-old forest ranger to get a booster who's thin and already had COVID,

02:38:43.120 and you see the absurdity of how they've brushed over the data, how there's this bandwagon effect, how the leadership has been dismissive of some of the data and cherry-picking other data.

02:38:54.100 When you have that back knowledge, that's what makes it particularly difficult to watch, to address your point, Peter, 0.99

02:39:01.020 because you see intrinsically this attitude of, you're stupid, don't ask questions, just do it. 1.00

02:39:07.800 And it's like, hey, wait a minute, that's not how I'm wired. 0.99

02:39:10.640 So I do worry about another pandemic that has a case fatality rate not of two-tenths of 1%, which is probably retrospectively what it's panning out to be with COVID,

02:39:23.340 to an infection with a case fatality rate of 5%.

02:39:27.020 Spanish flu had a case fatality rate of 2%.

02:39:29.580 Ebola has a case fatality rate of 50%.

02:39:32.620 What happens when we get a virus with a case fatality rate of truly 10%, as we were worried about from the early reports of China,

02:39:41.040 and we are acting like this sort of dysfunctional, tribal, big tech censored?

02:39:45.540 I mean, we might be hosed.

02:39:47.520 I mean, we've got to have an NIH that responds in seven days with bedside clinical trials to tell us what's happening, what works, what's effective.

02:39:56.820 We cannot be ignoring some therapeutics and parading around others.

02:40:00.760 I mean, we've got to have a completely different mindset.

02:40:03.980 This is going to be an unpopular and charged question, but I guess we can talk about it.

02:40:07.540 What are the ethics of having the people at the top of the NIH be both in charge of funding any academic in this country,

02:40:17.020 and yet also being the arbiters of what is appropriate to be said and not to be said?

02:40:22.400 I've spoken very privately with people who have shared this middle ground view, who have said,

02:40:33.380 I am not permitted to speak about this.

02:40:35.320 I am told I cannot speak about this or I will lose my funding, and my entire career is based on what the NIH gives me.

02:40:42.640 And I've been told explicitly, by the way, not implicitly.

02:40:46.160 I have been told explicitly by my department chair, if I ever say anything that counteracts the narrative of the NIH, I will lose my funding.

02:40:54.920 So we think about all the careers that are being ruined, this person that I mentioned who got fired in November for not being vaccinated from a very prestigious university.

02:41:06.220 Talk about the Djokovic's of the world.

02:41:08.240 This is a guy's legacy who could be altered by this.

02:41:11.500 And then you talk about people who are now being silenced and not permitted to say anything that is at odds with the narrative of their funder.

02:41:21.800 I mean, that's very problematic to me, especially within science.

02:41:25.960 Science has a currency of objectivity.

02:41:29.300 It's taken the single most precious currency and said, let's put that in the closet.

02:41:35.720 I mean, look at the Dewsburg thing that we talked about with Malone, this guy, Peter Dewsburg.

02:41:39.980 He kept his job.

02:41:41.100 He's a tenured professor.

02:41:42.220 He got to say what he wanted.

02:41:43.520 Other people proved him wrong.

02:41:45.060 It was a scientific process.

02:41:46.780 I don't know what happened with his funding.

02:41:48.360 I think he was affected, actually, funding-wise.

02:41:50.600 So this is a conflict.

02:41:53.080 I mean, it's clear because it does enforce a kind of groupthink.

02:41:56.160 In this case, there's a physical effector inhibition from the group mind down to the individual neuron.

02:42:02.260 Do not misbehave, or you will lose your ATP.

02:42:05.580 You'll lose your glucose.

02:42:06.500 You'll lose your source of energy.

02:42:08.800 And that's problematic.

02:42:11.040 Scientific freedom is a key component of actually being able to do science because science isn't a dogma.

02:42:16.400 It's a process.

02:42:17.000 So I think your concerns about further damaging the credibility, the trustworthiness of science in the future is valid.

02:42:24.560 I don't know if you guys saw the movie Don't Look Up on Netflix.

02:42:28.020 Oh, man.

02:42:29.020 It was depressing because it was so accurate.

02:42:31.680 It was like, wow, this is exactly what would happen if we had a true existential threat. 0.99

02:42:35.960 Humans would be so divided, so untrustworthy, so social media siloed, and behave like jackasses to the degree that we deserve to be wiped out. 0.98

02:42:42.800 It's funny you say that. 0.96

02:42:45.480 At the end of that movie, I was like, well, at least they had the right outcome here.

02:42:49.840 Yeah, me too.

02:42:51.020 I'm like, good riddance.

02:42:52.320 Good riddance.

02:42:57.080 But Peter, I've had so many doctors tell me exactly what you just described.

02:43:02.720 I've been threatened.

02:43:03.820 I've been bullied by my media relations department at my hospital.

02:43:08.680 My department chair directly told me, don't put this out.

02:43:12.700 Don't write this op-ed.

02:43:14.420 I've had people submit things for publication and then immediately insist before they're published that it be withdrawn because they're worried about how it could be perceived.

02:43:25.220 And often tell me, Marty, I believe in everything that you're talking about.

02:43:30.640 I believe in natural immunity confers a lot of protection.

02:43:34.860 I believe in spacing out the second doses to save more lives and give better durability to the immunity.

02:43:40.480 I believe in open schools that cloth masks don't work.

02:43:43.160 But I can't say anything from my position.

02:43:46.260 Keep going.

02:43:46.900 Keep being out there and saying things.

02:43:48.480 You get it, Peter.

02:43:49.680 I know, Zubin, you get it.

02:43:51.180 And you look at this national dialogue and you recognize the one common theme people say is that their local institutions are concerned how it could be perceived.

02:44:00.780 So basically, Twitter is now the ultimate arbitrator of whether or not institutions are willing to put things out.

02:44:06.320 And the other thing you hear is they're worried about their NIH funding.

02:44:09.000 And if there is one currency of academic medicine, it is NIH funding.

02:44:14.260 It is a direct requirement for every step of the promotions process.

02:44:17.800 And sometimes I do notice that those who tend to be more outspoken are those who are already tenured.

02:44:24.260 And it's not because they're just bolder.

02:44:26.120 It's because they have less of that concern.

02:44:28.700 And that is a direct conflict.

02:44:29.920 And we saw it with the lab leak hypothesis being discussed.

02:44:34.560 Why can't we just all agree to have no more gain-of-function research?

02:44:38.820 There is something where there should be broad consensus.

02:44:41.360 And I think people are afraid to go against Dr. Fauci, Dr. Collins.

02:44:45.580 And that is a tremendous amount of power concentrated in one human being, Dr. Fauci.

02:44:51.780 And it's even magnified because he's such a nice gentleman.

02:44:56.160 He's a great guy.

02:44:57.280 I mean, if you've ever talked to him.

02:44:58.880 So you have this very charming, very influential editor of Harrison's who's on every media outlet that has an FCC license every day.

02:45:09.360 And he's talking, controlling the narrative.

02:45:13.400 And so, for example, if he talked about fluvoxamine once, this entire pandemic, people would say, hmm, this is interesting.

02:45:22.000 Let's take a look at it.

02:45:23.080 Oh, you know what?

02:45:23.680 It's on the therapeutics page of COVID on the Johns Hopkins website.

02:45:28.160 It's on the list of recommended treatments under the University of Washington Medical Center site.

02:45:32.940 He has so much influence.

02:45:34.360 It is too concentrated.

02:45:36.180 It's not that he's bad or diabolical.

02:45:38.760 I actually think he's very well intended.

02:45:40.920 I've just disagreed with him on almost every aspect of the strategy.

02:45:44.680 But that, I think, is too much concentration of power, especially when he controls the NIH funding dollars.

02:45:50.400 By the way, final point.

02:45:51.680 I just heard from a doctor who's been funded by the NIH for 30 years who tells me he submitted a very elegant and extensive grant to study natural immunity, got a near-perfect score, and it's not been funded.

02:46:05.060 That's the kind of thing where it's like, look, if you've got $42 billion at your disposal at the NIH, that's one question that should deserve funding and to get an answer, rather than say we don't know.

02:46:16.540 How many studies have been funded by the NIH that look at disparities in COVID rates, Marty?

02:46:22.000 We just put this study out, my research team did, put it on the preprint server, 254 studies looking at COVID research on health disparities and social disparities.

02:46:33.460 And then there's been 254 studies on natural immunity as well, right?

02:46:38.120 Funded by NIH.

02:46:39.180 There's one prevalent study we don't have the results to yet, and it's outdated anyway.

02:46:44.900 And the other question is, how does the virus spread?

02:46:48.520 And they funded four studies on that.

02:46:51.000 And number of grants on masks, one.

02:46:54.140 So you had 254 grants the NIH put out there on social and health disparities in COVID, four on how it spreads, one on masks.

02:47:05.860 I'm all for addressing social and health disparities.

02:47:08.900 By the way, if you agree with me, you should be offended that Princeton is testing people three times a week, even though they're asymptomatic and triple vaxxed.

02:47:17.200 You talk about a disparity, high-risk people in the community can't get a test when they're sick and vulnerable, and yet we're testing the hell out of these young, healthy, triple vaxxed people. 1.00

02:47:27.760 So, I mean, that is unaddressed.

02:47:29.400 But I'm all for addressing health disparities, but how about knowing how it spreads because we were propagating surface transmission for way too long?

02:47:39.200 Or actually understanding what the natural history of the disease is vis-a-vis the immune system in the people who were infected without a vaccine.

02:47:47.320 But yeah, no, no, these are trite questions.

02:47:49.460 Gentlemen, any thoughts before we wrap this up?

02:47:52.620 We promised we were going to keep this short, and we kind of failed.

02:47:57.120 I got to say this.

02:48:00.320 I'm going to defend Fauci for a second from one particular entity.

02:48:03.460 The New York Post ran a piece about Fauci's finances that were disclosed, and I took personal offense to this because the guy's 80, and this is what he has, Peter.

02:48:11.920 You'll appreciate this as a financially literate individual.

02:48:14.760 Marty, not so much.

02:48:15.540 I know Marty's fast and loose with his money.

02:48:17.280 He's all over Swiss bank accounts. 0.97

02:48:19.300 He's just crazy.

02:48:19.980 So Fauci had $10 million in retirement stock assets that were diversified across very boring mutual funds at age 80-something, right?

02:48:31.660 And also a, like, $50,000 stake in a small Italian restaurant in San Francisco.

02:48:38.560 And this particular collection of stuff was billed as some kind of egregious wealth and conflict and all of this.

02:48:44.620 And I'm like, dude, the guy saved his money and happened to believe in the power of compounding and very generic mutual funds.

02:48:51.880 It's not like he owns directly, like, Pfizer or something.

02:48:55.120 But I thought that was interesting.

02:48:56.420 I'm like, man, God, I hope no one ever looks at my finances because, first of all, they'll laugh at why I'm not rich.

02:49:03.500 Like, what is this guy doing?

02:49:06.460 Yeah, no, that's an interesting point.

02:49:07.800 Well, first of all, I mean, that's a great example of – because he's a public servant, right?

02:49:11.680 I mean, he's been a public servant his whole life.

02:49:13.120 It's wonderful to see that he's been fastidiously saving, investing, and letting the miracle of compounding do its thing in his favor.

02:49:22.360 And, I mean, I think that's the problem with both sides of this.

02:49:24.920 When you view him as the pope and he's so holy that any questioning of him is tantamount to treason,

02:49:31.240 you're equally egregious to when you just think that everything he does is horrible and when we've established that nuance is not the forte of the mob.

02:49:39.480 So, anyway, gentlemen, I thank you again for this, and I know we were all made infinitely better by Monica's presence here.

02:49:47.040 She elevated the game quite a bit.

02:49:49.060 Yes.

02:49:50.080 It was awesome.

02:49:51.300 All right, guys.

02:49:52.320 Well, I keep saying we'll never do this again, but I'm not going to say never, so.

02:49:57.060 I don't think we'll be doing it for a while.

02:49:58.700 I think we've said all we need to say on this subject.

02:50:01.160 Thank you, Peter.

02:50:01.940 And thanks for diversifying our crew with some estrogen and keeping it really interesting and relevant, I think,

02:50:07.260 to people who are starving for, again, some honest discussion.

02:50:11.600 Yeah, great to see you, Peter.

02:50:12.700 Great to see you, Zivin.

02:50:14.540 Thank you for listening to this week's episode of The Drive.

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The Peter Attia Drive - January 24, 2022

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

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