Immunity Is The Only Way Through A Pandemic (w/Dr. Monica Gandhi)

– [Zubin] ZDoggMD. Dr. Monica Gandhi. Welcome back.

– [Monica] Thank you very much.

– [Zubin] Oh my gosh.

– [Monica] I’m asymptomatic and vaccinated, so here we are.

– [Zubin] Here we are, maskless in Seattle.

– [Monica] Maskless in–

– [Zubin] Well I mean, in San Carlos. It’s the same difference.

– [Monica] Yeah, same, same. Asymptomatic vaccinated.

– [Zubin] Asymptomatic vaccinated. Okay before we dive into that, because there’s so much I want to talk about with you, we’re gonna, okay, I’ll tell you the things that I’d like to hit. I want to talk about CDC’s messaging and their behavior. I want to talk about natural immunity. I want to talk about turning this pandemic into an endemic cold, and what’s going on in places like say Australia.

– [Monica] Yes.

– [Zubin] I want to talk about booster shots, I want to talk about vaccine mandates and passports, and I want to talk about Mu. But those are just some of the things. But before we do all that, we have to back up a second ’cause the last time you and I talked, we were like variants shmariants, vaccines are gonna save us, this thing is over. Okay, were we right or were we wrong?

– [Monica] I think we were partially right if vaccines had continued to be uptaken at a high rate in the United States. So who was right about that? The UK, Denmark, Ireland. Who kept in having good vaccine uptake? France, Italy. We will later talk about vaccine passports. We have to. But great vaccine uptake, kept on going, kept on going, and their society’s become more an open and open, even with Delta.

– [Zubin] So we were right just for the wrong country.

– [Monica] We are right for the wrong country. We didn’t vaccinate well here.

– [Zubin] We thought the uptake would be higher.

– [Monica] Yes.

– [Zubin] Now Delta turned out to be pretty high reproductive number and spread quite rapidly, which may have thrown a wrench in the variant shmariant part of our theory, except if we had vaccinated many, many, many more people. What would have been different?

– [Monica] I think if we’d kept on going at the rate that every other country was on that trajectory, right now we would have been without masks or masks for the, no masks for the vaccinated and masks for the unvaccinated. We wouldn’t have had to take that step back.

– [Zubin] Right.

– [Monica] And also we kind of made people dig in about, I mean I definitely think our vaccines increased after Delta, but we made some people dig in because they were like, doesn’t it sound like vaccines don’t work ’cause of our messaging, so why would I take a vaccine, and then the third thing that we did is that we made people feel like this is gonna go on forever, and actually nothing will go on forever, but an endemic respiratory virus that doesn’t cause severe illness is actually a controllable way to live, and I do think one thing Delta’s gonna do, it’s gonna give us a lot of immunity. Vaccinated people who see it are gonna get an immune boost. Unvaccinated people are going to see Delta and they’re gonna get immunity. So in a way it speeds things up.

– [Zubin] Yeah, and you brought up a point, so this is, I wanted to ask you about this. The messaging around this vaccine. We’ve almost done everything possible to convince people not to get the vaccine, right? Like, and I’ll tell you, ’cause my audience, they’re pretty smart people.

– [Monica] Yeah.

– [Zubin] Especially the vaccine hesitant people, because they’re asking all the right questions in the setting of the messaging they’re getting from CDC and others which is, you know what, these vaccines, first of all, you’re gonna need a booster, ’cause you know, not good enough, second, you’re gonna have to mask again, we told you not to mask, but you know what, meh, we were wrong ’cause you can probably still transmit a whole bunch, so wear a mask. Now is any of this true, and what do we do wrong? Tell me what you think about this.

– [Monica] Okay, so this is what I think. If we had just kept on a persistent message like by the way, Iceland did, which was really consistent about vaccines work and didn’t allow all this hesitation to come into their voices, I actually think we would have gotten a lot more people vaccinated. I think the messaging that the CDC did set us back because, okay, so let’s talk about two things that they did. One was transmission. So on July 27th, ouch, it was such a hard week. On July 27th they said we’re gonna put masks back for the vaccinated. We’re not actually telling you why. We’ll show you a study in a couple of days. It’ll come out on Friday. Just trust us. But vaccinated people transmit as much as unvaccinated, which seemed like really wrong microbiologically, because even if your antibodies in your nose come down a bit since if you had your vaccine in January, they’ll come right back up if they see the virus again, and also you still have T cells in your nose. You’re doing everything you can to kill that virus. It may just take a little longer. So it didn’t ever make sense that a vaccinated person could transmit as well as an unvaccinated person. And then they showed us the study on Friday, July 30th, and it was the Provincetown outbreak study that you’ve covered, and it’s literally showed at one point in time that the CT value, the cycle threshold value of the PCR test was the same in vaccinated, symptomatic breakthroughs, so they were sick, than unvaccinated people just at one point in time, and they stopped there. They didn’t say, oh, but do the vaccinated people bring their viral load down faster. Oh, let me culture the virus. Is it getting sick because all the immune cells are trying to kill it? And also they were symptomatic breakthroughs, so this says nothing about asymptomatic people who are vaccinated.

– [Zubin] So in other words, they were cherry picking the sickest vaccinated people who broke through, and going, okay look, their PCR cycle threshold, we’re seeing a lot of the positive viral load. That way is as high as the unvaccinated, but not actually going well, how long are they infectious, is that virus actually viable?

– [Monica] Yes, yes, yes. And so then like four studies came out that kind of did the right things, which was to try to study it. So Singapore literally, it was very interesting timing. They put it out the next day. It was like they were waiting. But the Singapore breakthrough Delta study showed, as you would expect, vaccinated people, their viral load comes down really fast. So you probably don’t have to isolate for 10 days, by the way, after a symptomatic breakthrough. We should let them isolate for a shorter period of time, ’cause your viral load comes down really fast. Then a Netherlands study, 161 symptomatic breakthroughs in healthcare workers, about like 22,000 people who had gotten the vaccine, and they had Delta, and then they cultured it, and they were sick, the virus was sick.

– [Zubin] So what do you mean by sick?

– [Monica] So it means that if really actually we can’t tell from a cycle threshold of a PCR. What is cycle threshold? It means how many cycles the PCR machine has to go through before it says, ding, ding, ding, it’s positive. And so if it goes through many cycles, then it’s usually a low viral load.

– [Zubin] I see.

– [Monica] But the viral load in the nose doesn’t tell you if that’s dead viral fragments. It’s just pieces of a virus. It doesn’t tell you if it’s living, live, can infect others. The only real way to do that is culture.

– [Zubin] Is see, so it’s like virus boogers.

– [Monica] Yes, yes, yes.

– [Zubin] But it’s just scum.

– [Monica] Yes, scum of the virus that you just killed in your nose actually if you’re vaccinated, hopefully. And so we need to now culture it and say oh, but is it alive, can it like pass over to people? So the Netherlands studies cultured it and said yeah, if you were vaccinated, even with a symptomatic breakthrough, you had a more sick virus, it didn’t culture as well, it was 2/3 less likely to culture. And then there was an Alpha symptomatic breakthrough that showed it couldn’t culture out at all. So probably Delta, there’s a little bit of transmission that occurs if you’re symptomatic, but there’s no data that if you’re asymptomatic and you are vaccinated, you’re passing it on, and the only way we can tell that is contact tracing, so luckily we had a study. So Singapore does very careful contact tracing. This is their thing. I think they also pick up litter.

– [Zubin] And they cane you if you chew gum.

– [Monica] They’re very meticulous.

– [Zubin] That’s what it is.

– [Monica] Meticulous.

– [Zubin] They’re meticulous.

– [Monica] So they’re very meticulous about their contact tracing, which is really the only way to tell, right. Like you can’t actually tell by a cycle threshold PCR test, did you pass it on to someone if you were asymptomatic and vaccinated. And they went all the way to July 28th. So they have data when during Delta, and there’s this website that I just posted on Twitter and, their website, and all you have to do is select asymptomatic and vaccinated, get their source code, which my postdoc did, and literally one person looked like they transmitted if they were asymptomatic and vaccinated. So putting back masks on all asymptomatic vaccinated people, like a healthy group of people, feel well, in a party together but they should be masking when they’re going to their party probably is not biologically make sense. So that’s what I mean by scared people, right, because who actually took that seriously? The vaccinated. Very like vaccinated people who are like very diligent, they’d been masking really well, then the CDC said they could take off their masks, and they said okay, I’m gonna digitally take off my mask, and then they got scared. Okay, that means that I can be around anyone and I can still get the virus again.

– [Zubin] Or give it again.

– [Monica] Ignore, or give it. Ignore, yeah, I’ll give it to my person who’s older around me, ignoring the biological plausibility of that, and also ignoring the fact that they are very protected from severe disease as a vaccinated person. That got lost with symptomatic breakthroughs. Like why did we develop a vaccine for this? Believe me, we don’t have a vaccine for rhinovirus and for the four circulating endemic coronaviruses that cause colds. It’s not that we don’t have the money or the technology. We don’t develop it ’cause colds don’t merit–

– [Zubin] Don’t kill you.

– [Monica] Yeah, they don’t merit vaccines. They don’t. We have so much other public health problems. They don’t kill you.

– [Zubin] Right, so this vaccine, the idea, and I’ve said this before, is you turn something that could kill you into a cold or a flu that doesn’t kill you.

– [Monica] Yes, yes. It’s such a defang, like that’s such a amazing aspect of these vaccines, and if we really know just simply how the immune system works, it’s because T cell immunity is durable and long, and that’s what protects you from severe disease. And your antibodies may go down in your nose, and you may get a symptomatic breakthrough if you’re exposed, for a few days, but the T cells are in your nose, they will activate your B cells, they’ll produce antibodies, bring down the viral load and you’ll feel well in a little while, much more well than the unvaccinated who are in the hospital.

– [Zubin] And that’s what we’re seeing is unvaccinated in the hospital. There’s some vaccine breakthrough because again, it’s a 90% against severe disease, so there’s 10%.

– [Monica] Yes, there’s some vaccinated.

– [Zubin] And it’s usually what, elders, people with immune compromised.

– [Monica] Yes. You know what I keep on thinking is actually we know there’s 7,000 vaccine breakthroughs because the CDC tracks them really carefully. Take those 7,000 people please and tell us their demographics, who’ve gone into the hospital after being vaccinated. Tell us how old they are. Boost those people. If they’re all over 70, boost them. If they have diabetes or chronic kidney disease, boost them. If they have, are they’re all immunocompromised or 40%, boost them. You just have to get that demographic dataset that they have, that people keep on asking, just tell us who’s getting severe breakthroughs, boost them first, boost them.

– [Zubin] Yeah.

– [Monica] We don’t want severe disease. It’s terrible.

– [Zubin] And so that actually ties into the CDC messaging, the booster thing. So now they come out and say, Biden says well I want to give boosters to everybody September 20th, right. What messaging? First of all, we’ll talk about the biological plausibility of that, and then we’ll talk about what message does that send about the efficacy of the vaccine. First of all, you call it a booster, which is like saying well this thing doesn’t work, so we gotta jazz it up, and ’cause these measured antibody levels are dropping, but as you said, there’s other things in the immune system, right–

– [Monica] Yes, that will produce those same antibodies, and they’re directed against the variants. I just want you to know that. Like I know we know this. Three papers show us that if your memory B cells produce antibodies, they’ll very cleverly be directed against the variants. That’s how great our immune system is.

– [Zubin] But how will the media get clicks if we say that? And so this is the thing. We’re living in a world that’s dictated by Rochelle Walensky and Fauci’s risk tolerance, not by the risk tolerance of rational average Americans, which is, I just don’t want to get severe disease. So what they should have said is get vaccinated, we turn this thing into a cold, it’s not perfect, if you’re really old, you’re immunocompromised, here’s a third dose–

– [Monica] Here’s a third shot.

– [Zubin] That will give you that extra jazz for that.

– [Monica] Which is who we usually give a third dose to, by the way, for like, we always give higher levels of the flu vaccine for older people every year, we give higher, we give a third shot to anyone who has a hint of immunocompromised, which is super smart, we give like an extra dose to an old person because we feel like, okay, yeah, just in case your immune system isn’t great. There’s always been defined populations we give third doses to, but to all immunocompetent people, what it sounded like to me, two messages. One is it felt like American’s lives were so much more important than the rest of the world. So 2% of doses of the vaccines have been given in low income countries. We talked about this, one of our, when we were talking about India and what it felt like to be Indian-American and to watch an unvaccinated nation get Delta was horrifying.

– [Zubin] Yeah.

– [Monica] It was watching severe suffering and death that could have been prevented starting March 3rd. It was so terrible, and we’re letting all of that happen in Sub-Saharan Africa. If you gave every American a third booster shot, you could’ve given Sub-Saharan Africa their first doses. So, it looks really kind of crazy insular nationalistic that America, a healthy 20-year-old would need a third shot over a healthcare worker in Botswana. But beyond that, yes, what does it tell an unvaccinated person who is on the fence about getting the vaccine, ’cause they were saying, well, I’ve just looked and Alex Berenson said they don’t work, and then they said oh look, they just told me it didn’t work. They said that we need three doses, and maybe we’ll need more. Like they just told me that the effectiveness of the vaccines isn’t that great.

– [Zubin] Yeah.

– [Monica] All I want, people should know about messaging. Messaging actually, in public health, is everything. And actually HIV people knew that. Like they knew when they took away condoms because we got PrEP and treatment is prophylaxis, that was a good day, but people don’t want to use condoms, people don’t want to wear masks. People like PrEP, and people liked treatment as prevention. People like their vaccines. Vaccines can be great, but we just messaged wrong, we messaged like we’re never getting out of this, we’re never gonna get back to normal life, nothing’s ever gonna be normal.

– [Zubin] Oh, I’m just sitting here getting so angry. Really, I–

– [Monica] Bad messaging.

– [Zubin] This is something that is near to me because what I do is message, right, and the thing is I try to do it the right way but I’m shooting from the hip. But this is what I found in my own practice of messaging.

– [Monica] Which is you’re very good at.

– [Zubin] Well I get hundreds of messages every couple days. The inbox goes from 100 messages, I’ve caught up, up to 100, and then it goes back to like 400.

– [Monica] Yeah.

– [Zubin] And what are they? They’re all people saying, I don’t trust CDC. I don’t trust Fauci because they said this, then they said this, then they said this. I don’t trust the media because they keep trying to shame me for asking questions about the vaccine. Then they say we need a booster. Then they say natural immunity doesn’t count, which we’re gonna talk about. Then they say this. Now, you’re the only person who didn’t call me stupid to my face, and it seems to me like you like the vaccine which makes me wonder, could I be wrong about not getting it?

– [Monica] Yes.

– [Zubin] Could you help me understand?

– [Monica] They have to trust you to want to get the vaccine. That is so true. It’s about trust.

– [Zubin] And the thing is, I get shit from the backseat public health doctors. Like they’re not public health doctors. They’re like backseat doctors. “I’m a public health doc.” You’re some rando doc in like who knows where who has a mask on your avatar saying wear your damn mask, you’re virtue signaling all over the place, and you’re yelling at me on Twitter because I said natural immunity actually is a real thing. “You’re gonna kill people with that statement.” “They’re not gonna get vaccinated.” No. What you say, your message.

– [Monica] You will discourage people from getting vaccinated.

– [Zubin] And you have.

– [Monica] Actually this is what I think. You probably have done more to increase vaccine uptake than someone who just continually scares and makes people miserable, and shames people, and when I get into trouble ’cause sometimes people will say to me, aren’t you being cavalier that we can unmask after we’re vaccinated, and I really think to myself, I have actually increased vaccine uptake by saying trustful things, by saying natural immunity is a thing, and let me explain that, and let me explain why I want you to get one dose, but I totally don’t blame you for asking, and I’m just wondering, this is what I would do, and also for acknowledging that people absolutely, it hurts to be shamed. Why would we shame people about their questions? We just, we want to answer their questions. Immunity is the only thing that has gotten any of us through any pandemic. That’s why I want people vaccinated. I want more and more people immune. We weren’t immune enough when Delta hit.

– [Zubin] Yeah, you’re right, you’re right. Some of that may be because we seem to have this idea that some people seem to have this idea that hiding behind masks, and closing down, and keeping schools closed, doing all this other stuff is gonna save us. Like look at Australia.

– [Monica] Australia.

– [Zubin] So Australia was like, okay gov’na. I don’t know why. They never say gov’na. That’s not even right. Hey mate. That’s not a mask. THIS is a mask. It’s a whole body suit. I mean lock down when like a case shows up, and then drop the ball on spinning up the vaccine. So now they’re still stuck. They don’t have any immunity, and now they’re way behind. Now yeah, maybe people didn’t die up front, but you gotta get immunity before you’re gonna solve this problem.

– [Monica] Their vaccine rate uptake will have to be something like 95%, whereas ours will have to be lower, like fully vaccinated 80%, because they have no natural immunity, so like you said.

– [Zubin] Ahh.

– [Monica] This is just gonna take me two seconds, but true history of infectious disease is really quick.

– [Zubin] Yeah.

– [Monica] So influenza pandemic is the one that we can remember the most, right, like black death. All of that was all, the only way people could get through it was immunity. What ended it was terrible ways of getting immunity which was death and suffering. Okay, so influenza pandemic 1918. Terrible death and suffering. Probably 50 to 100 million people dead, much more higher rate of death than we had here.

– [Zubin] By far, yeah.

– [Monica] And here we have, and it was about 3% of the population, and they tried masks, distancing. They couldn’t do actually testing. We didn’t have testing. They couldn’t do contact tracing. They didn’t have any of that, but they tried everything, but the only thing that really got them through it was terrible natural immunity, because 1942 was the first time a vaccine was developed for influenza. So it was terrible death and suffering, and then it ended, and then there was the roaring 20’s and everyone was happy, but it was miserable that they remembered 50 to 100 million people dead. Measles. It kept on coming, and people would get it, and then they would be lifelong immune. So like for example, we don’t vaccinate someone if they’re born before 1963, right.

– [Zubin] Right.

– [Monica] Because they have lifelong immunity, they got it. And then the vaccine was developed in 1963, and after that, the better way to get lifelong immunity was the vaccine. So great, that’s what you want, vaccine. Smallpox. People actually got immune. The old world got immune. They were actually getting over it. Then they bring blankets over here and they–

– [Zubin] Decimate the Native American population.

– [Monica] Decimate the Native American population ’cause there was no immunity here. It was truly bioterrorism, and there was no immunity, and the only way to get through it was terrible death and suffering. And then we got a vaccine. No terrible death and suffering. Vaccine eradicated it. So immunity is the only way to get through a pandemic, and what Australia did, and it was right to do limited lockdowns to keep the hospitals not from being full, but they did masks, distancing, ventilation, testing, contact tracing, they used those five strategies over immunity. They used it over vaccination so that when the vaccine, they’re a rich country, so when the vaccine came out, December 14th, 2020 is when we got our first vaccine here, should have been all about the vaccine so they could get their country through it. Now they finally admitted with Delta that it’s gonna be endemic, that they can’t–

– [Zubin] Eradicate it.

– [Monica] They can’t eradicate it. They’ve totally admitted it. They said it out loud, and now the amount of vaccination that they’re gonna need to do and get their people to trust them, right. Going back to that trust issue. You have to trust your government to take the vaccine. There may be people who didn’t quite trust them that they weren’t allowed to see their family in another country, for example, for 18 months. So they have to get that trust back and say we’re gonna, this is how to get out of the pandemic, please take the vaccine. We’re actually increasing trust. You have to increase trust by acknowledging studies.

– [Zubin] Right, so for example, natural immunity.

– [Monica] Yeah.

– [Zubin] So it seems like it was a big thing early on for the government and others, and even myself because I was kind of parroting some data about the antibody levels. So neutralizing antibody levels are higher in two doses of an mRNA vaccine than they are in natural immunity in some series or something, right, but then when you actually look at the Israeli data, right, it’s like wait, no, it seems like they’re at least equally effective and probably more effective in terms of natural immunity, preventing severe disease, hospitalization, re-infection.

– [Monica] Yeah. This is how I think about it. We should not look at laboratory studies actually, like okay. So it’s very important to know the immune system. So it is some important to look at laboratory studies in the sense that, remember, the vaccines or natural immunity make you have memory B cells, and then your T cells will help your memory B cells make more antibodies when and if you need them. So that’s in a nutshell either natural or vaccine-induced immunity. But going back to how we really want to prove this is look at reinfection rates, ’cause that’s a clinical outcome. Are you more likely to get reinfected if you’ve been naturally infected versus getting the vaccine? And I think it depends on the context, but in Israel at least that study was quite convincing that you’re more likely to get reinfected if you’ve had natural, sorry, if you’ve had the vaccine than natural infection. Think it has a lot to do with how they did their vaccine. They only did Pfizer ’cause they had a deal with the Pfizer company. They did it very strictly, three weeks apart, which actually makes your antibodies lower than if you had more time between doses.

– [Zubin] Spacing is something we can talk about–

– [Monica] Which is why the UK and Canada were so smart, ’cause they yeah, they spaced it out and that made your immune response better, your antibodies.

– [Zubin] And Marty Makary too.

– [Monica] Yes, yes, yes, yes.

– [Zubin] He did that too.

– [Monica] And my son, because of the myocarditis risk, I increased the spacing between his doses, and I feel really happy about that.

– [Zubin] Yeah.

– [Monica] And so all of that was really smart to increase spacing between doses. All vaccinologists said that to our government even early on, but we didn’t do that. So, Israel didn’t do that at all. So three weeks between doses, only Pfizer, and then they had a mixed population because they do have Palestinians that are not as very high vaccinated levels. Very problematic to have poor of a country who are doing a lot of essential work not as well vaccinated. So because of that, all of that put together, it actually looked like if you had had natural infection, you probably are more protected than if you had the Pfizer, and if you’re older, you may need a third dose for the Pfizer vaccine, but that doesn’t seem to happen with Moderna. For example, there was a Mayo Clinic study, remember that, that showed more reinfection with Pfizer than Moderna, probably ’cause Moderna had four weeks between it. Even the one extra week is helpful, and then a higher dose.

– [Zubin] And a higher dose. Yeah, exactly. I’m team Moderna just by default.

– [Monica] Yes.

– [Zubin] And I’ll tell you, that second dose was like a punch in the face.

– [Monica] Yes, and that was a, there was this like funny Saturday Night Live episode where someone at a party said to a woman, well I’ve just felt, like a man was trying to pick up someone or something and he said, I had such a terrible time after my second dose of Moderna, and she’s like, this is not a party line. But like yes, a lot of people had a terrible time after the second dose with Moderna, but yeah, it sure led to a lot of immunity.

– [Zubin] Yeah. It’s really interesting, and this idea that then with natural immunity, and we’re gonna get to vaccine passports and mandates and things like that, but let’s talk about natural immunity a little bit more. It seems like in that same Israeli series, people who had been naturally infected and then had a single dose of Pfizer did, they were superstars of immunity.

– [Monica] Seems like that’s as good as it can get. Like if you really want to rank like the best level of immunity, what I call is hybrid immunity, a lot of people call it hybrid immunity, is getting natural infection. No one wants to encourage natural infection. Who would ever want someone to get sick?

– [Zubin] Right.

– [Monica] We have to admit, the ship’s out of the barn. Some people have been naturally infected.

– [Zubin] Exactly, exactly, exactly. Oh, that’s the other thing. You’re gonna encourage people to go out and get infected.

– [Monica] That’s ridiculous.

– [Zubin] That’s ridiculous.

– [Monica] Acknowledging natural immunity increases trust and it just shows that you know the immune system.

– [Zubin] You know science, yeah.

– [Monica] You know the science. It doesn’t mean that you’re gonna encourage people to get naturally infected. That ship has sailed.

– [Zubin] That’s like, PrEP is gonna encourage gay men to have sex.

– [Monica] Oh, that’s such a good example ’cause that really bothered me as an HIV doctor that we would say that it would encourage gay men. And by the way, the same people who are messaging. Okay, that’s we talked about that once, but like the same HIV doctors were so nice about HIV, they were like of course you should have sex without a condom if you’re getting treatment as prevention, but they’re so mean about COVID. No natural infection.

– [Zubin] I’ve seen it. These are the ones that attack me on Twitter. They’re like, well you’re a problem.

– [Monica] No, you’re acknowledging the science and then people trust you.

– [Zubin] That’s right. You read their thing and it’s like HIV hospitals here. Wait, but you treat HIV. So what did you learn from HIV, that shaming people, by moralizing about them, by doing all that? Well these anti-vax people, they’re killing grandma and they’re the ones that are filling up our hospitals. Well yeah, no it’s true. Why are they filling up the hospitals? ‘Cause you’re a terrible communicator.

– [Monica] Yeah. I don’t know what we, so many things went wrong here because everything’s going so swimmingly in the EU, by the way. Like so many places in the EU are doing great, so there’s some, we have to acknowledge that something went wrong here. I know we all want to say it was Trump, by the way, like I know we all want to say everything is Trump’s fault, but I’m sorry, it was also the reaction to Trump that has led to the severe politicization of a pandemic.

– [Zubin] It’s true.

– [Monica] So okay, so going back to natural immunity. So, there are two things that you want, and then you know you’ve got it. You want T cells and you want memory B cells because you don’t, antibodies are great, awesome, they’re always gonna wane, they’re always gonna wane. Like I got an infection, I actually got chickenpox as a child so I didn’t need that VZV vaccine, so my antibodies have waned. Our antibodies are gone.

– [Zubin] Are we gonna get shingles now?

– [Monica] No, ’cause your memory B cells. If they see, if you’re an immunocompetent host, your memory B cells will produce more antibodies. They’re the blueprint of producing the antibodies, and just like a good architect, if they have to adjust something like they need to make antibodies that are directed against the variant, they’re good architects. They will create antibodies directed against the variant. University of Pennsylvania study, OHSU study, those are my favorites studies of all mankind. Then the second is of course your T cells which prevent you from getting severe disease. We knew from natural infection that T cells last a long time. SARS, they lasted, people got SARS in 2003 and then in 2020 there was a nature paper that said your T cells are alive and kicking at 17 years. So, it really depends if you make memory B cells, in my opinion, if you have a long and durable response to natural infection, and I think you’re less likely to produce memory B cells if you had mild infection than severe infection, which is why if I had mild COVID infection, I would think differently than if I had severe. And then giving that one dose, like you said, after a natural infection, that to me just solidifies the production of memory B cells, which there was a paper that showed that we can see them in our lymph nodes if you biopsy lymph nodes after vaccination, see them in bone marrow if you biopsy them after natural infection, so putting those two together, I would want someone in my family and also I’d like to publicly message that one dose after natural infection to me sounds prudent.

– [Zubin] Sounds prudent, sounds great, and in fact, something you said about if you had a mild case, asymptomatic, mild, that may be different in terms of generating immunity, which is I’ve been saying too, there’s an unpredictability.

– [Monica] Yes.

– [Zubin] If you look at the Israeli data, which was a pre-print, it’s kind of like they looked at it on aggregate, so it’s hard to know how much if that was minimally symptomatic and so on.

– [Monica] I wonder if they were mostly severe. The only reason I say that is that they had a seroprevalence study in September that showed only 2.44% of Israelis had antibodies, so they actually kept a lot of people away from each other and they did quite severe lockdown, so I’m wondering if the people who actually got sick were sick.

– [Zubin] Were actually sick, yeah. And now here’s a question, ’cause a lot of people will ask. Well then can’t I just measure my antibodies, and will that be some indicator of my memory B cell? Because people go and do this. They get these antibody tests. Well what’s the utility? Is there any utility?

– [Monica] You know, they really go down over time, and so it depends on when you got your natural infection, but you still could have good memory B cells. So you’re not having antibodies doesn’t mean you’re not immune, and on the opposite end, having antibodies doesn’t mean that you didn’t have like a really good antibody response. You’ve just recently got infected, but it doesn’t mean you made those memory B cells. So I feel like it’s not a good surrogate for being immune.

– [Zubin] Right.

– [Monica] And that’s why what Israel does, and that’s fair, they say when we do passports, ’cause they were the originator of passports, they said you can either show us that you’re, not your antibodies but show us that you’ve had COVID, and that gets you into the fun restaurant, or show us that you’ve been vaccinated. Their green pass included immunity passports as well. It was called immunity passports, wasn’t called vaccine passports.

– [Zubin] Right. So and that’s much more enlightened than what we kind of talk about here in the US, and we say well the logistics of it. I mean, that’s literally what they say is the reason we’re advocating two doses for everyone is just it’s logistics, because we can’t prove that somebody has been naturally infected and it’s harder–

– [Monica] You can though. You can prove someone’s been naturally infected like a hospitalization, God forbid, or–

– [Zubin] What about the honor system even?

– [Monica] Yeah, yeah, yeah, yeah.

– [Zubin] It’s kinda like, who are you gonna hurt if you go in there and you’re lying? Yourself.

– [Monica] Yeah, that’s true.

– [Zubin] It’s probably even less likely to hurt a vaccinated person or someone who’s been infected, with severe disease anyways. They might get infected, they might get sick for a few days, but they’re not gonna die.

– [Monica] Yeah, that’s a good point. That’s a good point. It’s that distrust thing, right. We’re creating distrust and we’re acting like we don’t trust human beings.

– [Zubin] Yeah, because they don’t, I think. I really think they don’t. Now speaking of that, this is something that now this is something where it conflicts with my own emotional bias towards freedom, and yet the scientific mind says, you know what, this is probably something that would save a lot of lives and work, and that is vaccine, either vaccine immunity passports slash mandates for vaccines. Now I want to have a conversation with you about, because I’ll tell you, a lot of my audience is very skeptical of this.

– [Monica] Yes.

– [Zubin] How should we think about this stuff in terms of solving our problem here which is generating immunity that keeps people from dying?

– [Monica] So I did also change my mind. So pre-Delta, I was a vaccine passports and vaccine mandates don’t seem fair to people, and then I changed my mind and I became a vaccine passport vaccine mandate person. And people did write me, and they said I liked the pre-Delta Monica better, and I will say to you clearly looking in the camera, I liked that person better too, but I also hate Delta.

– [Zubin] Heaven forbid, Monica, that we’re authentic and honest about when we change our mind about something, the why of it, right. It still feels difficult, right.

– [Monica] And I understand people are mad at me, but I will just tell you very clearly that immunity is the only thing that gets us through a pandemic. That’s like my, I mean no one who pre, anyone. By the way, with masks, just for a minute, masks are great, and I, our first conversation was about masks and why I believe in them, but please don’t message that masks are better than vaccines. No one should be messaging that, and if there is somehow coming out of someone’s mouth that they think masks are better than vaccines, they have just lost their trust, because immunity is the only way to get through a pandemic. So with Delta, we need higher levels of immunity. We just do. Alpha, I don’t know, I think 60% was what was needed. Delta, at least looking to Denmark and Ireland that are both opening up on October 22nd and 15th respectively and they’re really excited, looks like 80%. So we need more immunity. And we were, by the way, like we were not even getting there with Delta because of the distrust that we’ve created.

– [Zubin] That’s right.

– [Monica] So what did Europe do? What did the EU do? They did do a lot of vaccine passports and mandates. So, France was really clear about that, Italy was. Everywhere you go in the EU, there’s a lot of having to show your vaccine card. They variably call it green pass or not, or your immunity card. Germany, Spain, France, Israel also has one dose after natural infection is great, and so that’s vaccine passports, and then they set a lot of vaccine mandates. And I look back at history, I look back at 1905 where 30% of people in this country weren’t taking the smallpox vaccine, and there was a Supreme Court ruling called Jacobson versus Massachusetts where it became legal to actually mandate a vaccine, not if you’d had natural smallpox, by the way.

– [Zubin] Aha. Yeah, yeah. ‘Cause that’s such a sticking point for people.

– [Monica] And people had marks to show it that they’d had natural smallpox.

– [Zubin] That’s your passport is the scars.

– [Monica] Your passport is the scars from the smallpox, and so but they were, there is a legal precedent in this country to mandate vaccines, and I did change my mind after Delta, and I think it comes to a point, I mean at certain point, once we’ve gotten through Delta, because Delta is gonna cause immunity whether you get vaccinated or not, right.

– [Zubin] You’re gonna get it eventually.

– [Monica] You’re gonna get it, right, ’cause it’s so transmissible, and it will lead to decreasing cases because the unvaccinated will get immune. I mean it’s so marked what’s happened in the India and the UK, by the way, UK, oppressor of India, but okay. So 4% vaccination rate in India when Delta hit, and how did they get through it and why do they have pretty low cases right now in most areas? Because of terrible, terrible death and suffering, terrible. Okay, UK, it hit like seven weeks before it hit us. 76% vaccination rate. Did they have terrible death and suffering? No. They had lower hospitalizations, with the cases going up really fast ’cause they had the higher levels of vaccination. They fully opened on July 19th. They test a lot, they see cases, but their hospitalizations are staying low. So that’s the difference between a highly vaccinated or immune population, and someone has to get through it through misery.

– [Zubin] Right.

– [Monica] So who’s gotten through it misery? Missouri. I mean, for example, like Missouri the cases and hospitalizations are coming down now from the Delta surge, but they got through it because they had I think a 30% vaccination rate through misery, through a lot of hospitalizations, terrible, and now of course it’s coming down. People are like, why is it coming down? Immunity.

– [Zubin] Immunity. It’s what I, I did a piece called The Delta Surge Will Crash Faster Than We Think.

– [Monica] Yes, yes, yes.

– [Zubin] And it was about exactly that. Like it burns through all the dry tinder, and then it hits an equilibrium. Then human behavior changes too. So people are just like well I’m gonna mask, I’m gonna distance, I’m not gonna go to this event, I’m gonna do that, I’m gonna do that, I’m gonna go get vaccinated.

– [Monica] Yes, yes, and vaccines have increased.

– [Zubin] They have increased.

– [Monica] And that’s the good thing.

– [Zubin] That’s right.

– [Monica] But why do we have to do that through fear as opposed to like really positive messaging around the vaccines?

– [Zubin] So that’s where I had a problem with the mandates, because I felt like it was a failure of public health to have to mandate it, when we could have done it better. Now that we failed, not only failed but failed miserably. The messages I get, these are–

– [Monica] We’re the only developed country that’s this rich that has vaccination rates this low. Only one.

– [Zubin] Yeah, yeah, yeah, yeah, because freedom.

– [Monica] Yeah.

– [Zubin] No, not because freedom, because we don’t know how to message. We also don’t have a very centralized public health. We also don’t have systems thinking like some of the Europeans do. We certainly don’t have a national health system like in Great Britain where they can do this kind of thing. So we have those both advantages and disadvantages, depending on your point of view, right. I like freedom, I like certain things, but at the same time I also like people not to die, I like effective stuff.

– [Monica] You’re a good doctor.

– [Zubin] So yeah, so it’s kind of like well, now it’s like well okay if we’re gonna mandate a vaccine say for an employer or for say federal government or whatever, I think there ought to be, first of all, every educational effort still to try to say this is, hey, this something you just want to do, you don’t want to be mandated, you just do it, but then if that fails, then take into account natural immunity.

– [Monica] Yes, yes, and then that’s where the vaccine mandate comes in. I agree with you. Saying about natural immune, discounting natural immunity when doing vaccine mandates is making people really mad, and that’s very fair for them to be mad, but yes, I do think it’s gonna increase vaccination by doing vaccine passports and mandates for a while.

– [Zubin] Yeah, and it’ll just get us to immunity faster, ’cause what the Europeans are showing, and this may reverse, right, there may be Mu, which we can talk about, that will reverse it, but it seems like they get to open up.

– [Monica] They are really quite happy in Europe right, in most European countries right now.

– [Zubin] Now some Americans would say, on the libertarian end of the spectrum, well we can open up too, just means that we’re just gonna do what we do and there’s gonna be hospitals fill up, and that’s just what they do and too bad, and it’s mostly older people and minorities that are dying.

– [Monica] But it’s terrible. We can’t allow–

– [Zubin] See that’s the thing. So, then the doctors go but wait.

– [Monica] You can’t let people die.

– [Zubin] 96% vaccine rate in doctors, according to AMA surveys.

– [Monica] Yeah, that’s amazing.

– [Zubin] 96%. Now what does that tell you? I’ve said this before. Like if you were an insider trader in Wall Street, you would look for the insiders and you’d go, what are they doing? What do they know that I don’t know? What information do they hold close to the chest that if I had it, I would do much better in the stock market? Well, the doctors are like the insider traders of medicine, and they know something that the public may not have the capacity to know because they can’t parse the data, they can’t weed out misinformation, and they’re so politically divided. Now the doctors are politically divided too.

– [Monica] They are!

– [Zubin] They are, they really are. They really are. But the truth is they still can use the science, and go well I’m getting vaccinated. I don’t care what the politics are.

– [Monica] That’s amazing. That’s a really amazing statistic. That should make people feel they would like to get vaccinated. But again, maybe if you as a doctor who’s trusted are saying get vaccinated, and maybe if a doctor is getting up and saying, I’m not gonna tell you when your life’s gonna change, and don’t travel on Labor Day, and life is really yucky right now, and we’re not getting through this, and go get vaccinated, I just think all those five things you just said before, go get vaccinated, just you just lost your audience.

– [Zubin] They don’t understand human beings at all.

– [Monica] Yeah.

– [Zubin] And also you don’t understand science to some degree, because again, we were here saying Delta shmelta, this thing’s great. You had, well we’ll talk about that, but like you, and it would have been.

– [Monica] It would have been.

– [Zubin] It would have been.

– [Monica] Yeah.

– [Zubin] But so now, you had a friend with you. We should talk about this. Little Frodo, and–

– [Monica] It is the passage of life.

– [Zubin] It is the passage of life, and I think this actually relates to everything we’re talking about. So Frodo passed.

– [Monica] Frodo passed on August 7th.

– [Zubin] Frodo was 15 years old.

– [Monica] He was. He was an old dog.

– [Zubin] Was a beautiful soul. You can just feel it.

– [Monica] He was so beautiful. I know we’re gonna see him again.

– [Zubin] Yes, if not already.

– [Monica] Yes, yes.

– [Zubin] And so when you came and told me that, I was like ah, and you were like this is the circle of life. This is what happens.

– [Monica] Yes.

– [Zubin] You live, you have a wonderful life, you live your life to the fullest, and we all die.

– [Monica] We used to, I used to crawl on my hands and knees to give him like human food ’cause I loved him so much. So let me just tell you, he did actually have a good life, and right, the idea that there isn’t a passage of life actually, or the idea that we can keep ourselves safe from everything, that is not true. Like there is senescence, and there is death, and there is age, and there has something has happened in this country, I mean and maybe more in some certain parts of this country where we think we can have zero COVID, like your Australia, that we could have zero COVID. And then what happened in Australia is that people couldn’t see their relatives, and they got lonely, and there was depression, and there was anxiety, there was some suicides, there was a lot of overdose, there were people who had spent their whole life building a business, and their business died, and you have to put things into context. The best way to get through COVID is immunity, and we have to think about other things as well, and that means school closures and the risk on kids, suicide rates, weight gain. Did you see that JAMA article about how much weight gain occurred among children in our country?

– [Zubin] It was bad.

– [Monica] It was so high, and a lot of obesity, like not just the increase five pounds of weight gain, but a lot of pushing over our kids into obesity, and then a lot of pediatricians saying what’s gonna happen in terms of long-term problems with cardiovascular health, diabetes, hypertension, which by the way happened in 1918. We kept kids away from each other, and we closed schools, and then now we have the kind of hindsight thing, and you can see how many children died early. People who were born in 1918 died earlier than they would have ’cause of cardiovascular disease. There are studies on this. So you don’t want to, you want to put things in balance when you’re deciding about something, and yes, there are risks in life and we will actually all die, I’m so sorry to say it out loud, and we have to have balance in how we do things. School to me is a balance, it’s a complete balance. There are risks of getting COVID in schools, even though they’re really reduced by mitigation and teacher vaccination, and then there are terrible risks of closing schools for mental health and learning of children.

– [Zubin] And the truth is, if you want to protect, if you’re so worried about children getting COVID, which by the way, they’re low risk, but they can get sick, like it’s MIS-C, all these other things, vaccinate adults.

– [Monica] Yeah, vaccinate adults.

– [Zubin] This cocooning effect of vaccinated adults.

– [Monica] It’s so amazing how during this Delta surge, San Francisco, one point San Francisco Chronicle reported zero children in the hospital with COVID. We still aren’t vaccinating children, but we had enough teachers and adults vaccinated that there was zero at one point in time. That was different than in Missouri, because parents and teachers weren’t vaccinated.

– [Zubin] Right, or in that school in Marin where there was an unvaccinated teacher who took his mask off to read during a class and infected like the entire class.

– [Monica] Yeah. That to me proves, though, super spreading too.

– [Zubin] Yeah, it does.

– [Monica] Like there’s not, you know how we think every single person has COVID at all times and is spewing it out of their nose and mouth at all times? Inaccurate. There’s some super spreaders. That guy was a super spreader.

– [Zubin] That’s right. It also pointed out that the kids did just fine.

– [Monica] Yeah, yeah, yeah. They’re risk, yes.

– [Zubin] Low risk, yes. Yeah, I think that’s a key thing. Now less so, man there’s–

– [Monica] At one point where to do poor versus rich.

– [Zubin] Let’s do that now before we talk about Mu.

– [Monica] Well when we talk about like what school closures did, and I know there’s this kind of commentary that well the private schools got to stay open and the public schools didn’t. So right now, even now, San Francisco did this thing called modified quarantine where they said, if you have an exposure, stay out of school for a minute, but then get tested and then you can come right back, and you can shorten the quarantine, and all the private schools in San Francisco are doing that. They all have Binax tests, like they’re just totally prevalent, and if you have an exposure, you just quickly test out and you come right back to school.

– [Zubin] Right.

– [Monica] And San Francisco Unified School District is saying we don’t have the resources to do that so just stay out of school for 10 days.

– [Zubin] Yeah. They sent an entire class home recently ’cause of one case.

– [Monica] It’s so sad because this kind of again like poor verus rich equity thing. I keep on thinking the San Francisco I went to in 1996, like when I came here for residency, I came to San Francisco ’cause I thought it was a city that thought about the poor, but it was so, our COVID response was so favored the rich, and even the boosters actually because someone said well really do we care about global equity because, they didn’t say it that harshly, but they said, but I don’t want to get a cold.

– [Zubin] Yeah, it’s a cold

– [Monica] And I was like what San Francisco person wrote this to me, and I thought well but global equity, remember, we used to care about the world and we, apartheid, and so there’s something very differential about how our response affected the poor. It was so much harder on the poor.

– [Zubin] I agree. I came to San Francisco in 1994 after being in Berkeley from 1991 coming from the Central California, very conservative, and I was like oh my gosh, Berkeley, every is so open and such progressive ideas, and you go to San Francisco and oh, the people actually care about real justice and equity, and now it’s like, oh, it’s something has gone terribly wrong.

– [Monica] Something went so wrong that I get called. Now people aren’t getting as mad at me, but I used to, people used to get really mad at me in San Francisco ’cause they were like, some people would say oh you’re the voice of reason and then some people would say you’re just too cavalier, and I said, they said, where does this come from that you think that like it’s okay to open schools and stuff, and I said because I actually work with the vulnerable, and I work with the poor, and that’s what I do every day, and so my, I may feel differently than another public health official who doesn’t see how lockdowns were more difficult for the poor than the rich, and then now I think people have come around. What I mean by that is you didn’t see Delta close down the country again. Actually what it’s done is done vaccine passports, vaccine mandates, masks inside, made some people really scared, but the country didn’t close down again.

– [Zubin] Right.

– [Monica] And I think that was a deliberate thing.

– [Zubin] Right. I think you’re right. It’s an interesting thought experiment. I think we might’ve talked about this, you and I offline, that if Donald Trump had said, I know I said the T word, if Donald Trump had said, hey, you know what, we’re gonna give a third dose to Americans and screw these shit hole countries, like it’s about us.

– [Monica] That nationalistic.

– [Zubin] Yeah that sort of like this America first kind of thing, the left would have lost its mind.

– [Monica] They would have.

– [Zubin] They would have lost its mind. To prevent a cold? Like we’re already protected. Follow the science, Donald. Well now–

– [Monica] And they would have said we care about people in Sub-Saharan Africa. Like one city getting vaccinated here Botswana could the whole country could get vaccinated.

– [Zubin] That’s right, and it’s that city in Botswana say that generates the variant that’s gonna be the next thing.

– [Monica] Yes, yes, yes, yes. He would have been killed.

– [Zubin] He would have been eviscerated, but it’s done quietly, not so quietly with currently and people are just like yeah, of course. It’s so tribalized.

– [Monica] Yeah, it is.

– [Zubin] Can we look as objectively as we can, like both.

– [Monica] We have to look objectively. Yeah, we did something wrong.

– [Zubin] You and I have said things that are politically offensive to both sides of the aisle.

– [Monica] Yes, yes, yes.

– [Zubin] And we’ve changed our minds about certain things that would offend people that were formerly our friends. Why do we do that? Because we actually are looking for truth.

– [Monica] Yes. You just, if you follow truth, there’s actually a clearer thread that’s going through all of this and it’s actually about justice, and it’s about global equity, and it’s about safety for all, and there’s just this kind of thread, I think, that goes through all of this that makes you change your mind at certain points, and it’s terrible that we’re so tribalized that you get. I have never been so hurt as when I’ve been attacked by the left. I kind of thought I’d be attacked by the right, but I got so attacked by the left when I said it was okay to take off masks when you’re vaccinated, ’cause I wrote this Washington Post article saying that’s okay, this is why, and then I got so attacked by it. I wrote all these articles on school openings. I think I wrote 14. Then I stopped. I’ve just promised myself I’m not gonna write anymore because I’ve written in them, but I got so attacked by the left. I got so attacked. Emma Green from the Atlantic wrote this article that said liberals love their lockdowns, and she interviewed me and she said, was it painful? I said it’s so painful. Like I thought these were my peeps.

– [Zubin] Well to live in San Francisco, it is tough. I’ve had a similar phenomenon. What I’ve found is it pushes people who are just critically thinking, who have a lot of progressive values, right. Like we care about poor people.

– [Monica] Poor, addicted, homeless.

– [Zubin] That’s right.

– [Monica] Yeah.

– [Zubin] And but, and then I have this also bias, like I’m kind of a little bit of a capitalist because I ran a clinic and I think that we can kind of transform healthcare through proper capitalism. We’ve done it all wrong. So I have these other ideas, but it pushes me, the left pushes me more to what I call the alt middle, which is where I want to live anyways, but it really is pushing people that are more rational way rightward, which is exactly the opposite of what they would want.

– [Monica] No, they don’t want that.

– [Zubin] They don’t want that, and yet their behavior is doing that. So I think at some point we’ll all wake up to the alt middle and go, let’s just look at issues. What do we care about?

– [Monica] Yes, independently, yes.

– [Zubin] What do we value? And you know what? That’s local. So like a small town in Texas has different values than San Francisco. It has to by definition, ’cause the environment’s different, the density is different, the culture is different, so we have to accept that. We can’t just paint it all with a brush and then the coast call the center stupid, and the center call the coast elites, and it’s like ah.

– [Monica] Then we’ll go back and forth in the elections between both parties every single four years, because it will push, and then people will be mad, and then they’ll vote this way, and then be like yeah, we’re not. Actually I do, I did think, well, this is going off into politics. I don’t do politics.

– [Zubin] We get that. You know what? That’s fair. I think you’re smart. You learned the hard way.

– [Monica] Like as you can see when I tweet, it’s all about COVID.

– [Zubin] Totally. Well now speaking of COVID, now we’re gonna enter one last controversial thing.

– [Monica] Okay.

– [Zubin] Ivermectin and therapies, things like monoclonals, ivermectin, now we’re talking about fluvoxamine, some data coming out saying hey, maybe that’s working, right. I’m actually connected to Angela Reierson who’s the psychiatrist who ran that study. I’m gonna talk to her. It’s really interesting because apparently they found that Luvox, fluvoxamine, had this kind of interesting effect even before the pandemic on inflammation, and so there’s a biological plausibility for it and there’s a pre-print, but again, I’ve been burned so many times now by therapeutics.

– [Monica] I don’t understand why you get burnt when you talk about therapeutics. That’s all we do for HIV is antivirals.

– [Zubin] Right.

– [Monica] When I talk about antivirals, ’cause I talk about them on like webinars and stuff, no one gets mad at me. I talk about the anti, I know the antivirals really well, and I love them.

– [Zubin] Yeah, yeah.

– [Monica] So I don’t understand why talking about therapeutics would ever be controversial.

– [Zubin] So there isn’t a protease inhibitor mafia that comes at you on YouTube for questioning the data.

– [Monica] No, they’re like oh, darunavir and atazanavir. So I’ve never understood this anger, I guess.

– [Zubin] Yeah, so what’s your take on the data so far on ivermectin? Have you looked at it or no?

– [Monica] So I looked at it some. This is how I see, I guess, the therapeutics. I think I’m more excited about monoclonal antibodies. I think they really work.

– [Zubin] For sure. Even against variants?

– [Monica] Yes, though I think it’s combination, monoclonal antibodies not just like against one part of the spike protein.

– [Zubin] Got it.

– [Monica] Kind of want more than one monoclonal antibody putting in together, and yes, they work against variants and I think it’s really good for treatment. So like if you think about us turning this into an endemic respiratory virus, there will be some people who will need third shots, there will be some people in the future who will need more shots, there will be some people who will get a cold and they won’t even notice, there will be some people who will come to medical attention ’cause they feel like they have the flu, and we’ll do COVID testing, and we’ll do flu testing, and we’ll give Tamiflu to this person and send them out for flu, and we’ll give molnupiravir to this person and send them out with COVID. So we won’t give another vaccine likely ’cause that’s preventative. We’re gonna give them a treatment. So I think antivirals are the most effective and the ones I’m most excited about. That’s why I like molnupiravir, and unfortunately the company didn’t work with like big clinical trial settings like what ACTG was doing, so they’re just kind of on their own, so it’s taking a while. I’m excited about molnupiravir. I’m excited about monoclonal antibodies ’cause they’re more directed, and molnupiravir is a nucleus, it’s gonna be directed against the virus. Ivermectin I think is fluvoxamine, anything that’s anti-inflammatory makes sense to me.

– [Zubin] Right.

– [Monica] Ivermectin I think looked like it worked in vitro. The clinical trials to me did not convince me as much, and using that kind of so non-specific of an anti-inflammatory doesn’t seem as good as like going for an antiviral that is directed against the virus. So I’m not interested, or I’m not, I have never prescribed nor am I excited about ivermectin. The shaming though, and the mean thing, and the horse thing, and is really ridiculous I think because you and I, again, as people who have traveled globally, like ivermectin’s a super important human product for helminths worldwide, so don’t like, yeah, so don’t be.

– [Zubin] Don’t be hating on–

– [Monica] It’s that shame thing. It’s so like you’re not a horse. That’s a horrible message is you are not a horse. A human being is aware that they’re not a horse.

– [Zubin] Yeah, yeah, yeah.

– [Monica] But you just can’t get it, and so people thought it would be helpful and you can get it from the veterinarian world. Anyway, that’s going back. Let’s do kind messaging. So, but I’m more excited, and I need, I want that finishing of the phase three clinical trial, molnupiravir. And then fluvoxamine I was interested in for long COVID.

– [Zubin] Yeah, yeah.

– [Monica] But I don’t know enough about it.

– [Zubin] Yeah, I don’t know enough about it yet, but we may talk more about it. Be interesting, yeah. And again, ’cause you have to be careful because the minute you start talking about these things and they’re not really shown, there’s a run on the stuff, and people are popping Luvox, and they’re getting side-effects, right, ’cause not–

– [Monica] Yeah, and ivermectin has quite a few actually.

– [Zubin] If you overdo it for sure, yeah, yeah. I think my biggest difficulty with the whole ivermectin process, like I from beginning I said let’s study it, let’s see if it works, but there are some evangelists for it who have basically fallen into an anti-vaccine stance. They’re like well you could just give everyone ivermectin. This is a miracle drug, Pierre Kory and these guys, and they’ve associated directly or indirectly with this anti-vaccine kind of movement. They show up on the big podcast saying this stuff, and I think that’s harmful.

– [Monica] Very harmful, but wouldn’t you rather be preventative than a treatment? I mean isn’t that true for everything.

– [Zubin] Well and that gets to the cognitive dissonance of well I don’t want a injection, but I’ll take–

– [Monica] Something that can make me sick.

– [Zubin] Yeah, ridiculous non-quite approved dose of a drug that we think in some observational data may show some promise but then–

– [Monica] Prevention is always better.

– [Zubin] Prevention is better.

– [Monica] But because it’s gonna be endemic, we do need some good treatments.

– [Zubin] Exactly.

– [Monica] And those are the antivirals.

– [Zubin] Like flu.

– [Monica] We have Tamiflu here, molnupiravir here.

– [Zubin] I love it.

– [Monica] That’s the future.

– [Zubin] I love it. And then we have inpatient management with dexamethasone and remdesivir.

– [Monica] Remdesivir and dexamethasone, yes.

– [Zubin] What else did you want to talk about?

– [Monica] I want to say to people that when, I just wrote this thing in the San Francisco Chronicle that said immunity will get us through a pandemic but I don’t think we’re gonna eradicate Delta.

– [Zubin] Right.

– [Monica] And I got people saying that was really upsetting to me that the eradication, that you said that we couldn’t eradicate it, and I thought–

– [Zubin] Who set the expectation?

– [Monica] Yeah, and I thought that is what happened maybe, and maybe with the booster conversations, that thinking that you could take such a transmissible virus, especially when it got into Delta, which is 1,000 times, well, much more transmissible.

– [Zubin] Right.

– [Monica] That we could that setting that expectation will make people think only when there is a zero case out there can I go outside my house, and you can actually live really well with a controlled virus. Like I keep on thinking about measles, but like you and I hear about measles ’cause we’re doctors, but the public never goes on the LA Times website and see how many cases there are of measles, because number one, we don’t do asymptomatic screening for measles, but we’ve managed to get it under control. So living with a controlled respiratory virus, which is what measles is too, is a very happy way to live and I know we’re gonna get there. We are gonna get there, and the way to get there is stop having so much terrible global vaccine equity so we can’t get another terrible variant that somehow is even more transmissible than Delta, which I don’t know if you could be, and give it to everyone and then we’ll get there. So, you wanted to finish with the Mu variant. I mean it is a variant that people are watching, but also the problem with saying that it looks like it’s immune resistant is the most sort of shallow view of the immune system. So antibodies, tip of the iceberg, they’re gonna go down. It didn’t look like it responded so well in vitro to some antibodies, but the memory B cells that get created will adapt themselves towards the variants, adapt the variants of the antibodies they make towards the variants, and the T cells are so complex. The way I describe it is there is like 100 houses across a spike protein, and a T cell is a tea cozy that comes over each of those houses and totally like protects them.

– [Zubin] Right.

– [Monica] And then if you have 13 variant mutations from Delta or 14 from Mu, it turns around 14 of those houses so those T cells don’t work, but you still have so many T cells coming down to protect that neighborhood. So it’s gonna be impossible for us to get a variant that evades our entire T cell immunity ’cause it’s so complex, in breadth, and robust across the spike protein.

– [Zubin] Right, right, and the net result may be you get an infection that’s mild but you don’t die.

– [Monica] Mild, yes, because of the T cell immunity from the vaccine. So don’t worry so much about the Mu variant. Just worry about getting more people vaccinated.

– [Zubin] Man.

– [Monica] And that’s what we’re trying to do with our good, honest, changes at time, science-based message.

– [Zubin] That has hope.

– [Monica] You and I hope.

– [Zubin] Son, we’ve been at this during the whole game. I was just thinking as you were telling me about the tea cozies, I was sitting here, and I was feeling this like wonderful love for you, Monica Gandhi, because from the very beginning, like you’ve come here, you’ve had a smile.

– [Monica] Sometimes I had Frodo.

– [Zubin] Frodo who we, I would pour some out, but I’ll end up damaging my equipment, and–

– [Monica] I know I’m gonna see him again.

– [Zubin] Yes. We know it.

– [Monica] Water.

– [Zubin] And that’s the thing, that’s the other thing. Like, there are fates worse than death, and that means we must live our life with love and joy, and you have been a beacon of that, a beacon of hope and a beacon of truth, and you’re not afraid to change your mind when things change, and any time you want to come on the show, all you have to do is just, there’s a Z, there’s a Z signal that launches onto the fog. I see a Z and someone’s in danger. Monica, what do we need to do? And you come on the show.

– [Monica] Because it’s so much sunnier down here than in San Francisco.

– [Zubin] Right?

– [Monica] So I hate that fog, so I’m here also to go and wander around right after this.

– [Zubin] I’ll tell you all the great restaurants. That’s why I moved down here because I was in the inner sunset for so long, and I just start getting depressed. I got like seasonal effective.

– [Monica] We’re Indian. We need the sun.

– [Zubin] Give us the–

– [Monica] It’s in our blood.

– [Zubin] Vitamin D.

– [Monica] Vitamin D. We need sun.

– [Zubin] We need it.

– [Monica] Thank you.

– [Zubin] Such a pleasure, guys. Just share the show. I love you so much. We are out. Peace.