What if masks acted to reduce severity of COVID-19 infection for the WEARER, fostering immunity like a vaccine and allowing a full societal reopening?
Dr. Monica Gandhi is a UCSF professor of Medicine in the division of HIV, infectious diseases, and global medicine. She and her colleagues recently proposed just such a theory in the New England Journal of Medicine. In this fantastic interview she outlines the emerging data in support of the idea that masks may do more than we think.
Here’s a NY Times piece about her proposal, and here’s a paper she co-authored in the Journal of General Internal Medicine.
And here’s my piece on masks that summarizes some of Dr. Gandhi’s work.
Full Transcript Below (in the tab after the references)
References (directly from Dr. Gandhi):
Viral inoculum theory: Higher viral inocula or “dose” linked to severity of disease
Well described in animal studies and some human studies for respiratory and GI illnesses -higher infective dose thought to lead to faster/greater pathogen replication, leading to a more aggressive and damaging innate inflammatory response, or overwhelming adaptive immune response- all leading to more severe disease. This is a hypothesis for diseases in which immunopathology plays a role in viral pathogenesis, such as COVID-19 (Rouse BT, Sehrawat S. Immunity and immunopathology to viruses: what decides the outcome? Nat Rev Immunol. 2010;10(7):514-526)
Some evidence for the “viral inocula” theory for SARS/MERS. Evidence in SARS-CoV-2 fom degree of illness in household contacts/ health care workers at beginning of pandemic. Papers supporting viral inoculum theory.
- Guallar MP, Meiriño R, Donat-Vargas C, Corral O, Jouvé N, Soriano V. Inoculum at the time of SARS-CoV-2 exposure and risk of disease severity. Int J Infect Dis. 2020 Aug;97:290-292. doi: 10.1016/j.ijid.2020.06.035.
- Little P et al. Reducing risks from coronavirus transmission in the home—the role of viral load. BMJ 2020;369:m1728 doi: 10.1136/bmj.m1728
- Ryan KA. Dose-dependent response to infection with SARS-CoV-2 in the ferret model: evidence of protection to re-challenge. bioRxiv 2020.05.29.123810; doi: https://doi.org/10.1101/2020.05.29.12381
- Imai M et al. Syrian hamsters as a small animal model for SARS-CoV-2 infection and countermeasure development. PNAS Jul 2020, 117 (28) 16587-16595; DOI: 10.1073/pnas.2009799117
- Van Damme W et al. COVID-19: Does the Infectious Inoculum Dose-Response Relationship Contribute to Understanding Heterogeneity in Disease Severity and Transmission Dynamics? DO – 10.2139/ssrn.3649975. SSRN Electronic Journal
- Karimzadeh, S.; Bhopal, R.; Nguyen Tien, H. Review of Infective Dose, Routes of Transmission, and Outcome of COVID-19 Caused by the SARS-CoV-2 Virus: Comparison with Other Respiratory Viruses . Preprints 2020, 2020070613
- Han A, Czajkowski LM, Donaldson A, et al. A Dose-finding Study of a Wild-type Influenza A(H3N2) Virus in a Healthy Volunteer Human Challenge Model. Clin Infect Dis. 2019; 69(12): 2082–90. http://dx.doi.org/10.1093/cid/ciz141
- Memoli MJ, Czajkowski L, Reed S, et al. Validation of the wild-type influenza A human challenge model H1N1pdMIST: an A(H1N1)pdm09 dose-finding investigational new drug study. Clin Infect Dis. 2015; 60(5): 693–702. http://dx.doi.org/10.1093/cid/ciu924
- Watson JM, Francis JN, Mesens S, et al. Characterisation of a wild-type influenza (A/H1N1) virus strain as an experimental challenge agent in humans. Virol J. 2015; 12: 13. http://dx.doi.org/10.1186/s12985-015-0240-5
- Teunisab P. High infectivity and pathogenicity of influenza A virus via aerosol and droplet transmission. Epidemics 2010.https://doi.org/10.1016/j.epidem.2010.10.001
- Glynn JR, Bradley DJ. The relationship between infecting dose and severity of disease in reported outbreaks of Salmonella infections. Epidemiol Infect. 1992;109:371–388.
- Paulo AC, Correia-Neves M, Domingos T, Murta AG, Pedrosa J(2010) Influenza Infectious Dose May Explain the High Mortality of the Second and Third Wave of 1918–1919 Influenza Pandemic. PLOS ONE 5(7): e11655. https://doi.org/10.1371/journal.pone.0011655
- Virlogeux V, Fang VJ, Wu JT, et al. Brief Report: Incubation Period Duration and Severity of Clinical Disease Following Severe Acute Respiratory Syndrome Coronavirus Infection. Epidemiology 2015; 26(5): 666-9.
- van den Brand, J.M.A., et al., The Pathology and Pathogenesis of Experimental Severe Acute Respiratory Syndrome and Influenza in Animal Models. 2014. 151(1): p. 83-112
- Sutton, T.C. and K. Subbarao, Development of animal models against emerging coronaviruses: From SARS to MERS coronavirus. Virology, 2015. 479-480: p. 247-258. 10.1016/j.virol.2015.02.030
- Donnelly CA, Ghani AC, Leung GM, et al. Epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in Hong Kong. Lancet. 2003;361(9371):1761–1766
- Cowling BJ, Muller MP, Wong IOL, et al. Alternative methods of estimating an incubation distribution: examples from severe acute respiratory syndrome. Epidemiology. 2007;18(2):253–259
- Marois I, Cloutier A, Garneau É, Richter MV. Initial infectious dose dictates the innate, adaptive, and memory responses to influenza in the respiratory tract. J Leukoc Biol. 2012 Jul;92(1):107-21. doi: 10.1189/jlb.1011490. Epub 2012 Apr 13. PMID: 22504848.
- Nishiura H, Halstead SB. Natural history of dengue virus (DENV)-1 and DENV-4 infections: reanalysis of classic studies. J Infect Dis. 2007;195:1007–1013
- Taylor DN, Bopp C, Birkness K, Cohen ML. An outbreak of salmonellosis associated with a fatality in a healthy child: a large dose and severe illness. Am J Epidemiol. 1984 Jun;119(6):907–912.
- Reed LJ, Muench H. A simple method of estimating fifty per cent endpoints. The American Journal of Hygiene. 1938;27(3):493-7.
- Casadevall A. The Pathogenic Potential of a Microbe. mSphere 2017; 2(1)
- K.W.F. Jericho , G.C. Kozub. Experimental infectious respiratory diseases in groups of calves: Lobar distribution, variance, and sample size requirements for vaccine evaluation The Canadian Journal of Veterinary Research2004; 68:118 -127
- Bouvier NM, Lowen AC. Animal Models for Influenza Virus Pathogenesis and Transmission. Viruses 2010; 2(8): 1530-63
- Tao X, Garron T, Agrawal AS, et al. Characterization and Demonstration of the Value of a Lethal Mouse Model of Middle East Respiratory Syndrome Coronavirus Infection and Disease. J Virol 2016; 90(1): 57-67.
- Roberts A, Deming D, Paddock CD, et al. A mouse-adapted SARS-coronavirus causes disease and mortality in BALB/c mice. PLoS Pathog 2007; 3(1):
- Niederwerder MC, Stoian AMM, Rowland RRR, etal . Infectious dose of african swine fever virus when consumed naturally in liquid or feed. Emerg Infect Dis 2019;25:891-7. 10.3201/eid2505.181495 30761988
- McKenney DG, Kurath G, Wargo AR. Characterization of infectious dose and lethal dose of two strains of infectious hematopoietic necrosis virus (IHNV). Virus Res 2016;214:80-9. 10.1016/j.virusres.2015.12.020 26752429
- Roberts A, Lamirande EW, Vogel L, etal . Animal models and vaccines for SARS-CoV infection. Virus Res 2008;133:20-32. 10.1016/j.virusres.2007.03.025 17499378
- Bower H, Smout E, Bangura MS, etal . Deaths, late deaths, and role of infecting dose in Ebola virus disease in Sierra Leone: retrospective cohort study. BMJ 2016;353:i2403. 10.1136/bmj.i2403 27188404
- Couch, R. B., et al. “The minimal infectious dose of adenovirus type 4; the case for natural transmission by viral aerosol.” Transactions of the American Clinical and Climatological Association 80 (1969): 205
- Saliba, Gilbert S., Sylvia L. Franklin, and George Gee Jackson. “ECHO-11 as a respiratory virus: quantitation of infection in man.” The Journal of clinical investigation 47.6 (1968): 1303-1313.
- Yezli, Saber, and Jonathan A. Otter. “Minimum infective dose of the major human respiratory and enteric viruses transmitted through food and the environment.” Food and Environmental Virology 3.1 (2011): 1-30
- Atmar, Robert L., et al. “Determination of the 50% human infectious dose for Norwalk virus.” The Journal of infectious diseases 209.7 (2014): 1016-1022.
- DeVincenzo, John P., et al. “Viral load drives disease in humans experimentally infected with respiratory syncytial virus.” American journal of respiratory and critical care medicine 182.10 (2010): 1305-1314
- Mills, John, et al. “Experimental respiratory syncytial virus infection of adults: possible mechanisms of resistance to infection and illness.” The Journal of Immunology 107.1 (1971): 123-130.
- Lee, F. Eun-Hyung, et al. “Experimental infection of humans with A2 respiratory syncytial virus.” Antiviral research 63.3 (2004): 191-196
- Hendley, J. Owen, William P. Edmondson Jr, and Jack M. Gwaltney Jr. “Relation between naturally acquired immunity and infectivity of two rhinoviruses in volunteers.” Journal of Infectious Diseases 125.3 (1972): 243-248.
- Ward, Richard L., et al. “Human rotavirus studies in volunteers: determination of infectious dose and serological response to infection.” Journal of Infectious Diseases 154.5 (1986): 871-880.
- Engelking HM, Leong JC. The glycoprotein of infectious hematopoietic necrosis virus elicits neutralizing antibody and protective responses.Virus Res 1989; 13(3): 213-30
- S.E. LaPatra, J.L. Fryer, J.S. Rohovec. Virulence comparison of different electropherotypes of infectious hematopoietic necrosis virus. Dis. Aquat. Org., 16 (1993), pp. 115
- Kim R, Faisal M. Comparative susceptibility of representative Great Lakes fish species to the North American viral hemorrhagic septicemia virus Sublineage IVb. Dis Aquat Organ 2010; 91(1): 23-34.
- Brown JD, Stallknecht DE, Berghaus RD, Swayne DE. Infectious and lethal doses of H5N1 highly pathogenic avian influenza virus for house sparrows (Passer domesticus) and rock pigeons (Columbia livia). J Vet Diagn Invest 2009; 21(4): 437-45
[Dr. Z] Hey everybody, Dr. Z. Welcome to The “ZDoggMD Show.” Today I have somebody I’ve been wanting to talk to you forever. Ever since her work actually changed my mind about the utility of masking. This is Dr. Monica Gandhi. She’s an infectious disease doctor and professor of medicine at the University of California, San Francisco, my Alma mater. Let’s just jump into it. Monica, thanks for trekkin’ down.
[Dr. Monica Gandhi] Thank you for having me.
[Dr. Z] What’s up with the air quality man? I feel like I need to wear a mask just to be able to survive.
[Dr. Monica Gandhi] But then you need to wear a mask with a filter, but then that doesn’t help people with like, you know, COVID. And so it’s terrible, I don’t know what to wear.
[Dr. Z] Yeah, right. One of those like venty ones.
[Dr. Monica Gandhi] Yes.
[Dr. Z] Yeah, exactly
[Dr. Monica Gandhi] It’s terrible.
[Dr. Z] So, you know, you started talking about masks in a way that I had not heard anybody talking about. And it started with me for this. So COVID starts, everyone’s like “Okay, don’t wear a mask. “Don’t wear a mask, WHO, CDC,” because they presumably wanted to save them for health care professionals, right?
[Dr. Monica Gandhi] Right, right.
[Dr. Z] Was that the only reason?
[Dr. Monica Gandhi] You know, it’s very interesting. So I think that was the main reason because it’s true that we suddenly had this crisis and health care workers truly were really close to people. And there were people who were dying. Truly, there were health care workers who are dying. That’s actually the ophthalmologist in Wuhan who was the whistleblower who blew this later died. So very close contact with people who have an infectious disease is deadly. And so it was fair to say that at the beginning. But then what I realized about masks, and I think this is, this is different than the typical like it may prevent you from spreading it to others. Is this question of could masks still actually allow you to get some virus, but just enough. And what I mean by that is masks actually don’t totally protect you from infectious diseases. There’s no way that you can say that. There’s no way that a cloth mask or a surgical mask totally blocks out 95% of all viral particles. It doesn’t. N95 masks do. They’re super type fitting, they’re super uncomfortable, and they’re super tight. And these kind of cloth masks that the CDC asked the public to wear an April 3rd does not filter out all the virus. But they may do something else, and they may filter not all of it, but a certain amount so that if you get sick you don’t get as sick. And we can talk about that. But yeah, you’re right. It was confusing messaging about masking at the beginning.
[Dr. Z] Right. And then okay, so we’re going to get into this. So what happened with me is I saw this messaging and I said, “Okay, I get it. “I understand it ’cause if I’m in a hospital, “I’m 1,000% gonna wear a mask “because we know what the mass do “in close quarters,” like you said. And Dr. Lee, I think was his name, the Wuhan–
[Dr. Monica Gandhi] Ophthalmologist.
[Dr. Z] Ophthalmologist. Now ophthalmology, you’re in people’s faces, and you’re getting a massive load, potentially, of Coronavirus if you’re there on the front lines, which he was. And he died, he was only 33, no other medical problems.
[Dr. Monica Gandhi] Right, right.
[Dr. Z] And even in those days I was talking to Peter Hotez about this on the show. Could it be that inoculum, how much you get, actually may be correlated to severity of disease? And then CDC was saying, “Well, don’t do this.” Ah, okay. Then they said, “Well any kind of cloth mask will do.” And at that point, I thought, “Well, it’s gonna encourage people to touch their face. “It’s gonna encourage a lack of social distancing. “It’s gonna do all these things, “and it’s not gonna actually filter virus “and you’re gonna get viral particles and you’re gonna die.” But I started to see the light on this as I started reading about your work, and actually looking at some of the emerging data. So how did you come to this sort of understanding?
[Dr. Monica Gandhi] So when the CDC put out their recommendations on April 3rd, they said it in this way. They said, “Wear masks to protect others.” Now, by the way, that is not a good message to get everyone to mask because by definition human beings, you know, wanna protect themselves. And that’s really okay. It’s really okay to say that, “I may not wanna wear a mask “when all you’re telling me to do is protect others.” Like, you know, we are evolutionary creatures, and we wanna protect ourselves. So that messaging actually was sort of unevenly followed, right? It was like, people would say, “I don’t even know you’re talking about, “and I’m not gonna wear this.” And also, then there was this idea among many others that, “You’re telling me it doesn’t filter everything out, “and then you’re telling me to wear it. “None of this is actually making sense.”
[Dr. Z] 1,000%, and people–
[Dr. Monica Gandhi] It didn’t, it didn’t make sense.
[Dr. Z] Worst messaging in the history of messaging.
[Dr. Monica Gandhi] It was a terrible message because you’re saying, “Okay, “you only care about other people. “It’s not gonna help you at all.” And then you’re also saying, “It’s kinda gonna help you, “but actually cloth is not effective.” So it was truly confusing. But then what I was watching with this infection, and this is the most amazing thing about this infection is how much asymptomatic infection there is. That is so weird. Like a Ebola, you get Ebola you die. Like, Ebola, 90% get sick. Influenza, if you get a certain amount, you get sick. Like people are sick with bad viruses, bad viruses that cause a ARDS make them sick. SARS made people sick, the first one. What is this virus? This is so weird. It was like 40% were totally well and felt great. And then like people died. This is a completely protean manifestation to have such a wide spectrum of disease. It was so strange. And so what was it that was making so many people so fine and making so many people so sick? And you would say, “Oh okay, that’s all “’cause like the old people got sick and that’s why.” As you pointed out, that’s not accurate. It wasn’t just old people who got sick. It was people who seem to have been in close quarters with other people. It was young healthcare workers or someone who was in someone’s face or in a household where someone was really sick. They’d get really sick. And this inoculum idea, it became a profound like revelation that it seems like, “Of course the amount of virus that you get “should be possibly related to where you get sick.” And so then I started to look up, “Okay, “well that must have been known, right? “Like you look up the literature, “it must be viral inoculate and you get sick, “and this has been seen in multiple diseases.” And it actually hasn’t been written that much about. It’s quite surprising. It’s totally known in the animal literature. In the animal models, in the vet literature, they knew, they always did. Even animal models, that the more virus you get, the more sick the animals get. And in fact, there’s this LD 50, this lethal dose 50 concept, LD 50, which is the dose at which 50% of animals die if you spray it into cages.
[Dr. Z] Even that such a concept exists speaks to the inoculum effect.
[Dr. Monica Gandhi] Exactly right. And the first paper that looked at this is called, they actually called it the Reed & Muench theory because it was published in 1938. And they had like poor mice and they sprayed, you know, a virus in there and 50% of them died at a certain dose. So the idea of dose and how sick you became was actually always there. It’s just that somehow, why have we not talked about it that much? Because we haven’t been in a pandemic since we started writing. It’s been, like a really bad pandemic was 1918. And then all these other pandemics, they actually go away. And then things like HIV which is a true pandemic, if you really look at the literature, the more virus you get, the more sick you get. So if you get a big dose of virus from an IV infusion, you get super sick. You get a dose of Hepatitis C from an IV infusion and you get super sick. It may actually make you clear out ’cause you get a super sick response and then you clear it. But if you get a little bit of Hepatitis C, you don’t get that sick from sex. So this is known in other diseases, sexually transmitted diseases, GI. If I drink a bowl of norovirus, I get super sick. If I have it sprinkled on my lettuce I don’t get as sick.
[Dr. Z] So this is true in HIV too?
[Dr. Monica Gandhi] This is true in sexually transmitted diseases, gastrointestinal viruses, and respiratory viruses.
[Dr. Z] And you’re the director of Ward 86 at San Francisco General?
[Dr. Monica Gandhi] Right, which is the big HIV clinic there.
[Dr. Z] And that’s where I trained in my fourth year of doing sub-i.
[Dr. Monica Gandhi] Oh, you did? You were at Ward 86? It is a great place In ’97. It’s such a wonderful place to learn.
[Dr. Z] It’s a very wonderful place.
[Dr. Monica Gandhi] And a beautiful population of patients that need us.
[Dr. Z] That’s right, that’s right. So vulnerable, yeah.
[Dr. Monica Gandhi] Again, and I’m just gonna say this to camera real quick, for the people who don’t know what Dr. Gandhi’s bonafides are, she is really a top notch physician, researcher, and she understands infectious diseases. So, you know, back to what we’re talking about. So this idea of inoculum, in 1918, when you had this first wave of flu, a bunch of people died. But then the second wave, when troops came back, explain that from an inoculum theory what happened there?
[Dr. Z] That was so weird and interesting in a way, right? Because usually with a second wave of infection, and we’re seeing this right now with SARS-CoV-2, people get less sick. Because they get less sick ’cause there’s immunity in the population. Which is, by the way, okay to say, and we’ll talk about this later. People get immune from viruses, and that is really okay. Herd immunity is okay. And I really.
[Dr. Monica Gandhi] Thank you! I’ve been saying this too.
[Dr. Z] I wanna talk about that because I think it’s really strange how that word has become politicized.
[Dr. Monica Gandhi] Politicized and co-opted in a way. It’s an infectious disease principle, right? So we need to come back to that place.
[Dr. Z] 1,000%
[Dr. Monica Gandhi] But going back to 1918, what was very strange is that the second wave of infection there should have been more immunity in the population. By definition, people get less sick. Not only does it spread less, but if you have some immunity and you get a second dose, then you just seal it off and you’re asymptomatic and you get better. So it should’ve been that this first wave looks like this big peak, and then the second wave should’ve been less mortality.
[Dr. Z] Smaller.
[Dr. Monica Gandhi] But instead, it was the opposite effect. And it was all superimposing on history what was happening, that we were overcrowding, it was World War One, people were all close together, people are close together here in this country as they were making things for the troops, the troops were all close together and there was an overcrowding effect. And this paper that we cite in our paper, that “PLOS ONE” paper in 2010, postulated that the reason for the second wave having higher mortality was because there was more crowding. And that totally speaks to the inoculum theory, as you say. So does people in households getting more sick. So do build, lived in environments in Queens and Bronx boroughs, people getting more sick in New York City than people in Manhattan who could stay away from each other and who could sit in their homes, they got more sick. They were hospitalized at high rates. It’s called the built environment. They had more overcrowded conditions. All of this speaks to the theory.
[Dr. Z] Let’s talk about that more because 60, what is it? 60%? I forget if the cases in California are in the Latino, Latina population.
[Dr. Monica Gandhi] Correct.
[Dr. Z] And it is 30% of our population. Now, does that speak to crowding in those populations? The fact that they’re essential workers are still going to work that are, they’re getting larger inoculums. What’s going on here?
[Dr. Monica Gandhi] That is exactly what it speaks to. So, for example, there was a mass testing campaign that Dr. Havlir and Chamie and Marquez people did at UCSF. Then I was participating in the calls to people afterwards to tell them that they had COVID. And when you ask them their living situations, they were very crowded. They were in San Francisco, crowded where you’re living in kind of like an apartment that it was not meant to be apartment for multiple families.
[Dr. Z] You mean like my medical school experience?
[Dr. Monica Gandhi] Yes, where we were like Porta was really.
[Dr. Z] 30 Irving Street, yeah.
[Dr. Monica Gandhi] Very, yeah, like 30 Irving Street. And I lived right by you. And so we all had to be on top of each other because we were crowded, built environment. And so San Francisco, by definition, so expensive people are living in very crowded environments. You don’t actually even know the people with whom you’re sharing a bathroom ’cause the other family is next door. And all that overcrowding and all that built on top of each other. Of course, that’s where we got the illness. And it’s not just that, like their cases are in Latinx, the illnesses are Latinx population. So when we talk about severity of disease, going back to that question who gets super sick with the virus, I think it’s the people who got a high inoculum. New York, by definition, is people on top of each other. It’s so much population density. We didn’t actually mask at the beginning. Not that we didn’t know about masking, but because of these confusing messages and because it’s been a long time since 1918. So masking wasn’t part of our public health strategy in March. And so people got on top of each other, there was a lot of inoculate, and there was so much illness. And Italy, same thing.
[Dr. Z] Italy as well, same thing. Let me ask this question then. So in the slums of Mumbai, it’s been sort of documented, there almost an 80% prevalence, or 60 or 80% in those slums. Now those guys are not distancing. Why are they not all dying? Because the death rate was quite low.
[Dr. Monica Gandhi] I actually find that really interesting. And you know what I think it is, but I don’t know this for sure? I think it’s the dupatta. I honestly think it’s like, if there’s anything that you have in the slums, it’s an ability to take to cover with a simple cloth mask. That is the only thing you could do. You can’t sit in your little slum and do your like tech thing from home. You can’t like, you know, socially distance. But what you can do, and absolutely is being done in India, we cover our mouths and noses in India anyway because of the smog. We have so much cloth. It’s like part of our national costume no matter who you are. I think it could be, this is just my theory, I think it could be that was the only modality of self protection. And if you cover your mouth and nose and you get in less viral, inocula do you not get as sick? And do you not have as high rate of deaths? There’s clearly been profound exposure in Mumbai in the slums. That’s my theory.
[Dr. Z] And I think, now let’s clarify this for people who are listening, this is all theory at this point because we have circumstantial evidence, we have some data but it’s observational, we have some ideas, it makes biological plausibility. But again, people will push back and they have. You had a “New York Times” piece come out, and you do you get a virologist from somewhere and a virologist from somewhere saying, “Well, it’s an interesting theory but I don’t know. “You see, I’m a little skeptical,” which you should be. But here’s the thing, you’re talking about masks now. ‘Cause when we talk about masks, what’s the downside of this in terms of if we’re saying, “Well, maybe masks lower the amount of virus you get, “which means if you get sick at all, “you may be asymptomatic.” Like you said, it’s a spectrum, this protean spectrum. If you get less dose, you may develop immunity, and then not get ever very sick from it. And all it took was putting a piece of cloth or whatever on your face in places you can’t socially distance. That’s the bargain on hand here. Now the question that, immediately before we get into that, I think a lot of people who hate masks and I think partially this is an emotional, moral thing. How dare you tell me what to do in my own town, with my face, et cetera. And I totally am sympathetic to that because I’m a bit of a contrarian. And when people tell me to do stuff, I don’t wanna do it, which is why mass mandates and I are always, they don’t really settle right. I think people should just do the right thing with the right messaging, but we haven’t had that. So the question is, what’s the harm of an individual putting a mask on. Am I gonna, you know, not get immunity to things that I need immunity? Is it gonna affect my immune? You know, all these things that people say, let’s debunk that first, before we get into the–
[Dr. Monica Gandhi] Yes, so I think it’s fair to say that the thing that I’ve been really interested in masking is that whatever you wear should be comfortable and acceptable to you. So this idea that like a tight thing, that’s actually really uncomfortable. I don’t think that people should wear N95s. I think it should be whatever kind of works for you, bandana, and neck gaiters as well, by the way, ’cause there was some press on that, but I believe anything that blocks in, you know, getting virus into your mouth and nose will either prevent you from getting the infection. Or if you do get enough viral particles you’ll still get infected, but you’ll get mild disease rates, symptomatic infection. I really believe that. It’s totally a theory, but I think there’s been a lot of observational evidence around it.
[Dr. Z] And we’re gonna talk about that evidence, yeah.
[Dr. Monica Gandhi] So that kind of comfort, whatever works for you and making it comfortable. I also think, and I’m with you that yelling at people to do the right thing is not a helpful or acceptable. And I’m an HIV doctor by training. That’s my entire life. I’ve done it for so long, for 20 years, and Ward 86 means a lot to me, and I’m privileged to be the medical director there. I would never tell anyone either to wear a condom, either. I will maybe stress before we had prep, and before we had a treatments, prevention, and other ways to prevent HIV without a condom. I would talk about condoms, and I would like talk about them and pros and cons and, you know, but I would never, you can’t yell at people. I think it’s harm reduction principles 101 is you’ve just alienated someone if you’ve shamed them or yelled at them. So I also agree with you that I don’t believe that we should be shaming anyone or ever call anyone stupid or say wear a damn mask or like all, or even more like wear an F mask. I think there’s just, a lot of people have Twitter handles that I think are really not helpful.
[Dr. Z] Counterproductive.
[Dr. Monica Gandhi] It’s just counterproductive.
[Dr. Z] They come off as preachy. They come off as disconnected. And if you disagree with any of their dogma, suddenly you are ex-communicated from the tribe of medicine. And we’ve seen that.
[Dr. Monica Gandhi] Yes, we’ve seen that.
[Dr. Z] So what happens to the average Joe who’s already skeptical because of miscommunication from government entities.
[Dr. Monica Gandhi] Which is what happened, right?
[Dr. Z] Which is what happened. And now there’s some ding-dong on Twitter going, you know, “Hey, I’m a ZDogg “wear a mask or you’re a loser, dummy, MD” And that’s why I, you know again, and I had to change my own stance on masks purely based on the emerging data, which you’re gonna walk us through. But the idea that shaming someone about this is, it’s not only counterproductive, it’s just kind of a mean, not nice thing to do.
[Dr. Monica Gandhi] It’s literally mean. I actually think that. I literally think that when we used to tell gay men that you were being, you know, unsafe, you’re like exposing society, don’t come around my children, don’t. This is, to me, also sounds like what we do is yell at people. I think it’s so awful. What you do is you gather evidence, you hopefully put out information that could protect you which I think is a powerful thing If you think something’s protecting you and your family because, by definition, we’re those kinds of creatures, we’re evolutionary creatures, we do things that help ourselves. Fine, good. Right, right? That’s normal.
[Dr. Z] Right.
[Dr. Monica Gandhi] And you put out enough information, you educate, and then you leave it at that. And that is what harm reduction is. That’s the harm reduction model. Like if people don’t want to stop using drugs, in harm reduction you give people needles and you make things better and safer, but you don’t yell. You don’t yell and you don’t preach, and you don’t act like we are the only people who know what we’re talking about. And I think that problem is we have contributed to the polarization in medicine, and public health has contributed to the polarization of what’s going on right now with their angry preachy messages. So, okay I’m with you on that.
[Dr. Z] I thought I liked you when we talked on the phone. I was like, “I like this.” And you know what’s funny? You know, I’m full transparency. I’ve told a few people that you’re coming on the show, She’s a UCSF professor, she’s a HIV doc, this and that. And these fans of mine said, “Well, don’t let her boss you around with her liberal BS “because she’s going to try to tell you tsk tsk, “and you gotta do,” and I’m like, “No, I wouldn’t have someone like that on the show.”
[Dr. Monica Gandhi] I don’t like the tsk tsk. I mean, I actually think it’s really, I think it’s actually the combination of being an HIV doctor and being an infectious disease doctor that makes me profoundly against yelling at people, or tsk tsking and calling anyone stupid. That is actually completely the wrong messaging with sexual health. It is not how you ask people to think about possibly working on their sexual health. That is actually their own private business. And what you do is give people information on how to keep yourself and others safe, and then you allow people to live with that information. But you cannot. To me, this reminds me of some of the stuff that happened with stigmatizing behavior at the beginning of HIV and I cannot stand it.
[Dr. Z] Well, wasn’t Robert Redfield, our CDC director, a big abstinence guy in the eighties on HIV?
[Dr. Monica Gandhi] So, good point. You can’t tell people not why, that I don’t agree with that messaging. You don’t get to have sex because you’re a gay man.
[Dr. Z] Gay man.
[Dr. Monica Gandhi] And so you’re like typhoid Mary, and you have to do this because you are, you know, living in a red state. Let’s give out our public health messaging based on policy and science, and try to persuade people through, how do you explain it? Like through loving, kind, harm reduction, education. Don’t yell at people. Don’t shame people. I think it is the exactly wrong thing that we’re doing. There was this article in “San Francisco Chronicle” where someone called, like people just gathering together a horror show. I don’t agree with that messaging, I don’t. I think that people are lonely. I think people miss their family. I think they miss their friends. I think that there are ways to do things safely. I think we have to talk differently if we ever want anyone to listen to us.
[Dr. Z] Oh, I couldn’t agree more with this. And it’s a matter of love. It’s a matter of being loving in the world. Like why, why, why? We’re doctors. And, you know, our own tribe, like you said, is so complicit in this fear-mongering. And we will inflict our own values on society as a large. You old person hide out in your house, avoid your grandchildren, don’t talk to them. I mean, they’re going, their life expectancy is.
[Dr. Monica Gandhi] They’re so lonely.
[Dr. Z] One to two years and you’re taking away the one thing that they’re alive for because of this risk, which is a real risk. This is not a hoax, right? We see people die of this thing.
[Dr. Monica Gandhi] Yes.
[Dr. Z] But put it in a perspective.
[Dr. Monica Gandhi] Put it in a perspective. So there are ways to visit safely. There are ways with masking to visit safely. There are ways to, if I lived with my parents who are 85, and I lived with my children who are 10 and 12. I want my children to go to school, and then I would keep them, you know, distanced or masking. I would do things to keep everyone as safe as possible, but I would never create this message that you’re doing something wrong ’cause you want to see your family or your friend. I think that’s, I don’t know. My mind is being blown by the current public health messaging actually. It’s not consistent with how HIV doctors work. And that’s why I’m maybe different than infectious disease doctors who don’t work in the context of agency.
[Dr. Z] And I’ve gotta say, your work on this thing has made me more convinced that we can open up, we can return to life if we just do the main thing which is a face covering. And again, this is a change for me. And now I would love it if you walked us through the available data that supports this theory.
[Dr. Monica Gandhi] Yes, yes. So you’re right, it’s a theory. Though, more and more things keep on coming out that seem like it goes along with it. But essentially, when we started putting this together, it really looks like there are three major fields that come together that provide evidence for this. And it’s virologic evidence, epidemiologic, or outbreak evidence, and then ecologic evidence, and ecologic means country-level data or big settings.
[Dr. Z] Got it.
[Dr. Monica Gandhi] So to go through each of those, the virologic. Okay, so what I was watching with this infection is this crazy asymptomatic infection rate. Like one setting would have 20% of people becoming asymptomatic, and then one setting would have a lot higher proportion being asymptomatic. And the CDC finally settled on a number of there’s 40% of people with asymptomatic infection with SARS-CoV-2. So then when you look at just this, let’s look at this first field, this virologic level of evidence, it really is looking at animal data a lot. That in animals, this is profoundly well known apparently, that the more virus you get in, the more sick you get. And this has been known since, the oldest paper we could find was 1938, that this concept of LD 50, lethal dose 50. But if you spray viral virus into cages, then 50% of animals get sick at a certain dose. You need a certain amount to make the poor animals die.
[Dr. Z] And I saw it was a 1938 study.
[Dr. Monica Gandhi] 1938 study.
[Dr. Z] And you know what’s funny about that city? I looked at it ’cause you sent me some of the charts. They hand draw the graph. It’s so awesome.
[Dr. Monica Gandhi] I love the hand drawing.
[Dr. Z] It’s like you can just see a guy, like, “Well listen see, we’re gonna draw this out. “The more virus you give these little hamsters, see, “the more they die, see.” It was really amazing.
[Dr. Monica Gandhi] It was quite excellent that you could do your own drawings, but you’re right. And so it was an excellent paper and it started out it out. In fact, it so started it, that it became called the Reed & Muench theory. ’cause that was the two authors.
[Dr. Z] I got it.
[Dr. Monica Gandhi] And over time there’s probably like, I don’t know, like 50 animal studies more. There’s multiple studies published that the more virus you get in, the more sick you get. So this is apparently in the veterinary world totally known. Then you say, “Okay, well, “how many experiments have been done “with spraying virus into humans “and seeing how sick they get?” Not that many, ’cause it turns out we can’t do a lethal dose 50 of humans. You can’t do this to humans.
[Dr. Z] Why not? Come on!
[Dr. Monica Gandhi] It’s like unethical So the only true study are virus challenge experiments. There have absolute been studies with influenza A, for example. We were trying to develop a vaccine and you give people a little bit of influenza A or you give them a lot and they get more sick. So this was this clinical infectious disease paper in 2015 that you gave people more influenza. And these were volunteers who agreed to do it. And they got severe cough and shortness of breath when they got a lot of virus. And they got very mildly coughing when they got a little virus. So this has been, the experimental dosing has been done in humans as well.
[Dr. Z] That’s awesome.
[Dr. Monica Gandhi] And then the other evidence around viral inoculant in humans has just gotta be sort of evidence that with SARS-CoV-2 and other illnesses, the more crowding you get, the more people get sick. Okay, so that’s the virologic evidence. Then move on to epidemiologic, or outbreak investigation. So at the beginning of this viral infection, like on the Diamond Princess cruise ship, 20% of people were asymptomatic. And then that was one analysis by a Japanese group. And then when they tested more people, they said 40% of people are asymptomatic. And so the CDC on July 10th said, “Yep, that’s the number.” That’s the percentage of people who are asymptomatic with SARS-CoV-2 in a typical outbreak.
[Dr. Z] Across the board? Across the world, yeah.
[Dr. Monica Gandhi] Across the board. Yeah, really well done studies. In a typical outbreak, that’s your number. 60% of people are gonna have symptoms. 40% are gonna be asymptomatic. And then you’d get all these outbreak investigation reports. And there’d be these very interesting settings where 95% of people are asymptomatic. And so we started looking at those more closely. So another cruise ship outbreak, this was an Argentinian cruise ship, they also didn’t let people off ’cause they never let people off cruise ships who are like getting SARS-CoV-2 outbreaks. They make them stay there. But in this case they like threw masks over there, and they let them all have masks. And all the passengers masks was surgical masks. All the healthcare workers masked with N95 masks and their percentage of asymptomatic infection was 81%.
[Dr. Z] That’s a huge variance.
[Dr. Monica Gandhi] It was a huge variability from that 20 to 40% with the Princess Diamond. And the difference was the compliance, and the mandating, and the giving of masking. And they were the same age group, like who goes on a cruise are older individuals. So it wasn’t that it wasn’t any difference in any other demographic variable. It was all, this was the one variable. And these are kind of closed experiments, right? Like a cruise ship is a closed setting
[Dr. Z] Literally ecology in itself.
[Dr. Monica Gandhi] Yes, and so then that was the first study that like seemed so different. And then all these other outbreaks, and I think the ones that are most convincing are food processing plants because quite a few food processing workers got sick at the beginning of this pandemic. And the president actually said, “Okay, that’s essential work. “I don’t care. “We have to do processing. “We have to keep the meat processing plants open.” But they said, “Okay, well, “we’re gonna give our workers masks.” And so this was a very strict guideline by food processing plants in this country, “We’re gonna give people masks. “We’re gonna keep them apart, “and we’re going to mandate masking.” And then all the other food processing plant outbreaks that have occurred since mandates were put into place with masking have shown 95% asymptomatic rate. So really high asymptomatic rate.
[Dr. Z] That’s super high, right. It’s almost a not disease.
[Dr. Monica Gandhi] And it’s so different from what was happening at the.
[Dr. Z] Anymore.
[Dr. Monica Gandhi] Beginning. Almost a not disease anymore. And only 5% of people getting sick. And then there’s a paper I’m working on now in another company where they just gave everyone masks and the rate of asymptomatic infection is 95% after their outbreak. So this is kind of, this has been seen in outbreak settings. And then the final piece of evidence is ecologic, or country-level. Just in general, and I know this is the weakest line of evidence because people can say there’s a lot of differences between countries. But just in general, countries that masked from the very beginning, which were all the countries who were used to it from SARS, Hong Kong, Singapore, Thailand, Vietnam, Japan, urban areas in China, they just knew to mask. That was their thing from SARS. They took out their masks, they all started masking. And then the Czech Republic, and I always point out the Czech Republic because they weren’t used to masking from SARS, but on March 23rd they just pulled it out. They said, “Everyone has to mask. “I’m sorry, this is our rule. “Make ’em at home, crochet them, cute. “Make ’em cloth. “We don’t wanna like take it away “from healthcare coworkers, like use cloth, “but everyone has to mask.” March 23rd, earlier than any other European country. And the rate of illness and death has been so low in these countries that when you look at the case fatality rate, it truly is, it is low. Now that people will say, “Well, that’s “’cause they’re only doing testing “of people who are symptomatic.” And then you can say in return, well then the case fatality rate should be even higher because these people
[Dr. Z] Yeah, it should be higher.
[Dr. Monica Gandhi] Had symptoms, right, that you’re testing. And then how many people die who have symptoms? That should be quite high if you’re not testing any asymptomatic people to dilute out your denominator, to make your case fatality rate ’cause case fatality is the number of fatalities over cases. But yet their case fatality rate and even their fatality rate from SARS-CoV-2 have been very low. Taiwan has had less than 10 deaths. This is a country of 23 million people. High population density.
[Dr. Z] It’s next to China. Next to China. On March 6th they said, “You know what? “All our factories are gonna make masks. “We’re not gonna do anything else. “Make masks, make masks, make masks for our populace.” And then anywhere you go, you’re just handed surgical masks. Like you can’t get into a public transportation. You just were handed masks. You wore a mask.
[Dr. Monica Gandhi] Surgical level masks. Surgical level masks.
[Dr. Z] Surgical level masks, two-ply. And they get into subways and they’ve had so few deaths. And so that’s the other layer of evidence that I think masking is associated with severity of disease.
[Dr. Monica Gandhi] Now I think it’s important because you said this at the beginning, there’s a lot of confounders and those, like they had early suppression testing, contact tracing, all that. But regardless of that, you’re painting a picture across the virologic, the epidemiologic and the ecologic spheres that really support this idea that masks may be, through reduction of inoculum, are reducing severity and reducing the case fatality rate. Which is interesting because that means that it, then people are saying, “Well, this is no worse than a flu.” Well, it could be true if everybody universally masked.
[Dr. Monica Gandhi] If everybody universally masked the case fatality rate is similar to flu in countries where you’re universally masking. And then you’re right. You have to say that there’s all these other confounders, but I’ll give another good example of San Francisco because we’re gonna be doing this analysis with these two data scientists contacted me from MIT. And they’re like, “We have access to a lot of big data. “Do you wanna look at different municipalities “in the United States?” And I said, “Yes. “Let’s look at the severity of disease in places “in the U.S. that mask a lot, and don’t mask very much.” So a good example of San Francisco. Their number of deaths total have been 88 deaths since the very beginning. Very low compared to the number of cases which is over 10,000 now. Their case fatality rate, and this is a place that tests, contact trace does everything perfect, right? But their number of deaths have been very low. Masking in San Francisco has been a big part of the public health campaign. April 17th, we had a mask recommendation. Then they strengthened it on May 28th. Then they put out masking even more. Masking is like a very strong part of public health messaging in San Francisco, and “Vox” magazine did this report that they think probably 80% of people mask in San Francisco. If that is true, that is this golden number by another
[Dr. Z] Another study.
[Dr. Monica Gandhi] Model that we put in there. This study said that is the golden number where you get the deaths so low. If you mask at that rate that you can be completely unlocked down, un-socially distanced. It’s about masking. That’s what these modelers in Hong Kong did. So it could be San Francisco is one place where it’s showing that. And I think the case fatality rate has been higher in places that don’t mask as well. And that’s what we’re going to try to show in this paper.
[Dr. Z] I can’t wait to see the results of it. Because if this is true, what this is saying is, okay, 80% let’s say is this magic threshold where if 80% of population masks, you don’t have to worry so much about all those other things. You open up, go back to school, open up the salons, which there’s data about salons from–
[Dr. Monica Gandhi] They need to open up the salons. I feel so sorry for those hairstylists, yes. There is data, true, like you said, from the CDC that someone, you know, two hairstylists in Missouri had active COVID, but they were masking all their plants were masking. 139 people were exposed. And the interesting thing about that study is 67 agreed to test, and they were all negative. Maybe those other 72 weren’t that got COVID.
[Dr. Z] Got infected.
[Dr. Monica Gandhi] But they didn’t know it
[Dr. Z] They were asymptomatic. They’re not dead.
[Dr. Monica Gandhi] They were totally asymptomatic. They were completely, no one was ill of that 139. That’s where they got that asymptomatic rate. Not all agreed to be tested.
[Dr. Z] And I’ll tell you what, not only is that something we care about, we really only care about it.
[Dr. Monica Gandhi] You have to care about not getting ill, right.
[Dr. Z] But you know what? Oh God, oh man, there’s so much I wanted to ask you. I wish we had three hours. Oh my gosh. Okay, so if you get to that 80% threshold then, let’s say that that’s real, all right? Let’s say your theory’s right. You have a 20% variance. That means the libertarians, the people who are PTSD, they can’t have something on their face.
[Dr. Monica Gandhi] They don’t have to mask. I really think that. That’s actually why I don’t want anyone to yell at anyone because I think it doesn’t.
[Dr. Z] Because it doesn’t matter.
[Dr. Monica Gandhi] Have to be 100%. It really doesn’t. This model really showed 80%. And so if you’re able to mask, and you have that ability to mask, and if you just, it just goes against everything. That’s okay. Like if the city in general, 80% is masking, I think it’s okay.
[Dr. Z] But then when you tell people, “Hey, “it’s not just about protecting other people “from a hoax you don’t believe in, “it’s about actually protecting yourself. “So even if it is a hoax and there’s a small chance “that you could die from it, “you just throw piece of fabric on your face, “I don’t care what it is, you could be safe.” I think you’d get that up to 90%.
[Dr. Monica Gandhi] See that’s why this has been a very important message for me to write about, and then other people take up and write about. Because I think that idea that mass protect yourself is how we need to message that as well. So California just changed their messaging. They are going to say masks protect others and you. San Francisco changed it two weeks ago.
[Dr. Z] I saw that chart. It was beautiful.
[Dr. Monica Gandhi] It is. This is very important because, and I think it’s okay. Like we’ll say, “Oh, we’re just “so non-civic duty minded here, “and we don’t care about other Americans “when we messaged that it protects others.” But that is sort of kind of human nature that you may not, it’s complicated to keep on going back to condoms, but it is complicated. Like if you have HIV and you don’t wanna wear a condom, that’s okay. I don’t know. I just think it’s complicated when you’re yelling at people. And so again, but this idea that it protects yourself will increase our compliance rate with masks.
[Dr. Z] I agree 1,000%. I mean, I wear a mask myself, always do because I’m a doctor and I know it protects me. And then it also, if I’m sick, then there’s that secondary benefit of, “Hey, I’m not gonna .” It’s pure human nature.
[Dr. Monica Gandhi] It’s pure human nature.
[Dr. Z] Yeah, it’s pure human nature.
[Dr. Monica Gandhi] And that’s okay, there’s nothing wrong with that. So I want to protect my, I put my children in their masks. I wanna protect them. That’s very natural of me to wanna protect them.
[Dr. Z] Absolutely. And again, there’s no harm here. You’re not directly harming these children. Now, here’s an interesting idea, and then we gotta get to herd immunity, and we got to talk about the fear-mongering because we have a limited, ’cause I know you gotta get back to your kids. So here’s the thing, here’s a crazy theory that I don’t think is true, but could it be also that the reason you get less symptomatic disease with masking is that you’re actually blocking more of the inhaled stuff, but getting a more fomitic spread from people touching their face, adjusting their mask. And that fomitic spread is a low dose, fomite meaning from surfaces. It’s a lower dose, so that’s a lowering inoculant. Could that be a component of it?
[Dr. Monica Gandhi] That’s interesting. Maybe, but I actually wanna get people away from the fomite thing. So I think that at the beginning, people were tremendously scared. They were like, “Oh my God, it must be like everywhere. “It must be on surfaces.”
[Dr. Z] Sanitize everything.
[Dr. Monica Gandhi] You can always culture viruses from surfaces, by the way. It’s not just like SARS-CoV-2. You can culture, like, we all remember this from medical school. You can like culture this piece of fabric and there’s gonna be a bunch of stuff in there. That doesn’t mean that’s how you get it. And in fact, I wanna get people away from this idea about surfaces and fomites. Please open playgrounds. Please let people, you know, please let people like not, you know, don’t make people wear gloves which luckily we did stop doing that. Of course, basic hand hygiene. That’s really important. But I don’t want people to be scared of surfaces. And so in a way, I don’t even want that to be part of the theory. I also actually don’t think that ocular transmission is a very big thing. I think that it’s the big holes in the mouth and the nose where virus enters and where virus and that’s why it’s that light what’s comfortable for you covering of the mouth and nose that I wanna encourage.
[Dr. Z] It’s a pie hole related scenario.
[Dr. Monica Gandhi] Yes, yes, they’re big.
[Dr. Z] Okay, so now let’s think about, and again, I’m gonna link to all your stuff, the “New England” piece, “New York Times” piece, there was a “General Internal Medicine” piece I think that you had, wonderful, wonderful stuff. And people can dig through the references and tear it apart if they want.
[Dr. Monica Gandhi] They can, they can, they can. It’s a theory, yeah.
[Dr. Z] Exactly, but I’ll tell you this, the T-cell mediated immunity, the innate immunity to COVID that some people may have, and the idea that we could be inoculating the population with low dose exposure through masks as a bridge to getting us to vaccine, start to unpack that for me.
[Dr. Monica Gandhi] Yeah, so that is this article that came out this week and we call it “Facial Masking a Potential “for Variolation to Vaccination.” But I really had to explain that.
[Dr. Z] Yes, yes please.
[Dr. Monica Gandhi] So what we meant by that is that “Okay so now let’s do the transitive property “of quality and take this one step further.” If masking, facial masking, and comfortable cotton masking, me, I think it blocks virus for sure. It blocks transmission. We’ve seen that in the hospital that people with surgical masks, they get less transmission But if you do get virus inthat you get less sick because it’s less virus. Then take that point and then take the fact that even having mild or asymptomatic infection, we’ve had great studies over the last five weeks really, published in “Cell” and “Nature” and “Science,” very exciting studies that even mild and asymptomatic infection can be associated with strong T-cell immunity. So just really basic, right? Like, B-cells produce antibodies, T-cells are cell mediated immunity, and there’s two arms of the immune system. And if we only focus on B-cells and antibodies, we’re missing half of the way that we, most of the way that we actually protect ourselves from viruses which is cell mediated immunity. So these particular papers that I’m talking about that we referenced are excellent ones from UDaB, one’s from here at UCSF, one’s from Sweden, they’re all over the world that shows really strong T-cell responses even when you have mild or asymptomatic infection. Don’t know how long they’re gonna last, but it’s gonna give you immunity for awhile. So if you’re wearing a mask and you happen to get infected and you get asymptomatic disease and you would get immune to boot, that is like having your cake and eating it too, in my opinion. And so it’s a theory, meaning we can’t keep society closed forever. We just can’t. It’s actually very, very detrimental to, you know, children who need to go to school. And it’s very detrimental to society as a whole, our mental health.
[Dr. Z] Our mental health, yeah.
[Dr. Monica Gandhi] We’re also depressed.
[Dr. Z] It’s a regressive tax on the poor.
[Dr. Monica Gandhi] It’s the most unfair to the poor.
[Dr. Z] You and me can summer in the mountains and work from home.
[Dr. Monica Gandhi] We can sit in our houses as much as we want with our lovely wireless communication.
[Dr. Z] In our elite bubble, right.
[Dr. Monica Gandhi] It is elite. It is elite.
[Dr. Z] It is, it is.
[Dr. Monica Gandhi] It is elite to say that you can keep society closed because, by definition, people need to eat. By definition, people the essential workers are those who are out. And by definition, it will always hurt the poor more to do such a blunt measure as lockdown. We had to do that at the beginning ’cause we didn’t know what was going on. It was so scary. It was so weird. It was spreading so fast. Now that we have these public health tools that are so effective like population level masking, which I truly believe in, I think we need to open in those settings that we can open with that tool in play. And some more tools, which would be things like, right now, keeping away keeping from each other, not large crowds. I don’t think people should be congregating in large crowds right now even with masks. Not social distancing as much as you can, hand hygiene testing for SNFs in vulnerable populations, testing for jails setting for testing, you can do some surveillance testing, you know, testing and tracing when you need to. I believe in masking so much. I believe it’s so important to help protect you and others that I think we have to now start thinking, Okay, there are other issues going on in the world. There’s other public health concerns. We have to think about the poor. And we have to just put together now a comprehensive public health strategy that mitigates the impact from this particular new infection, for sure. And also thinks about all the principles of public health. That’s where we are now at this point in September. And so the immunity question is, okay, so if it generates strong T-cell immunity, then can we buy ourselves some time until we get to an effective vaccine? And that’s why we called it variolation ’til vaccination. What was variolation? Variolation was different than this. Variolation was a deliberate process. Variole is the name of the smallpox virus, the DNA virus, and the idea of variolation because we didn’t have a vaccine and we didn’t even know about vaccines. It’s what led us to understand vaccines was actually giving people small amounts of smallpox through a cut, like a scab, a gross small pox piece of hair, or someone from someone with puss on it, and giving it to them in a scab, and they would get really asymptomatic or mild infection if you were lucky, and then they would get immune. And certainly we’re not at all telling people by masking to deliberately expose yourselves.
[Dr. Z] Go have a COVID party.
[Dr. Monica Gandhi] Not at all. We do not believe in COVID parties, pox parties, and any of that. That would be dangerous. That would be if we were not in this situation where we are now, where we have a modality that I think, and I know it’s a theory, but I really feel like there’s so much more accumulating evidence where it protects you. And then if you get mild infection and you get immunity to boot that can help bridge our society until we get to a vaccine. And that’s all the theory is propounding. It’s definitely, there’s been some controversy. There’s people yelling at me and saying, “You’re telling people to get deliberately infected.” That is not what I’m saying. That’s not what I’m saying.
[Dr. Z] And why is herd immunity such a bad word?
[Dr. Monica Gandhi] It should not be a bad word. I have to say, I’m literally flummoxed about it. So I wanna be honest, I can’t even exactly explain the politicization of that word because what herd immunity means is, any infectious disease doctor that knows anything about infectious disease, that is a true strategy by which infection rates are slowed. So it means that you essentially get lower number, more people have been exposed to the virus, either through vaccination, if you’re lucky, but we don’t have a vaccine for SARS-CoV-2, or natural infection in a setting. Here this is such a transmissible virus, we’re getting more and more people exposed to the virus. They likely have immunity. And then by definition, the virus can’t go as many places because they try to hurt this person, they try to get to this person, and they’re not susceptible, they’re immune. So by definition, it slows down spread of the virus in the community while you’re waiting for that vaccine. And so herd immunity is not a bad term. It shouldn’t be. I’m not sure about the co-opting, I’m confused. But I do have to say that I do think that herd immunity is occurring along with masking in our society right now. And I think it’s decreasing mortality rates. I gave a talk for medical grand rounds at UCSF just two days ago, and I think there’s five factors that decreasing our mortality rate. I think that one of them is better treatments for sure. I think that second is that we’re doing a much better job at isolating and mass testing in SNFs and keeping infection control. Sorry, in nursing homes. I think the third reason is masking. I think it is decreasing the mortality rate, and we’ll do this analysis and see is that more true in places that mask, and more mortality rate in places that don’t. We’ll see that. We’ll look at that. And then the fourth reason is that I think that there is immunity developing. There is immunity developing in the population. We haven’t eradicated this infection. It’s very hard to eradicate. Vietnam did an amazing job. They controlled it. They opened up a little bit. They had no cases for four months, and then they got cases back, why? Because it’s a very transmissible, it’s a very contagious virus. People are going to be exposed. And because of that, if people become more and more immune, that will reduce spread. It will. It’s an infectious disease principle. And so my hope is that we can get to immunity with asymptomatic infection, not symptomatic infection. I would never propound people getting sick to get to herd immunity. So that is where I differ from anyone who’s trying to yell at them.
[Dr. Z] Just let it rip through the population.
[Dr. Monica Gandhi] That would be terrible. I would be horrified if there were deaths and severe illness.
[Dr. Z] That are preventable
[Dr. Monica Gandhi] That are preventable.
[Dr. Z] ‘Cause we can’t everything.
[Dr. Monica Gandhi] You can’t prevent everything. Some people will die from SARS-CoV-2. That’s right, that’s right. As they will die from many things. And it is terrible.
[Dr. Z] Now, you know, 0.6% of our population is SNF nursing home patients. They are 40% of the fatalities.
[Dr. Monica Gandhi] That’s why those places have to be the most, that’s where we do mass testing. That’s where we do masking and symptomatic testing. I don’t think that we should stop people from seeing people, but that’s where we do fundamental masking when we have people that .
[Dr. Z] Do you think we’re over testing and creating a case-demic right now, instead of a pandemic. In other words, we’re seeing all these very low level people that are asymptomatic, that test positive, and you’re calling it a case. But in reality they have no symptoms, they’re now immune, is that useful information?
[Dr. Monica Gandhi] I think it was useful information to know who was infected when we were in a state where we could have maybe contact traced it into oblivion. However, I think this is a super transmissible virus actually. And yes, we did things that were wrong in this country. And we could go into that, but there’s no point. We’re now in September. This is where we are. There’s a lot of virus circulating, and I don’t think that we can contact trace and get this into oblivion. We simply can’t.
[Dr. Z] Yeah, I agree.
[Dr. Monica Gandhi] We cannot eradicate this virus.
[Dr. Z] I agree.
[Dr. Monica Gandhi] So I would put our resources into mass testing campaigns, into nursing homes, jails inpatient hospital settings, the central worker communities, but only if you give them money to isolate. I would not mass test Latina, Latinx San Francisco without ensuring that you have what one of the supervisors did, which is a right to health. And she literally ensured, Hillary Ronen, ensured that people had ways to stay home and isolate during their period of isolation. How do you say to someone, “Hey, I’m gonna test you. “And then by the way, “I’m gonna give you nothing to stay at home.”
[Dr. Z] What are you gonna do?
[Dr. Monica Gandhi] And you have to like get money from your family? That is a very harsh thing for us to do. So essential worker communities, and then supporting essential worker communities that I really believe in. But yeah, testing everyone and all these people who are in tech and they’re testing themselves ’cause they have the money to do it and then they’re getting cases or they sometimes get cases are not, I think that is a waste of resources.
[Dr. Z] Yeah, yeah I agree. And you know, what’s interesting too, is when the Europeans do their lockdowns, like Denmark say, they do something that we don’t do, which is they take care of their poor people. So they’re not punishing poor people with lockdowns. In this country we do do that which is why I think–
[Dr. Monica Gandhi] We’re the opposite.
[Dr. Z] We’re the opposite which is–
[Dr. Monica Gandhi] We like to do the wrong thing. We actually punish people by putting a lock down so the rich people can stay in their house, and then we don’t help the poor people.
[Dr. Z] That’s right.
[Dr. Monica Gandhi] It is unbelievable.
[Dr. Z] It’s unconscionable.
[Dr. Monica Gandhi] It’s like the worst where you could do things.
[Dr. Z] And this is not a political statement. This is a humanistic statement.
[Dr. Monica Gandhi] No, it’s the truth.
[Dr. Z] It’s the straight truth.
[Dr. Z] So what happens well, okay, how about we spin up production of surgical level masks even, and give them to everybody like the Taiwanese did. That would be a simple way to get through this, open up the economy and get back to life. Instead we monger fear on the left, denial on the right, division everywhere.
[Dr. Monica Gandhi] -Yes, we are doing it the worst way possible in this country. Worst way possible. Really, and we’re doing it the worst way from both sides, right?
[Dr. Z] Yeah.
[Dr. Monica Gandhi] So I’m someone who really believes in, who is very interested in poverty, and it’s what got me into infectious disease. I really do believe that we have to support the poor. And I have just been watching with horror that we would mass test the poor, and not ensure that they have ways to isolate with masks, food and $1,200 a week during that time. I think it’s, or $1,200 a month, it’s unbelievable. So actually we’re just doing everything wrong.
[Dr. Z] Yeah, I agree with you. I’m with you. But one thing that we’re doing right is we’re having a discourse, you and I. And even if people may disagree with the theory, the great thing is we’re gonna study it more. I think personally, you have compelled me enough. And I totally understand, and we could dig, and I could pick apart these different things. But the point is the people will do that, and I want them to. What I want to say is if you’re right, 80% of masks doesn’t even need a mandate. People can just do it because they’re compelled.
[Dr. Monica Gandhi] Yeah, they can do it. They’ll become convinced.
[Dr. Z] By the masses. That’s right.
[Dr. Monica Gandhi] I really think so.
[Dr. Z] And if we’re wrong, and I saw this spelled out somewhere, if we’re wrong and people like say Ivor Cummins, who’s an Irish chemical engineer, who’s done a lot of data analysis, he doesn’t believe in masks, but he also thinks this whole thing is our fear is outweighed and consequences of our response have outweighed the damage of the virus. He thinks it’s following seasonal patterns of what an influenza would do. And I think those are ideas worth exploring, but tear apart the data, see if it’s true. But you know, I think guys like that, let’s say they’re right. And this whole thing has been a mis-response. Well, at least we did something with good intent, which is masks, which caused minimal harm.
[Dr. Monica Gandhi] Harm, yeah.
[Dr. Z] Which had a precautionary principle attached to it, which is, “Well, okay we just don’t know enough.” And we can sleep with good conscience as opposed to saying, “Oh, it’s nothing. “We’re gonna let it rip through the population.” And then we see the people die.
[Dr. Monica Gandhi] Right, right.
[Dr. Z] Not the person making that statement.
[Dr. Monica Gandhi] Right, people have died.
[Dr. Z] Yeah, and so again, our response has been pure fear, which is terrible, catastrophizing on the left. And that’s what I hate is this catastrophe, it’s a cognitive distortion. And you and I were talking a little bit even beforehand, it’s a fear of death as the worst possible thing that can happen to a person. Which I think is a failure of our own understanding of what it means to be a human.
[Dr. Monica Gandhi] It’s also the most definitive thing that will ever happen to a person. And so I do think that we have to balance right now, all the etiologies of death, all the etiologies of misery and all the etiologies of public health when we decide on our strategy in this pandemic. And I am thinking of the massive number of overdose deaths in San Francisco that are an excess over the last four months. How do we not provide a society where we haven’t taken care of an ability to be safe with drug use? Right now we are exposing the ills of society, I think, by this response. And I completely agree with you. Now that we go forward and we have a new disease in our midst, a disease that’s spread by a respiratory pathogen, a disease that we can possibly help ourselves with wearing a mask for the next six to 12 months, now it’s time to think about all the other ills of society and all the other public health concerns, mental health, including everything else, HIV. My biggest concern is that our HIV patients are gonna lose virologic suppression because they’re not coming into clinic. And we have analysis on this from Ward 86. They’re so scared to come to clinic. That was their linchpin of getting better virologic suppression rates is the connection that they had with Ward 86. They’re not coming. We, at the beginning, told them not to come. And they’re losing their ability to maintain their virologic suppression. We just had an analysis on this published.
[Dr. Z] And nobody talks about that. They’re not talking about.
[Dr. Monica Gandhi] We need to talk about everything else.
[Dr. Z] The missed cancer screening, the mammos that aren’t happening, all this other stuff. And yet we pound the drum about, you know, protect everyone from COVID. And you forget that this is a holistic web we live in.
[Dr. Monica Gandhi] As doctors, actually, we have to be talking about those other things, right? Like as physicians, I have a friend who’s doing more poorly with cancer than he would unfortunately right now, because he can’t get access to cancer trials. And as doctors, we have to be talking about that and not call that political. That is our job.
[Dr. Z] That’s our job.
[Dr. Monica Gandhi] That’s our job to protect people from illness.
[Dr. Z] I’m actually encouraged that we’re gonna hit a turning point here.
[Dr. Monica Gandhi] I think so.
[Dr. Z] Yeah.
[Dr. Monica Gandhi] Maybe this conversation will help a turning point.
[Dr. Z] I will tell you 100%, I wanna tell you something, and this is a compliment to you and everything that you’re trying to do. I’ve had people message me who say that they are very, very much on the right end of the right word, leading political spectrum. And first of all, they appreciate that I don’t put politics out on the table as a bludgeon because my own politics are somewhere in the center, and I see all these sides. But what they said was they heard my talking about your work in a video we did called “This is What Masks Actually do.” And it convinced them to go, “You know what? “There’s no harm in throwing this thing on “to protect myself and other people “if there’s a chance it’ll help “even though I think this thing is overblown, “even though I haven’t seen anyone die of it.” That means you may just prevent one case of someone being on a ventilator, if your theory is right, without causing a lot of harm.
[Dr. Monica Gandhi] That would be so great ’cause I don’t think it causes harm. And it would be so great if we’d save illness and it’d be so great if we get to immunity and it’d be so great if we now turn our conversation as doctors to both minimizing the impact of COVID and minimizing the impact of the ill effects of the COVID response on illness and human society. That is the time. It’s September.
[Dr. Z] I couldn’t agree more. Monica Gandhi, it has been a joy. You know,
[Dr. Monica Gandhi] Thank you.
[Dr. Z] What I love about you is I emailed you, and said, “Hey, I’m this guy ZDogg MD. “I do a show. “I live in the Bay area. “You wanna come down and do the show?” And you didn’t really know what I did or who I was, but you said, “Yeah, if it’s talking about this, “I’ll come down the peninsula. “And I’m busy and it’s hard.” And you did it with a smile on your face, and–
[Dr. Monica Gandhi] ‘Cause I wanted to talk to a person in real life. I cannot stand Zoom. Thank you so much for inviting me. It’s so nice to see a human. Thank you, thank you.
[Dr. Z] You have made my weekend. It’s true, this social connection is priceless.
[Dr. Monica Gandhi] It’s really important, thank you.
[Dr. Z] Well, we hit it off on like minute one.
[Dr. Monica Gandhi] For talking to me. Thank you.
[Dr. Z] That says something profound, you guys. Z-Pac, if you love these kinds of conversations, just share it. That’s all you need to do. You can become a supporter, all that other jazz, but it doesn’t matter. Share it, read about Dr. Gandhi’s mask works. See if it compels you to be one of those 80% that we need to mask up if the theory is right and we could end this thing. We could end this thing. All right, guys? I love you. We’re gonna have you back.
[Dr. Monica Gandhi] Thank you.
[Dr. Z] Would you please come back?
[Dr. Monica Gandhi] Yes, yes. I will definitely come back.
[Dr. Z] There’s so much we can talk about.
[Dr. Monica Gandhi] Okay, I will definitely come back.
[Dr. Z] I wanna talk about prep and HIV. I wanna talk about.
[Dr. Monica Gandhi] Oh yeah, those are my actually true favorite topics.
[Dr. Z] I figured. All right, guys, I love you. And we out, peace.
- The ZDoggMD Show (772)
- Featured Videos (188)
- Doc Vader (139)
- Against Medical Advice (128)
- Medical Humor (93)
- Public Service Announcements (87)
- Music Parodies (74)
- Nurses (59)
- ZVlogg (36)
- Meditation (33)
- The VPZD Show (31)
- ZTalks (28)
- ZBlogg (24)