Johnson & Johnson, Vaccine Passports, & More LIVE (w/Dr. Vinay Prasad)

Dr. Z: What’s up, guys? It’s your boy, me, Dr. Z. Today, I got this guy. Welcome back.

Dr. Prasad: I’m back. Yep, good to be back.

Dr. Z: And it’s really great to see you, man.

Dr. Prasad: Yeah.

Dr. Z: By the way, today’s my birthday.

Dr. Prasad: Happy birthday.

Dr. Z: I am 40-f’n-eight.

Dr. Prasad: That’s a good age.

Dr. Z: a terrible age, everything hurts.

Dr. Prasad: I was just being nice, yeah.

Dr. Z: You are just being nice, yeah.

Dr. Prasad: Just being nice yeah.

Dr. Z: You being 10 years my junior, and the thing is, the best birthday present ever is you showing up and us doing a live show right as they’ve made the decisions.

Dr. Prasad: Yeah, it seems like, yeah.

Dr. Z: For Johnson & Johnson FDA emergency committee met. So we’re going to talk about Johnson & Johnson and what we think about that. We’re gonna talk about vaccine passports.

Dr. Prasad: Oh, yes.

Dr. Z: We are gonna talk about schools in Chicago and when they’re gonna open. We’re gonna talk about whether the pandemic is ending in the United States. We might touch on what’s going on in India, and we might do-

Dr. Prasad: Talk social media.

Dr. Z: Talk some social media stuff. So I’m excited.

Dr. Prasad: I’m excited, too.

Dr. Z: So you just, let me, okay, first of all, let’s make sure we’re getting some live supporter feed here.

Dr. Prasad: Yeah, we’re actually talking to anybody.

Dr. Z: Yeah, well, there’s 1,400 people on Facebook watching us.

Dr. Prasad: Amazing, okay.

Dr. Z:  So that’s always nice. Nothing to panic about, Vinay. A lot of people wishing me a happy birthday which is very uncomfortable for me. Let me just pop out these comments real quick. Meanwhile, I’m going to let you tell us, while I’m getting the comments set up, switch to you ’cause I gotta to do everything. I gotta switch the camera.

Dr. Prasad: I know, you’re the crew.

Dr. Z: I am the crew. Tell us what is going on with Johnson & Johnson right now from what you’ve been reading with the live meeting.

Dr. Prasad: I know, and we’re literally, since we’re live, it’s hard to keep up with what’s going on on Twitter and trying to set up here. But I guess, you know, people will know that about a week ago, a week and a half ago the pause was instituted for Johnson & Johnson an adenoviral vector vaccine. The basis for that is some women have, particularly in a certain age group, have cerebral sinus vein thrombosis in the setting of low platelets, which are thought to be activated in a way similar to HIT. So it’s some sort of a runaway platelet activation and a blood clot in the brain. And we just had the hearing where it appears they have voted and they have voted to re-institute Johnson & Johnson, I think in anyone over the age of 18. They’re talking about the warning that they’re gonna put on there. I haven’t seen them vote yet on the warning. Warning might be something like, women under the age of 50 should be a bit cautious about TTS or thrombosis and thrombocytopenia. So that’s where we are right now, at least as far as I understand it. I have some thoughts and I’m sure you have some thoughts, but I’ve been following it with some interest.

Dr. Z: Yeah, so basically they said, okay, go ahead and keep taking it more or less, right?

Dr. Prasad: More or less.

Dr. Z: But here’s the warning. Now, this is the problem. The damage for this vaccine in my mind has already been done because the way the public is going to look at this is they’re going to say, wait, so you’re telling me that this vaccine has this very small risk with especially women have this really potentially catastrophic syndrome, which is again, exceedingly rare, but you paused the vaccine and guess what, if this were the only game in town, that’s one thing but it’s not, we have these mRNA vaccines. And in fact I read today that we have enough mRNA vaccines to vaccinate the entire US population. So now that this has already happened, don’t you think that the well is poisoned for public opinion on this vaccine?

Dr. Prasad: Yes, I do, I think the well is poisoned. I think the well is poisoned certainly for women younger than 50. I’m happy to argue right here that I think it probably ought to be poisoned for women younger than 50. So I disagree with a little bit of their modeling. We can talk about that, but we have two alternatives. We’ve got Moderna, we’ve got Pfizer. The amount of people who have received those vaccines probably one order of magnitude larger than J&J and no adverse safety signal has yet emerged. So I think we have some strong confidence that those vaccines don’t have, you know, they certainly don’t have this problem with it at this frequency. What do we have here? We have this syndrome. You know, all along I was irritated when people tried to compare this syndrome to a blood clot in the leg. And the moment they heard about the pause, they heard of six women, 7 million vaccines were given. They said things like, oh, it’s one in a million. And they made these memes that compare vaccine clot from J&J versus the likelihood a woman who takes oral contraceptives for many years will develop a clot versus the likelihood a hospitalized ICU COVID patient in the first wave would be found to have a clot in one of the many studies. And the answer is this is a lot lower than those other things. But the other answer is, this is different than those other things. This isn’t a blood clot in the leg. It’s not an ICU patient who you’ve done surveillance Dopplers on and found a blood clot. This is an intracerebral clot in the setting of likely runaway platelet activation. It is a very difficult problem. It is a problem that can kill you with a high fatality rate. And if it doesn’t kill you, it can leave you in a permanently disabled state. So I took it very seriously when I heard about the problem. And now we have some better estimates of how often it occurs and because of how often it occurs, because of the ability of alternatives, I think it will do a lot to the American consciousness about public perception. I think this whole episode will.

Dr. Z: Yeah, now, okay so let’s unpack a little bit about what you’re saying because you now have a vaccine that again, it is exceedingly rare, but the anti-anti-vaxxers who are a bit of a cult in themselves let’s be totally honest. Really the minute it came out, they were on the defensive pushing the idea that this is a minuscule risk, et cetera, which it is a very small risk.

Dr. Prasad: Correct.

Dr. Z: But like you said, they have no, I think they have no understanding of how humans actually work. And this is why anti-vaxxers always win when you put them head to head with an anti-anti-vaxxer because they know how to prey on people’s emotions, on their intuition. Okay, I’m a young woman, I have a choice between an mRNA vaccine and the Johnson & Johnson vaccine. I know I’ve been told again and again that this risk is infinitesimally small, on par with being struck by lightning, let’s say. Am I still emotionally gonna be willing to take a vaccine that like you said, can cause something catastrophic and is actually associated with it, has a potential physiological reason for doing it, at least speculation in terms of anti-PF4 antibodies, et cetera, which we’ve talked about. The answer is no, many are not. Now the thing is, what about everybody else? What about guys, what about older people, et cetera? Well then they have to be given the information, but I bet there’s bleed-over even to those populations, right?

Dr. Prasad: Of course, yeah. I mean, we can talk about the social implications of it and the bleed-over, but maybe for a second, I don’t know, I want to make my case about the risks or about what should happen. So when you hear about a bad safety signal, if your gut reaction is to say, oh, it’s just one in a million and let me make a meme. Let me tweet a meme, you’re not really a scientist. I’m sorry because you don’t, when a safety signal is first flagged, we very rarely know the precise numerator and the denominator. And that day I tweeted, I won’t be surprised if it’s actually one order of magnitude more frequently than one in a million, one in 100K. And I think the number now, I’m looking at about one in 140,000. The reason I said that is the denominator wasn’t everyone who got the shot. The denominator was women in the age group who would have been susceptible or at risk of the event who got the shot. The first day, we didn’t know that. We did find that out last Friday, and the answer was 1.4 million. Then the next thing is the numerator. The numerator is not six. That was the numerator last week. Now the numerator’s 13 and there are, I’ve heard, some other unadjudicated cases that they will add to it. So that numerator is also in flux, why? Because some people may have seen this. They didn’t even think twice to try to implicate it with the vaccination. Now, of course, that cognitive circuit is triggered and they’re looking for it.

Dr. Z: Right.

Dr. Prasad: So one thing is when you hear about a rare adverse event, you know, it’s not the kind of thing you want to put your money on what the precise rate is that day. You need some time to adjudicate it. Now, it’s a separate debate from whether or not they ought to have had a pause.

Dr. Prasad: That’s a separate debate. I mean, I think you could, one could argue that they could have paused in the age group in question. Whilst paused, they could have given it to the other age groups where there was no signal. That’s another strategy. But I think the wrong answer is to immediately leap to defending the product when you don’t yet know the number. Okay, so that’s what I’m willing to say. So I wouldn’t defend it yet. In the week that has emerged, we now have a better idea of the safety signal. At least 13 cases of women between the ages of 18 and 50 have this problem. It’s a bad problem. And I don’t know how to describe it, but imagine-

Dr. Z: And you’re a hematologist so this is your-

Dr. Prasad: I’m a hematologist, yeah, my field. And in fact I’ve treated many people with cerebral sinus vein thrombosis, and I’ve treated many people with HIT, heparin-induced thrombocytopenia and thrombosis which is a platelet factor 4 activation condition. You did a nice job kind of explaining that path.

Dr. Z: Oh, thank you.

Dr. Prasad: Yeah.

Dr. Z: Yeah, I feel like my attending approves now. I’m like all happy, you know?

Dr. Prasad: Yeah, I’m talking fast. But yeah, yeah.

Dr. Z: No, that’s good.

Dr. Prasad: But you did a good job of explaining it. And I guess I would say it is a thorny problem to manage. I mean, often we are, in the case of HIT, we’re using things like argatroban. And I don’t know if you’ve ever dosed argatroban.

Dr. Z: It’s very tough, yeah.

Dr. Prasad: Oh, it ain’t so easy to keep it there. I mean, it’s a difficult thing. The treatments are difficult.

Dr. Z: ‘Cause you can’t give heparin, you can’t give Lovenox, yeah.

Dr. Prasad: I mean, we are, I guess some people think you can give like fondaparinux the pentasaccharide at the end of heparin. Some people think there are different ways you can get around it. But right now with this particular condition, I think there is some genuine uncertainty about how you ought to treat it. The other thing I’d say about CSVT, when these patients have a clot sometimes the clot gets to be profound. And sometimes it’s occurs in the setting of concomitant cerebral hemorrhage. They’re also hemorrhaging. Often we continue to anticoagulate based on scant data. But the idea that the outflow track is obstructed and if you don’t alleviate that pressure you’ll get even more hemorrhage and bleeding. It is not always a great situation, yes, it can-

Dr. Z: You’re pushing and pulling at the same time basically, yeah.

Dr. Prasad: Yes. It can lead to death. It can also lead to, I think, promote neurological impairment. And we’re talking about people who are getting something who walk into it totally fine.

Dr. Z: So actually, let’s double down on that piece because these are people who are healthy who have this much, you know, whatever their risk is of COVID and complications of COVID, which in Britain they were quantifying as like one in anywhere from 0.9 to 6.8 in 100,000 being ICU hospitalized. But now you’re giving them something that puts them at, you know, this one in, what did you say, one in 145,000?

Dr. Prasad: I think one in 150K, yeah.

Dr. Z: Yeah yeah, roughly, roughly.

Dr. Prasad: At least now, it may change in a day or two.

Dr. Z: That’s right.

Dr. Prasad: But it’s not gonna go back to one in a million, it can only go one way now. You know, it’s only gonna go to one in 100K. It’s not going to go to one in a million anymore ’cause at least we’ve ascertained something about the numerator and denominator.

Dr. Z: Got it, got it. It’s funny, I’m forgetting to switch the cameras occasionally as I’m trying to multitask. Speaking of like poor form, bad science. So this idea that then you’re telling people, okay, now make an, what we’re saying is we’re saying, okay here’s the information.

Dr. Prasad: Yes.

Dr. Z: Now you can make a decision, but here’s a question, and you and I may agree or disagree on this. Can the public be trusted to make those decisions given information?

Dr. Prasad: I guess I would say that everyone, the right person to make the decisions for you is you for everything, I think, from everything. However, we use regulation to prevent you from making decisions that at the outset cannot be in your own best interests. You’re not positioned to make the decision. That’s why you have to wear a seatbelt in the car even if you may choose not to. So you have to wear a helmet when you ride your whatever, motorcycle. I mean, there are some things we, right, that’s why you’re not allowed to have access to a drug that we never tested to any human being. These are regulations society imposes to protect you from decisions you might make out of ignorance or desperation or lack of knowledge. And so I think it’s good for society to limit some choices people have. The question is, what should they do here? Okay, I want to give one more aspect. So now we’re knowing a little bit more about the risk of clot, one in 150K. What is the risk if you don’t get that vaccine? Okay, this is the crux of it. It’s a risk benefit analysis. What is the benefit if you do get the vaccine? And I would say the benefit is, if you get a J&J vaccine now you will have a reduced risk of getting SARS‑CoV‑2, a reduced risk of all of the dreaded complications including the ICU and death. And if you don’t get the J&J vaccine now the counterfactual is you will likely get an mRNA vaccine in some weeks, some weeks. So this is the crux of the debate. What is the difference in your outcome if you get this one now versus waiting a few weeks? And it has to do with a lot of moving parts. Here are the moving parts. One, if a woman in this age group gets SARS‑CoV‑2, what’s her risk of dying? Some of the statistics that people have used are from the first wave last year, and those death rates are significantly higher than the death rates are in the modern hospitalization.

Dr. Z: Yeah, and actually, that’s, we should really make a point about that. The care of COVID patients had changed a lot assuming that the hospitals aren’t overwhelmed. It’s really gotten a lot better. We’re not over-ventilating people. We have ways to manage now with dexamethasone, et cetera

Dr. Prasad: Et cetera, yeah. And remdesivir, polyclonal drug antibody cocktails. And maybe we’re not doing as much cowboy medicine. We’re not, perhaps, iatrogenically hastening death. The other variable that goes into this calculation is, what is the rate of SARS-CoV-2 in the community that these people are in? And so right here in California with SARS-CoV-2 rates that are bottoming out, I mean, I think, you know you’re talking about, it’s a different calculation than potentially in a hotspot like Michigan was a week ago. Now Michigan’s on the way down, too. The next thing I think is the agency of the person. The type of person who may leap for a J&J vaccine who the counterfactual would be that they’d have to wait three weeks, that might be the kind of person with the wherewithal, the commitment to abiding by restrictions even longer. So we’re not even talking about, you know, who’s the person who’s gonna jump and get the vaccine sooner? It might be the most compliant person not the least compliant, right?

Dr. Z: The most compliant, yeah, the one who’s wearing masks, who’s distancing, is washing hands, not going out. Yeah, yeah.

Dr. Prasad: Right, so it is not an easy, I mean, I just saw right now they’re tweeting slides and they say Johnson & Johnson has done some modeling. And the modeling suggests under a number of assumptions they’re calling conservative that it’s better to get the vaccine now than it is to wait. I question many of these assumptions. I mean, I’m happy to question them. I don’t think they know what the case rates are. I don’t think they know the rate of positivity in the next 12 weeks. I don’t think anyone knows. If we did know we would have had better predictions all along this pandemic. We’ve frankly fucked up. I mean, I’ve seen every model be erroneous, you know, for the whole pandemic. And now you want me to trust your model? So I don’t think they know that rate. I don’t think they have a great, I will have to look at their model when they someday post it on the internet, but I’m not sure what death signals they’re using. The death rate for a 20-year-old is different than a 50-year-old woman, that’s for sure. And frankly, it’s quite low in a 20-year-old woman. And then the last thing is, these particular people who your decision will impact, who are these people and what might they do in the other world? Frankly, it’s pure speculation what that would be.

Dr. Z: So it sounds to me like it’s a complex risk calculation. That’s probably beyond the fold of someone who isn’t a genius in risk calculation like maybe yourself.

Dr. Prasad: No, I don’t claim to be a genius, but I do think about such things and do a lot of work in this space, but I don’t claim to be that good at it.

Dr. Z: Well, so here’s a question. What if we developed a government-sponsored risk calculator that took all the data you were talking about and put it through an AI algorithm, and then you could put in your data and it would tell you, okay, we think you should get that. Like, it’s paternalistic to some degree.

Dr. Prasad: I love it, I love it, yeah, yeah.

Dr. Z: We think you should get the vaccine.

Dr. Prasad: Okay, so I love the way you’re thinking. And I guess what I would say is, in situations like this what have we outlined? You know, just from talking for a few minutes we have outlined the idea that it is a complex trade-off, that you know at least one thing for sure. You know the floor of the clot risk. We’ve established the floor. The floor can go up, but it ain’t gonna go down. We know the floor of that risk. We don’t know the risks on the other hand with the detail. There’s a huge uncertainty interval. What I think is, the purpose of trials and drug regulation, the purpose of empiricism is that, and the reason we don’t just approve drugs based on AI and modeling is that we’re not that good at that kind of stuff. We’re not that good at these kind of situations. The threshold for giving a vaccine is some reasonable confidence that the benefits far exceed the harms in that population. That’s a medical principle. That confidence comes from empirical data. It doesn’t come from some model that somebody did postulating certain rates of COVID spread that may or may not be realized in the real world. So, you know, putting my cards on the table, I’ve been tweeting, I think the right answer in my opinion was to rescind approval for women younger than 50 or potentially 55, just to rescind it entirely, to take away that choice because there are alternatives and because the uncertainty here is too great. And to keep it in everyone else, because I think that in men now they have advanced safety signals. We see nearly nothing. And in older people, again, it doesn’t appear to be affecting them, and they may still stand to benefit. So that’s where I fall on it yeah.

Dr. Z: Okay, okay, this is really interesting, man because you’re not saying, okay, this is fascinating. You’re saying regulations are in place to try to keep you from doing something that’s abjectly not in your interests.

Dr. Prasad: Yeah, correct.

Dr. Z: If we have enough information in this uniquely specific population about this uniquely specific complication, why not say, okay, it’s not approved for y’all, but everyone else for whom the risk is way outweighed by benefit, go ahead and it’s approved. So you’re saying a selective disapproval of this.

Dr. Prasad: That’s what I would have done.

Dr. Z: Yeah.

Dr. Prasad: They didn’t do that. They’re keeping it in everybody. And we will see, then we get to the next point which is that, you know, they’re not selectively disapproving it in this cohort of women, but who actually gonna want that? You know, who’s actually gonna want that?

Dr. Z: That’s my thing. I get messages all the time, I don’t want this thing now. And on top of that, you hear what Johnson & Johnson did in the beginning of this. They went out and their PR people said, well, you know clots can be a problem with all the COVID vaccines.

Dr. Prasad: Yeah, so-

Dr. Z: Well, it turns out that’s not really true, right?

Dr. Prasad: What is it? The best vaccine is the one you’re offered. Well, unless you’re in the fifties and you’re a woman, then you probably want to go to the other one, right?

Dr. Z: Right, right, right, right.

Dr. Prasad: There’s a better one for you, right?

Dr. Z: And there’s a better vaccine for your population that’s available widely.

Dr. Prasad: Yes, I guess what I would say about it is, you know. obviously I have a lot of annoyance with people whose reflex is to defend rather than learn. And I think that was the crux of the problem. And I think that the reason they leap to defending rather than learning is because they are triggered to some degree by the anti-vaxxers who are irrational, and they say things that don’t make sense. And they push for, I think, policies that are frankly, deeply detrimental and harmful. And they say lots of non-scientific things. And in response to that is a group of people who feel like we have to combat that at all costs. And they themselves don’t realize that to some degree if you reflexively leap to defend something, you compromise, I think, who you are as a scientist if you claim to be a scientist.

Dr. Z: I mean, I agree 100%. I’m looking at some comments here. So Coodle1 on YouTube says Canada did a selective disapproval. I didn’t know that, did they?

Dr. Prasad: I haven’t seen that yet.

Dr. Z: I haven’t seen that yet.

Dr. Prasad: Jeez, man, you know, it’s hard to keep up.

Dr. Z: Okay, never trust anything you read on the internet, it may be true.

Dr. Prasad: It may be true, but I guess I’d say, I’ve been in five places at once today. Okay, so I think that’s the right way to handle it. The next thing I would say is, you know, I think we’re getting at something that’s kind of hard to articulate, which is that when it comes to drugs, when it comes to devices, when it comes to medicine, the standard you really want to show is that the net benefits outweigh the harms. We’re proving you that with data, we’re not proving that with a model. We’re not proving that with some sort of speculative way. You know, that’s really why we do studies in all the different fields.

Dr. Z: Right, right, right. Now, you and I are vaccinated. We happen to get the mRNA ’cause those are the ones that were available. And the question now is, so let’s start to pivot this. Let’s say, do we need the Johnson & Johnson vaccine in the United States to get to a state of equilibrium where we’re happy?

Dr. Prasad: Yeah, I mean, that’s a question that is an incredibly contentious question because I think the truth is that the equilibrium state where things get really good and dare we say, that’s called herd immunity, but that equilibrium state, it’s not a static number. It’s a number that varies. It varies based on the, I guess, number of people who are sick, the rate with which unvaccinated people come into contact, how much we resume our activities, whether or not we continue to have different restrictions. It varies and it may even vary by the time of year. I mean, it may be different in the winter than it is in the summer, very slightly differences. And it may vary by region by region. So I think what that number is, I don’t know the answer. I know Tony Fauci likes to look at what the polls say and he said, but I don’t do that. I mean, I think we’re going to find that answer when we find it.

Dr. Z: Wait, so let’s do a thought experiment because you know, our mutual ancestral homeland here, India is suffering incredibly right now. Would you say that a Johnson & Johnson risk benefit analysis in young Indian women in that age group would bear fruit as we see it currently right now with 300,000 new cases a day in India?

Dr. Prasad: Yeah, so that’s a very different situation. So I said, if you have J&J in India, give it to every man you can find. Give it to every elderly woman. And the trade-off point there might even be women in their forties, might be women in their thirties. I don’t know exactly because I don’t know what mortality outcomes are like for if a 25-year-old woman in India were to be afflicted with COVID. I also know their hospitals are absolutely saturated. and they have 300,000 cases a day. So it is really a dire situation. And there, I think, as you point out it could be incredibly favorable risk benefit profile to say AZ or J&J, right now, and that’s very different than California.

Dr. Z: Yeah, and we really don’t know why this is happening now in India, do we? Is it because they opened up their, you know, they’re having mass gatherings, Hindu celebrations, political events, is it because the first wave affected mostly older poor people? And then second wave is affecting younger people? What’s going on?

Dr. Prasad: What makes you think I know anything about India? No, just kidding.

Dr. Z: I’m profiling. I’m like, Vinay Prasad, come on guys. Like, what the heck?

Dr. Prasad: Well, I want to come to that, but there’s one thing that, you know, I’ve been meaning to say about the other topics.

Dr. Z: Yeah, yeah.

Dr. Prasad: Okay. So what have they done now? You know, they’ve approved it back. It’s gonna be on the markets and be for everyone. And I guess we’ll see what they put as to whether they put a warning. There will be some women who still are gonna do it, you know, from 18 to 48.

Dr. Z: Yeah, yeah, for sure, yeah.

Dr. Prasad: 18 to 50, who are those women gonna be? You know, it’s not going to be the person who was critical of it or on the fence, it’s going to be the most sort of enthusiastic vaccine proponent, right? And I bet that person is the person who’s most likely to have been willing to abide by restrictions for another 16 weeks.

Dr. Z: So they didn’t even necessarily need to rush to get a vaccine.

Dr. Prasad: That’s a hypothesis, you know what I’m talking about?

Dr. Z: That’s an interesting idea, exactly, yeah.

Dr. Prasad: I mean, I think the way you have to think about it, it’s even more complicated than their modeling, and their modeling always assumes the average person is a person whose behavior changing. Somebody’s going to get the vaccine, a few people and those people are going to do so because they in their heart believed that the net benefit profile is favorable. I bet that kind of person is the kind of person that had they not gotten it, they would have been very good about staying in their house. And you know, they’re not the kind of person who’s having get-togethers and choir practice in their garage.

Dr. Z: Yeah, yeah, yeah, no, that makes sense, that makes sense.

Dr. Prasad: So I think it’s even more complicated which is also why you need empirical data and not sort of theory. Okay, now I’m back to your question about India.

Dr. Z: Yeah, so people are pointing out online for the Indian question, is it a variant issue or do we have a more contagious variant or more lethal variant?

Dr. Prasad: Oh gosh, they love to say variants.

Dr. Z: They love to say variants, variants, yeah.

Dr. Prasad: Variants, variants, variants, yeah. I guess it’ll be interesting to see just a Google frequency of the use of the word variant this pandemic ’cause it was quiet, quiet, quiet, quiet, quiet. Vaccine was approved, quiet, quiet, quiet, vaccine was given variant, variant, variant, variant, am I wrong?

Dr. Z: Yeah, because how else will the press make money if they have nothing to talk about? ‘Cause look, let’s, okay, okay, this is something that I feel very strongly about. I feel barring something new that happens, and I’m not going to say the word variant because I actually don’t think it’s going to be a variant, barring something new that happens in the United States, our pandemic is winding down here. I mean, it’s because of vaccination. If you look at what’s happening in Michigan, you could go well, okay without vaccination, Michigan’s vaccinated but they haven’t vaccinated the people who are getting sick.

Dr. Prasad: Right.

Dr. Z: Vaccines are the way to prevent this illness. Now again, it’s a question of risk benefit for individual people. Like, what’s your risk of COVID? We talk about that in depth, but I think that once the press and the hoi polloi in the public health community that are really enjoying this thing, and they’re not everybody. I get valid criticism when I say stuff like that from people that work very hard. I’m talking about the people that really, this is like, it’s like, you know, again like “Lord of the Rings,” like the Nazgul, it’s our time. We’ve been waiting all this time, and when you have nothing to talk about and you’re no longer in the limelight that can be like having a rug pulled out.

Dr. Prasad: Right, right, right.

Dr. Z: Whereas I think you and I are rooting for this thing to be over so people stop looking at us, right?

Dr. Prasad: Right, well, yeah, I guess I’d say a couple things. I mean, the reason I kind of laughed when I heard variant was that, you know although it’s easy to say, one does not need to postulate variant to explain what’s happened in places like India. Pandemics come in waves, and although many people were optimistic that what they had seen earlier was the worst of what was to come, it’s clearly not the case. And now they are in the worst they’ve ever seen. But who knows what their future will be. I mean, you have a population that’s a huge population, vast with tight living quarters in many cases with no vaccination. In fact, they were exporting a lot of their vaccines to wealthier nations for months, which is part of the, I think, the hegemony of vaccine politics and that they were just set up for where they are now. My heart aches and breaks for what’s going on there right now. So I think it’s a tough time.

Dr. Z: It’s horrible to watch. I mean, and, you know, I think my cousin is actually ill.

Dr. Prasad: I’m sorry to hear that.

Dr. Z: Yeah, it’s legitly upsetting, but the thing is, you can look at Brazil, you can look at the parts of the globe are now having it. So talking about vaccine hegemony, I mean yeah, okay. We sucked early on and we had a lot of disease. And you know, when I say we sucked, it’s like, well is it something we did? Or is it just the way this disease plays out in this population of fat, ill, chronic disease? You know, Jay Bhattacharya on the show was mentioning that something like 80 odd percent of people who’ve died in the US had two or more chronic diseases.

Dr. Prasad: I haven’t seen that stat, but I wouldn’t be surprised. And I think a tremendously high percentage have been people who were in a nursing facilities.

Dr. Z: Nursing facilities, yep, already. So yeah, it’s quite specific in terms of, so US suffered a lot, we have a lot of chronic disease. But now India, you say, well, maybe they don’t have all that chronic disease. Although I’d argue actually there’s a lot of skinny, fat diabetes.

Dr. Prasad: Of course, yes, MODY, yeah, right.

Dr. Z: And so they are prime-

Dr. Prasad: At a lower BMI their rates of insulin resistance are higher of course, yes.

Dr. Z:  Let me double down on that to explain to people. So even though they’re not overtly fat that you can measure, they have visceral fat and a pattern of insulin resistance that really puts them at risk for not just diabetes, but other things, hypertension, metabolic syndrome, et cetera. And that may be why we’re seeing now this dry brush catching on fire.

Dr. Prasad: But you know, I mean, one of the points you’re making that I think is an astute point which is that, you know, first of all, we have to be honest. There’s not a single person I’m aware of who has accurately predicted pandemic waves in any nation consistently. I mean, all the modelists, the people who are paid hundreds of millions of dollars to run these centers that they’ve been notoriously wrong. So that’s one thing we have to say. I mean, why do nations do better than other nations? I think it is easy to ascribe everything to the actions of people, that is the natural temptation. You did well ’cause you did this. We did poorly, we did this. You did well ’cause you did this. We did poor, you know, that kind of thing. However, it’s possible human actions play a big role, an oversized role, that’s one bucket. There are other buckets. The other buckets are, you know, when you were alerted to the problem, what was the seeding load in the nation? How many people already had the condition?

Dr. Z: Bingo.

Dr. Prasad: It might be different in New Zealand and Australia than in the US. We simply just don’t know the answer right now. We’ll find out in five, six years. The next thing is, are there advantages in terms of the natural habitat, the fact that how tightly you can police and control your borders, the rate in which people enter your borders, those sorts of things.

Dr. Z: New Zealand, China, et cetera, yeah.

Dr. Prasad: The next bucket, the types of people in this country. I mean, Australians are people who are lovely. I love, I mean, I was just in Australia and I had great laughs with many people, but they’re people who follow the orders of government. And somebody was telling me that they sealed the states off, whatever they-

Dr. Z: Individual provinces or states, yeah.

Dr. Prasad: Individual provinces, I forget the term they use in Australia. They sealed those off. You think you can seal off a state in this country?

Dr. Z: Good luck, good luck.

Dr. Prasad: Good luck. Are we the kind of people that you tell me to do all these things, we’re all gonna do it? I mean, some of us are, not all of us. We’re Americans, we’re quite a range of people.

Dr. Z: We are the people who gave the middle finger to England and left, we’re not the same DNA right?

Dr. Prasad: Yeah, we’re not the same. We’re not the same types of people. Somebody told me that what they’re doing now, this person is an Australian living in the States and they want to go visit, and they say, if you want to go visit, you have to fly to Australia. You have to pay like $3,000 to stay in a hotel for the quarantine period, et cetera. You think you could get away with imposing that in this country, you know?

Dr. Z: Mm-mm.

Dr. Prasad: So I think the place is different, the culture’s different. So it’s the actions you do, it’s what the people do. And then I think, you know, it’s all of these things probably to some degree. And then the other thing is that some of it is stochastic. It’s random, it’s chaotic, which means in chaos you have five people with COVID in one country, five people with another, five people. Some of those, it’ll die out just by chance alone. It’ll die out, but in others, it’ll be the brush fire. So I think it’s very hard.

Dr. Z: And actually I think with COVID, it is an over-dispersed disease in that their stochastic effects, random effects are amplified because who’s a super spreader? Where are they, what’s going on? Once that seeds you are so behind. And I think in the US probably they’ll look in retrospect and go, oh there were a few super spreaders that set the place on fire well before we knew what was going on.

Dr. Prasad: Right.

Dr. Z: And we don’t have the ability like they had in China to shut down everything without regard to human freedom or dignity, we don’t do that.

Dr. Prasad: Right-

Dr. Z: And we’re not New Zealand having the grace to live in the Southern hemisphere in a summer during the beginning of the thing and being able to close our borders.

Dr. Prasad: And with a population of 6 million in a certain amount of land area with certain density and certain social safety net, yeah, right.

Dr. Z: Absolutely, yeah, so I think, so speaking of that. Now speaking of the inequity of the whole thing, and stochastic effects, vaccine passports, man.

Dr. Prasad: Oh, God.

Dr. Z: So here we are now with a relatively unequal global distribution of vaccines. Not relatively, drastically, but even in the US it’s like, well, the older people got a little bit first. Healthcare workers got it first. Now it’s open to many. You wrote recently on vaccine passports. What’s your thinking on this?

Dr. Prasad: Yeah, and I’ve been doing even more thinking since I wrote about it, I guess what is a pass-

Dr. Z: Don’t, wait, wait, stop, no. You form your opinion and you defend it to the death 100%. You don’t adjust your priors.

Dr. Prasad: Silly me, silly me.

Dr. Z: Yeah, silly you, thinking from the alt-middle, why would you do that?

Dr. Prasad: Yeah, I guess to define what a passport is first. I guess, what is a passport? A passport is some non-forgeable record you had this done. If we’re going to talk about that card that’s in my wallet right now, that ain’t exactly the most robust document. We could all print that shit out and write some shit on it. Okay, so that’s easy. The next thing is, it’s gotta link it to you which means as you and I both know, if you were an Indian man who went to college and you wanted to go to a bar, you just needed the ID of any other Indian man. You get right in, am I wrong?

Dr. Z: Oh, are you down to clown with brown? Heck yeah, here’s your card.

Dr. Prasad: They just look at it and they’d say, uh…

Dr. Z: Looks the same to me. I don’t know why the white guy’s talking with an Indian accent, but…

Dr. Prasad: It’s really, it was kind of a joke but not really a joke ’cause, yeah.

Dr. Z: It works.

Dr. Prasad: It used to work. Anyway, so I’ve read, I’ll say that just so… So anyway, so you need it to link it to the person. So that means either fingerprint or retina or a photo. And then the third thing is it has to be gatekeeper, a gatekeeper for something. You know, people make a big deal about, is it a government issued passport or a privately issued passport? It doesn’t matter. Somebody put it and it’s a gate and blocks you. And then the next thing I was thinking is like, why are people so eager for this passport? Why do you like it? Like, I really want us to have the passport. I think they have good intentions. They want us all to be safe, and they think this is the way to get safety. And I started to think long and hard about it. And I think part of it is they want themselves to be safe and they think it’ll help their safety. So I thought long and hard about it. And I have this little thought experiment. Can I walk you through it?

Dr. Z: Oh yes, you can, sir.

Dr. Prasad: Okay, so here’s my thought experiment. And here I’m confining my remarks to domestic passports. And in my thought experiment, there are two movie theaters. Movie theater in the world without a passport. And then let’s get to the movie theater in the world with a passport. Okay, movie theater in the world without a passport. So a movie theater this summer, you know, there’s no passport, who’s going to be in there? There’ll be three groups of people. One, people who’ve been vaccinated like you or I and older people, we’ve been vaccinated already. What’s our chance of something bad happening to us? Almost nothin’, zero.

Dr. Z: Zip.

Dr. Prasad: Yeah, super, super low.

Dr. Z: Yeah.

Dr. Prasad: Okay, some of us have been vaccinated and we are receiving active chemotherapy, B-cell depleting chemotherapy. Very rare or few of us. Those people have some slight risk if they go to the movie theater. To be honest, they know that. They probably won’t even, might not want to go. The next group, people who can’t be vaccinated. Who can’t be vaccinated? Well, right now, kids under the age of 16. They just don’t yet have an approval. They can’t be vaccinated. They might be in the theater, but you know what? What’s the chance something bad happens to them?

Dr. Z: Hm, it’s quite low.

Dr. Prasad: Quite low. The third group in the world without a passport, there are people who have opted not to be vaccinated. They’ve chosen not to be vaccinated. Could something bad happened to them? Sure, they’re in the movie theater without being vaccinated. Something can, but they’re also the ones who have chosen not to be vaccinated. Okay, now let’s imagine the world with the passport. ’cause I’m trying to figure out, who’s the passport helping? The world with the passport. Okay, group one, those of us who’ve been vaccinated. Are we any safer? We might be from 99.999% or 99.9999998, you know. We’re slightly safer but we were already super safe. The next group, the kids, are they safer? They were already super safe. They’re slightly super safer ’cause we got the passport. We’re blocking people who are unvaccinated. The third group of people, the person with B-cell aplasia who got vaccinated, Maybe they are going to come into the theater now ’cause they know there’s no one to be there who’s un-vaccinated so maybe a couple people in the theater who otherwise would stay home. The third group, the unvaccinated people. Well, they’re not gonna be allowed in the theater. They’re not allowed, they don’t have the vaccine. The passport is excluding them from the theater. Are they better off? And I said, well, it depends on what they do instead. If you assume they go home to their houses and they knit, you know, then there’ll be safer. Okay, are they gonna do that?

Dr. Z: The people who don’t get vaccinated are probably not the type that are going to go home and knit.

Dr. Prasad: Yeah, I don’t know if they’re going home and knit. Not only they didn’t get vaccinated, they didn’t get vaccinated, they went to the God damn movies, they paid their money and you didn’t let them in. I would imagine they’re not so happy.

Dr. Z: Right.

Dr. Prasad: Okay. So here’s what they’re going to do. They’re either going to go to their garage and say, you know what, my 12 buddies who aren’t vaccinated, come over to my house, let’s watch a movie. Okay, what’s their risk now? Actually the risk in the whole population might be higher. It might be higher because actually now instead of dissipating them in a movie theater with certain ventilation, you packed them all in a garage.

Dr. Z: You created a super spreader event.

Dr. Prasad: Maybe, yeah, and the next thing they might do is, I mean, they might have other gatherings in places that don’t have fire codes and packed places. They might spread COVID more. It might make all of us more unsafe. People don’t think about, the other possibility is perhaps God forbid some of them are so angry that they do what angry people do in this country which is they do things that are unpredictable, chaotic, and can harm a lot of people. And if one of those two bad things happen, you’ve undone all the good-

Dr. Z: Undone all the good of it.

Dr. Prasad: Right, so the more I think about it from a policy standpoint, as a policy person, as somebody who’s like, if I was in charge of government, would I do it? I would say it’s different in this country than it would be in Australia, perhaps because they have different sort of rules and obedience. They also probably have a lower rate of people who are opting not to do it. In this country, it would be an incredibly polarizing thing. It’ll lead to backlash. People will be angry. It has unprecedented, and after one year of this kind of suffering, the anguish people are under, I don’t want to put ’em in the squeeze like that. Who knows how they’ll act out.

 Dr. Z: That’s the best argument I’ve ever heard because it doesn’t bring into bear things where people go, well, I don’t care about that. Like equity issues, fairness issues, things like that. You can pull that off the table and just go from a pure policy standpoint. It’s not gonna improve outcomes so why do it? Why then deal with the equity questions of like the fairness questions and so on and the liberty questions and the fact that our population, just forget it, you don’t need it. This is what I said when I did my first piece on vaccine passports, here are the pros, here’s the cons. Here’s what I think, why are we talking about it? Get everybody who wants to be vaccinated, vaccinated. Everybody who wants to be vaccinated vaccinated.

Dr. Prasad: I think that’s the key, yeah.

Dr. Z: And we’re already getting there. I think half the US population now has had one vaccine.

Dr. Prasad: Yeah.

Dr. Z: Yeah. So it’s happening anyways. I don’t think we need it. I think we need to then look at things like, well, can we go ahead and stop talking about opening schools and just open schools, right?

Dr. Prasad: Right. I would come to that and say, but I guess I would just echo your last point, which is, you’re right. The particular argument I’m advancing is not an argument from principles. It’s not an argument about equity, although I am concerned about equity.

Dr. Z: Yeah, me too.

Dr. Prasad: But it’s not that argument. It is an empirical argument that one, although you hypothesize this will make us all safer, one, there are reasons to doubt your hypothesis. The true answer is, I don’t know if you’ll be more or less safe in these worlds. I’m just giving you enough sort of inkling that perhaps it won’t go the way you think. And a lot of policy things don’t go the way you think.

Dr. Z: Yeah, like ACA.

Dr. Prasad: What about the Indians and cobras, you know this story?

Dr. Z: Indians and cobras, wait, what? Tell me this.

Dr. Prasad: Yeah, this is a, it’s a old policy issue. I think when Britain conquered India, of course, you know, they held us, our-

Dr. Z: And I miss those guys so much. You know, my people, the Zoroastrians, we prospered under the British. That’s not true.

Dr. Prasad: Yeah, so I’ve read. Yes, of course my father was born in British India so that was a different world.

Dr. Z: Yeah, as was my grandfather, yeah.

Dr. Prasad: As you must be, yeah, maybe even your father.

Dr. Z: My dad was yeah, he was born in ’39.

Dr. Prasad: Yeah, for sure, yeah.

Dr. Z: Yeah, and actually my grandfather had a handlebar mustache and a vaguely British Indian accent. And it was like, you know, “the Brits, at least they brought order.” That’s my grandfather.

Dr. Prasad: The unintended consequences story that comes out of Britain and India was, you know, obviously, there are cobras in India, they naturally occur. And I think in some places they paid for people to, if you kill a Cobra and you bring it to us and you show us the dead Cobra, we’ll give you some money as an incentive to get rid of cobras. And guess what happened? Indians started having cages and farming cobras.

Dr. Z: Oh.

Dr. Prasad: Grew a lot of cobras, killed them and then brought ’em in. And so they had many more cobras than there were. And then when they did away with the policy, guess what happened? They opened all the cages. Yeah, so there was a bigger problem than when they started. But I mean, I guess it’s the law of unintended consequences.

Dr. Z: Every time you say cobra I just think of G.I. Joe, though. You know, I think of a Cobra Commander, “Hey, Destro.” But that’s not the cobra we’re talking about. But see, this is again, it’s like top-down solutions that they think with good intention, great intention. They have these unintended consequences because nobody’s actually empirically looking at what could actually happen. That’s why we need better artificial intelligence to replace the lack of straight up intelligence in some people.

Dr. Prasad: I think in this case, you’re onto something, which is that the passport issue is motivated by a strong emotion. And I think there are two types of emotion. One emotion is, if I did it, damn, I should be safe.

Dr. Z: Right.

Dr. Prasad: And I think the, sort of the cognitive error is that you are already super safe, and this is going to make you very, very modestly safer. But you know, it’s gonna take a lot of political capital to accomplish. The other cognitive error is that people who choose not to do it are bad people. And I think that’s also into the passport issue.

Dr. Z: Yeah, yeah, it’s a moralization thing. And the other thing, and that goes back to Fauci not letting vaccinated people be okay hanging out, right? Like, oh, you still need to wear a mask. You still need to do this. I gotta tell you this. Now I’m just going to rant for one second. I am tired of this. The Bay Area has a very low case rate. The chances of me getting COVID unmasked with other people out there is like infinitesimally small. The idea that we still are required to wear masks outside makes me violently angry because it’s spring. Today I went hiking. It’s my birthday, I went hiking on my own trail which I’ve complained about many times. I did not bring a mask. If anyone was going to ask me about it I was going to get in a fight with them. That’s how at the end of my rope I am. And I’m with my wife who’s like triple masked because she’s she’s compliant. She was like, “Well, but it’s the law.” And I’m like, “I’m not playing that game.”

Dr. Prasad: Yeah, well, I guess my understanding of the law is that you have to wear a mask outside if you cannot maintain distance.

Dr. Z: Correct, okay, okay, well then-

Dr. Prasad: There’s a loophole so you just say, I can maintain distance

Dr. Z: I can maintain distance. There you go, yeah, yeah.

Dr. Prasad: And then I guess I would say I mean, I don’t know if it was, it’s a stupid rule to wear the mask outside. Okay, it’s a stupid rule right now.

Dr. Z: Yeah, I agree.

Dr. Prasad: It should be done away with.

Dr. Z: It was probably a stupid rule in the beginning.

Dr. Prasad: Yeah, it probably is. Yeah, it was probably always a stupid rule. Yeah, it was always a stupid rule. It was always one of those rules where, you know, you could see it and made us feel good. We knew we were the good people.

Dr. Z: Right, virtuous.

Dr. Prasad: Not the bad people. We’re the virtuous people, we’re the good people. You probably knew who I voted for, too.

Dr. Z: Yeah, that’s true, that’s true. You don’t have to put it on your mask. You just put the mask on, right, yeah.

Dr. Prasad: You know who I’m voting for, you know, okay. But you know, that wasn’t really necessary. And I think that Paul Sax, actually, the ID chief at the Brigham I think he wrote in “New England Journal” a little blog post about it. It didn’t get as much traction as it ought to have probably because, you know, there’s still a few people in this world that people don’t like dunking on. And I think Paul Sax at the Brigham, ID doc, excellent. You know, great guy and nobody wants to dunk on him. And, and you know, he was probably right all along. He’s obviously right.

Dr. Z: Mm-hmm, should we look at some comments, you think?

Dr. Prasad: Sure.

Dr. Z: Or do you want to talk? Do you have something you really, really want to talk about?

Dr. Prasad: No, I guess I got all worked up by the J&J thing.

Dr. Z:, I think it’s good that we talked about that because that’s gonna be all over the news right now. People are worried about it, man. I get a lot of, you know, it’s crazy dude. Like, I get people messaging me who have run small companies and they’re worried that their employees aren’t getting vaccinated. And I say, well, I think whoever needs to get vaccinated wants to get vaccinated, get vaccinated. And the employees that aren’t vaccinated, I don’t think they’re going to put you at very high risk depending on where you are, you know? So we have this latitude. Let’s see what kind of comments we have here. New Hampshire dropped the mask mandate a week ago and now cases are soaring and schools have gone remote, Savannah. Okay, explain what’s going on with that when that kind of thing happens?

Dr. Prasad: Well, I guess, I mean, I guess one is, I guess I don’t know for sure that the facts in question are true. However, simply because they occurred in a row doesn’t mean they’re there due to each other.

Dr. Z: That’s right, that’s right. It’s a correlation causation thing. And this has been going on throughout. And again, I’m leaning towards the idea that now that COVID is so widespread, our interventions on a public health level are not as powerful as we think, we have much less control. And instead the one thing we do control quite well, is, you know, once you get enough people vaccinated it’s just less wild brush to catch on fire.

Dr. Prasad: I’ll say one thing on that caught my interest. You know, Michigan a couple of weeks ago was going through hell. You know, their cases were exploding. And you know, I said something like, send ’em vaccines. And then other people said, things like-

Dr. Z: Lock ’em down.

Dr. Prasad: Lock ’em down or tell ’em to wear the masks a little more. You know, that’s the thing. And I’m like, you know, when your house is on fire, you call the fire department. You don’t just go throw a bucket of water on it, you know?

Dr. Z: Yeah.

Dr. Prasad: And that’s what’s going on in Michigan. And I think there are a lot of misconceptions. One misconception was like, when does the vaccine start working, start working? I don’t care when the highest antibody titer is. I care when it starts working. And the answer is in a randomized controlled trial the cumulative frequency plot. It’s not a multiplier, it’s a cumulative frequency plot, separates at day 10. That’s when it starts to separate. The end point is symptomatic infection. You have had COVID for several days before you’re symptomatic. If by day 10, we can see in a population a difference in symptomatic infection, when did it start working? Several days before day 10. So it’s working even a few days after you give it. So when the house is on fire it is putting water on the fire right now, they ought to have done it. I don’t know why. Actually, I do have some theories why the government where it was slow to or didn’t divert vaccine supply there. But that’s the answer when there is outbreaks in this country, which there will be, you take your vaccine and you push it there and you vaccinate people. You don’t ask ’em why they shouldn’t stay home. You don’t suddenly make them wear a mask on the trail. You don’t tear a swing down off the playground. You don’t, you know, all this bullshit we do to make ourselves feel better. You give ’em the vaccines. You have the answer, you have the solution.

Dr. Z: Yes, that’s what I think, too. And you know, look, look, look, we’re just two docs, right? There’s plenty of other docs who are like, lock it all down. But I’ll tell you this, those are only the most loudest docs on Twitter. If you pull a bunch of on-the-ground physicians they’re not sitting here going, lock down, do this, do that. Even when they’re working 36-hour days taking care of COVID patients.

Dr. Prasad: I’ll just say one thing about the lockdown. Okay, I know the vaccines’ efficacy ’cause we’ve run a couple of, we’ve run many randomized controlled trials. How much does a lockdown work? When does a lockdown work? What was the seeding condition that a lockdown works? How long does it work for? Which countries does it work in? When does it work? We don’t know the answers to these questions. Someday we will, probably in a decade, we will have really good studies that I think are done by all of the people who are quiet right now ’cause they’re actually scientists and they’d reserve judgment until they actually can do the right study. And we will know. And I won’t be surprised if many of these people who say these things turn out to be quite wrong so.

Dr. Z: Yes, I agree. You know, the burden of proof is on you to do something very disruptive to people’s lives like that.

Dr. Prasad: I think you get like one crack at it, you know, like the beginning.

Dr. Z: Early.

Dr. Prasad: Right, it’s fine. But you know, when you start to, like, you talk about like year long years of prohibitions, I mean, at some point someone’s got to ask for some data. I don’t know, at some someone’s gonna be like…

Dr. Z: Why? I mean, you can just do stuff. I mean, they’re rolling the dice with hundreds of millions of people and it’s not a harmless thing, right? Like, you know what I mean, Jay will talk at length about the potential harms of these policies.

Dr. Prasad: I’ll say one thing about the harms. You know, the other thing that I keep seeing is that people were like, suicide. They’re like, well, you know, suicides are actually not going up, they’re stable.

Dr. Z: Right, right.

Dr. Prasad: And I’m like, you know, suicide is not a marker of a good mental, it’s like a very extreme thing. It’s like saying that like, you know, my relationship with my friends is good as long as I don’t commit homicide, you know? Like, yeah, so as long as you don’t kill your-

Dr. Z: The homicide rates haven’t gone up to that means that generally social cohesion’s there.

Dr. Prasad: That’s exactly right.

Dr. Z: Yeah, right, right, right, right, right, yeah.

Dr. Prasad: You’re right, it is. It’s like, yeah, but you know, people can have suffering and anguish and emotional thing and not get to that level.

Dr. Z: And they actually did show that.

Dr. Prasad: Yeah, of course.

Dr. Z: They showed that the levels of anxiety and all that are true. I mean, this is the thing, man. I think that we are still barely out of the primeval ooze in terms of our understanding of our fellow humans, complex social systems and things like that. And anybody who thinks they know that and is absolutest about you should walk the other way. And unfortunately I think those people may be making policy in this country. They’re certainly tweeting policy in this. Oh shit, I forgot to change the camera, there I am. They’re certainly tweeting policy in this, am I right? Am I right?

Dr. Prasad: You’re right.

Dr. Z: There we go, yeah, just too much to do, man. On my birthday, it’s too much to do. You’re asking so much of me. Actually, I told you, I’m like, let’s go live. And you were like, “Wait, what, live? Why would we do that?”

Dr. Prasad: These days you need a safety net.

Dr. Z: I know, you really do ’cause you can get canceled so easy.

Dr. Prasad: You want to talk about the people to avoid in life. The people to avoid are people who don’t like to laugh. If they don’t like to laugh, if everything’s like, that’s not funny, then all right, all right, it’s not funny. Okay, I go my way. I wanna have a good laugh. I don’t want to be unfunny all day.

Dr. Z: So angry with you right now, Vinay because basically I don’t like to laugh.

Dr. Prasad: Well, actually, if I must be full disclosure, you know, when I’m in your neck of the woods and I always come to hang out with you, the reason is, I enjoy our conversation.

Dr. Z: You know, me too. And the audience doesn’t get to see this, but we’ll just do it now. How we talk with each other is, it’s every other thing is punctuated by either outrage or laughter every five seconds. And it’s just a joy because it’s back and forth, and we’re working out what we believe in real time based on what we know. And it’s just fucking great, man.

Dr. Prasad: That’s a good comment, the art of conversation.

Dr. Z: And you know, so now I’ll make a little philosophical statement. The third space, like Robby Pearl was on the show the other day talking about why doctors are so miserable. And one of the reasons is the loss of that physician lounge where we could get together and talk so much shit and work stuff out, talk about like, okay, how would we think about this patient? What’s going on? What’s going on in the news? What an idiot this guy is. I mean, it’s great stuff.

Dr. Prasad: That’s a great point.

Dr. Z: Do you have one at UCSF or?

Dr. Prasad: I’ve never, I don’t have the key. But I will say that actually probably as a physician in a teaching hospital, which I know you’ve spent many years at, it’s always like, you know, at the end of rounds you guys chat for 10 minutes or at the beginning, you know, that kind of stuff. Those conversations are vital for everyone’s emotional wellbeing, to recharge, and to maybe think about a patient in a different way. And that’s like the best part of the job.

Dr. Z: Yeah, I agree, it really is. That’s what I loved about, and I told Robby that when we did our interview. I was talking about that, I was like, I actually started getting a little emotional because I was remembering the early days of my job at Stanford where I had a team of house staff, everything from a medical student all the way up to the R2, R3. I had a group of people in my multi-specialty group that would tell me, we are happy to subsidize your salary as a hospitalist because you provide such amazing service to us as orthopods or surgeons or whatever and let us do what we’re good at, thank you. So collegiality, connection, mentorship with the house staff. We had the time and the resources to see our patients. Epic was read only at that time, rather than writing and reading. And so we got data in, but we didn’t have to become data clerks. And it was so awesome. Like the social workers, the case managers, the physical therapists, we were all friends walking through the hospital. You couldn’t get down the hall without high-fiving someone or fist bumping someone or “Hey, how’s so-and-so doing?” “Oh man, it’s a train wreck.” That was a joy, dude, it was a joy. And the problem is when they start pulling each piece away because they start mandating more productivity. The EHR becomes a bigger part of it. House staff work hour restrictions mean less house staff coverage. Next thing you know, I have no house staff and I’m just by myself. Yeah, that was the end of it. I lasted one year after that because I was like, everything that made my job meaningful has been slowly taken away. And the problem is, when do you pull the plug? Do you continue to slog on going, this is the best I can do? Or do you go, this isn’t me?

Dr. Prasad: Well, unlike you, I have no career options so I gotta, I gotta stick with it. I gotta stick with it.

Dr. Z: You got no choice.

Dr. Prasad: I got no choice.

Dr. Z: Well, you’re 10 years junior to me, when you get-

Dr. Prasad: That’s not the only difference, but yeah.

Dr. Z: When you’re 48, then you’ll be like, nobody’s gonna tell me how to live my life anymore because it’s gonna end soon. That’s how I feel. I woke up this morning, I’m like, everything hurts. I’m tired, well, what changed? I’m one year older. Not really!

Dr. Prasad: Yeah, I mean, I think you’re doing a great job of reminding me the pros and cons of academic medicine. Okay, the pros are, you’re right. And they have been taken away, but the biggest pro of course is getting to work with people who will someday sit in your chair or in your shoes, the trainees. Because like, you know, whether they, in my line of work and I always work with the fellows. So the fellow’s gonna eventually be an oncologist. Although, you know, so often their interests are in like one specific disease type or the other. My interests are very diffuse but nevertheless they are interested in, we have some shared interests and so you could tell him what little wisdom I have to impart. I think the other part about my job I like is the research in the sense that sometimes you have some ideas, and find some junior person who’s way smarter than I was at their age. And I tell them this just vague idea. And then they go run with it. And then they come back to me like two weeks later and they say, “Hey, let me show you this.” And they show me this graph. And I’m like literally like Magellan. I’m the first person who, maybe that’s not the right analogy. I’m like-

Dr. Z: Captain Cook?

Dr. Prasad: I don’t know, some explorer, the first to see something. I’m the first to see something. I’m like Neil Armstrong.

Dr. Z: There you go.

Dr. Prasad: Okay, that’s a better analogy, yeah. I’m the first to see what this data looks like. And that’s kinda cool. Like, I don’t know, that’s science, that’s discovery. Like, you know, it can be whatever in my line of work. So that’s the plus. I think the downsides are the funding. You know, I talk about academic medicine. You know what it’s like? It’s like being a Mary Kay cosmetics salesman. You know what this is?

Dr. Z: Ooh, yeah, yeah.

Dr. Prasad: During the 1980s and ’90s?

Dr. Z: It’s a total pyramid scheme.

Dr. Prasad: Exactly, it’s this crappy company where, I don’t know all the details, but I vaguely recall from when I was a kid and my mom, my mom’s friends, that you would like buy this case of cosmetics and then you’d have to sell it to your colleagues.

Dr. Z: Nowadays the nurses do it, it’s called LipSense. It’s actually a real thing.

Dr. Prasad: Oh really?

Dr. Z: Yeah, yeah.

Dr. Prasad: It’s a real thing? But you know, it feels like that as a professor, because I’m like going around in my hat in hand saying, “Hey, would anyone want to give me some research funding so I can keep my project going?” I’m like, what kind of world is this? I’m like basically like, you know, I work for university, but I’m trying to get all my funding from the outside. So it really feels like you’re an independent vendor. That’s terrible, I mean, it’s a terrible system because the people who are controlling the purse strings, by the way, we never talk about Fauci. One of the biggest purse string controllers. You talk about a guy who I like a great deal, but he’s done some things that I’m critical of. But you wonder why so few ID doctors are critical of this guy. You know, he’s the guy who controls their funding.

Dr. Z: Yes, yes.

Dr. Prasad: So you don’t want the guy on TV, the guy who controls the funding ’cause no one can say something bad about this guy. Even when he says things that are I think wrong like that one vaccine two vaccine debate he was wrong about, the mask flip-flop he was wrong about, the herd immunity threshold. I don’t know what he’s doing, but he shouldn’t be inflating it based on what the polling is. And if he was, he shouldn’t be telling Don McNeil from “The New York Times.”

Dr. Z: Oh, man.

Dr. Prasad: Those are some of his-

Dr. Z: That’s a powerful thing, too because people don’t realize that people are scared to speak out if you’re an academia, and academia is where you should be speaking out. Dude, I know you have a hard out.

Dr. Prasad: Oh, I do have a hard out, huh?

Dr. Z: So we got like just five, couple minutes.

Dr. Prasad: Five minutes, okay, we got five minutes.

Dr. Z: So you know what we’ll do is, let’s see if there’s a comment or two here that we can do here. Oh, speaking of which, you know, I gotta say this. One thing that’s been nice. I used to have to hustle for sponsors all the time. Now I don’t worry about that. My supporters who subscribe to the show pay for all this. It’s so liberating, dude. Like, I can say what I want, I don’t have to worry. Academia is a pyramid scheme says Carissa Davis. She’s a PhD so she knows.

Dr. Prasad: It’s true.

Dr. Z: David Stanek says, when will the CDC earn its trust back? I feel like it’s lost for about half the country, I agree. But I think it can happen right? Maybe?

Dr. Prasad: Well, I guess I would say it’s broader than the CDC.

Dr. Z: Yeah.

Dr. Prasad: It’s public health.

Dr. Z: Public health.

Dr. Prasad: And I guess I would say that if you want to earn someone’s trust back, you first have to admit that there’s a problem. And I think that a lot of people have not yet admitted that there is a problem. And I think the problem is multifold, but the problem is overstating things when there’s uncertainty. The problem is turning matters of science into matters of mortality. The problems is tribalism making us more tribal, pushing us. And then the last problem is intertwining public health and science and political processes.

Dr. Z: Oh yeah, oh yeah.

Dr. Prasad: Yeah.

Dr. Z: Well, I think those are fixable issues, but we better get to fixing ’em ’cause otherwise we’re all, I mean, you need a reasonable public health apparatus to get anything done that needs to be done. Although that’s always in question-

Dr. Prasad: The part we’ll agree on is that it desperately needs to be fixed.

Dr. Z: Yes, yes.

Dr. Prasad: I wish I share your optimism.

Dr. Z: Vinay Prasad, my brother. This has been a joy, man. We gotta do this again. I think we’ll mix live and pre-record because they’re totally different vibes, man.

Dr. Prasad: Uh-huh.

Dr. Z: Like, I like this live vibe because it’s a little intense.

Dr. Prasad: It’s intense.

Dr. Z: Like you get that cortisol. Whereas when we’re doing pre-records we’re like, okay, let’s talk some smack.

Dr. Prasad: It’s more like how we’d talk.

Dr. Z: Exactly. There’s a lot at stake, right? Because you actually have, you have a lot more to lose than me. It’s hard for me to get canceled anymore because I have this platform. But man, you’re still you. We need you, we need you in academics. We need you doing research. We need your voice, we need your podcast, Plenary Session. We need this, and speaking of needs, I need you to share the show. I need you to comment. I need you to, if you want to become a supporter do that otherwise, hey, you know, Vinay loves you. You know I love you. That’s it, that’s it. We gotta go, right?

Dr. Prasad: Yeah.

Dr. Z: Man, this was real. All right, now here’s the fun part. I gotta learn how to stop the show. So I’m gonna go over here and stop the show. All right guys, I love you. We is out, peace.

Dr. Prasad: And this is the part of the show where ZDogg told me to just sit here quietly while he stops the show.