#189 - COVID-19: Current state of affairs, Omicron, and a search for the end game
Drs. Marty Makary and Zubin Damania join Peter Attia to discuss the Omicron variant, vaccine risks/benefits, natural immunity, and the poor messaging surrounding COVID-19. They explore the difference between science and advocacy, the erosion of trust, and the path to an "end" to the pandemic.
Deep Dive Analysis
20 Topic Outline
Understanding Omicron: Virulence and Transmission Compared to Delta
Immunity Measurement: Beyond Circulating Antibodies to T-Cells
Defining the COVID-19 End Game and Return to Normalcy
COVID-19 Policy Framework and the Problem of Groupthink
Distinguishing Science from Advocacy in Public Health Messaging
Evidence and Policy on Naturally Acquired Immunity
Erosion of Trust in Science Despite Rapid Progress
Evaluating Current Mandates and Policies with Existing Data
Vaccine Risks: Myocarditis and Labeling Concerns
Myocarditis Incidence: Pfizer vs. Moderna in Young People
Booster Risk-Reward and Policy Divergence
Lack of Honesty and Humility from Public Officials
Rationale for Widespread COVID-19 Testing
The Missing Endpoint: What Defines the Pandemic's Conclusion?
Downstream Consequences of Lockdowns and Draconian Policies
Tribalism and Polarization in the COVID-19 Discussion
Lessons from Past Pandemics and Future Preparedness
Parental Strategies for Unreasonable School Policies
Identifying Voices of Reason and Independent Thinkers
The Value of Holding Strong Convictions Loosely
6 Key Concepts
Science vs. Advocacy
Science is a messy, uncertain, and evolving process that speaks in probabilities, constantly changing with new information. Advocacy, conversely, communicates with complete certainty, often simplifying complex scientific nuances to promote a specific policy or action.
T-cell Immunity
A crucial, often under-recognized, component of the immune system that provides robust and long-lasting protection against severe illness from COVID-19 variants like Omicron and Delta, even as antibody levels wane. It is difficult to measure with commonly available tests.
Natural Immunity
The protection acquired after recovering from a COVID-19 infection, which studies suggest is reliable and long-lasting against reinfection and severe disease. This immunity is often based in the local mucosal area, potentially offering different protection than systemic vaccine immunity.
Groupthink in Medicine
A phenomenon where a small, non-diverse group of politically appointed individuals make decisions, leading to a vacuum of scientific research, suppression of dissenting opinions, and flawed policies based on foregone conclusions rather than evolving data.
Peacetime vs. Wartime Vaccine Communication
Peacetime communication emphasizes vaccine absolutism, minimizing discussion of risks for community benefit. Wartime communication, however, faces uncertainty, changing data, and stratified risks/benefits, yet often applies the same absolutist approach, leading to mistrust.
Alt Middle
A 'synthesis position' that seeks truth by integrating various perspectives, rather than adhering to extreme, polarized viewpoints. It involves critical thinking and a willingness to question one's own beliefs, fostering common sense and understanding.
11 Questions Answered
Omicron is about 90% less efficient at replicating in lung cells, leading to milder symptoms (more upper respiratory) and less severe disease, confirmed by lab, epidemiological, and bedside data.
Yes, it is postulated that COVID-19, particularly with variants like Omicron, may become the fifth seasonal coronavirus, similar to how the Russian flu of 1889-1891 may have evolved into one of the four existing seasonal coronaviruses.
Public health officials have fixated on antibody titers because they are easily measurable, leading to a scenario where the immune system's broader cellular immunity (memory B-cells and T-cells) is undervalued, and a constant chase for high antibody levels through boosters is created.
There is no clear, articulated end game from public health officials, leading to an ongoing cycle of restrictions and mandates based on case numbers rather than severe outcomes, without a defined strategy for returning to pre-pandemic life.
Multiple studies, including a large Israeli population study, suggest that natural immunity is robust and long-lasting, providing significant protection against reinfection and severe disease, potentially more so than vaccinated immunity in some contexts.
Trust has eroded due to the blurring of lines between science and advocacy, suppression of scientific discussion, academic bullying, inconsistent messaging, and a lack of honesty and humility from top officials, particularly regarding topics like natural immunity and gain-of-function research.
mRNA vaccines, especially Moderna, carry a risk of myocarditis or myopericarditis, particularly in young males aged 15-25, with rates as high as 1 in 7,600 after the second dose. While often mild, the long-term effects are not fully known, and this risk needs to be weighed against the ultra-rare risk of severe COVID-19 in healthy children.
Widespread asymptomatic testing for COVID-19, especially with antigen tests, may cause more harm than good by creating stress, unnecessary quarantines, and financial burdens, without significantly impacting transmission of highly contagious variants like Omicron. Testing should primarily be used when it changes patient management, such as for symptomatic high-risk individuals who could benefit from therapeutics.
Lockdowns and stringent policies have led to significant negative downstream consequences, including a mental health crisis in children (e.g., 51% increase in self-harm admissions in young women), reduced cognitive performance in children born during the pandemic, and a potential decline in routine childhood vaccination rates.
Dr. Monica Gandhi (UCSF), Dr. Amesh Adalja (Johns Hopkins), Dr. Martin Kulldorff (Brownstone Institute), Dr. John Mandrola (EP doc), and David Katz (Yale) are mentioned as rational, data-driven voices who advocate for a holistic perspective and are willing to change their opinions based on new evidence.
Parents should demand clear endpoints to restrictions, question the rationale for mandates (e.g., booster mandates for low-risk children), and engage in nuanced discussions with pediatricians about vaccination strategies, such as considering a single dose of Pfizer or acknowledging natural immunity.
26 Actionable Insights
1. Prioritize Self-Awareness and Inner Peace
Focus energy on self-awareness and managing your internal state, recognizing that external frustrations often reflect internal conflicts. Limit exposure to negative influences like social media (e.g., Twitter) that hack dopamine drives and contribute to discomfort, as this can improve personal well-being and longevity.
2. Practice Humility and Honesty
In interactions, particularly when errors occur, prioritize humility and honesty by acknowledging mistakes and explaining what could be done differently. This approach builds trust and can prevent negative outcomes, even more so than the severity of the error itself.
3. Value Adaptability in Beliefs
Trust individuals who demonstrate an ability to change their opinions and adapt their beliefs in the face of new information, rather than those who rigidly adhere to the same stance regardless of evolving data. Embrace the mantra of ‘strong convictions loosely held.’
4. Differentiate Science and Advocacy
Understand that science is a messy, uncertain, probabilistic process that evolves with new information, whereas advocacy often communicates with complete certainty. Recognizing this distinction is crucial for interpreting public health messages and avoiding the blurring of these lines.
5. Combat Tribalism with Openness
Actively combat tribalism by being a role model: listen to others, admit when you are wrong, and avoid echo chambers that reinforce extreme views. Foster open discussion and diverse opinions to navigate complex issues.
6. Assume Good Intent in Others
Cultivate the practice of assuming good intent in others, especially those with differing views. This approach can help overcome tribal tendencies to villainize out-groups, level the playing ground for constructive conversation, and reduce personal anger.
7. Evaluate Policy Holistically
When considering public health policies, evaluate them from a holistic, integral perspective, focusing on broader societal well-being (e.g., preventing deaths, avoiding hospital overwhelm, economic function, mental health) rather than a reductionist focus solely on preventing cases.
8. Seek Diverse, Independent Voices
To find reliable and rational information, seek out diverse, independent voices in the medical community (e.g., Monica Gandhi, Amish Adalja, Martin Kulldorff, John Mandrola, David Katz) and be wary of information from politically appointed physicians or those with strong political angles.
9. Acknowledge Natural Immunity
Recognize that naturally acquired immunity to COVID-19 is a real phenomenon that generates good protection against reinfection and severe disease, and individuals with natural immunity should feel confident in their immune protection.
10. Risk-Stratify COVID Treatment
Tailor COVID-19 treatment and prevention strategies based on individual risk factors, age, and health status, as a one-size-fits-all approach can lead to overuse of interventions in low-risk populations.
11. Explore COVID Therapeutics
If you contract COVID-19, discuss with your doctor evidence-based therapeutics like fluvoxamine (reduces mortality by 91%), budesonide (steroid inhaler, reduces hospitalization), and hypertonic saline (nasal rinse), as these are often underutilized. Note that supplemental Vitamin D has weaker correlative evidence.
12. Rethink Widespread Asymptomatic Testing
Question the utility of widespread asymptomatic testing for respiratory viruses, as there’s little precedent for tracking infection rates outside of morbidity and mortality. Only order a test if the result will directly change patient management.
13. Question Mandates for Low-Risk
Critically question mandates (e.g., boosters, quarantines) for low-risk populations like healthy college students, especially when their personal risk is low and professors/community members have access to their own protective measures.
14. Demand Policy Endpoints
If you are subject to public health restrictions, especially in schools, demand clear endpoints and criteria for their removal. Policies should not be implemented indefinitely without defined conditions for their cessation.
15. Manage Respiratory Pathogens Responsibly
Adopt reasonable strategies for living with respiratory pathogens: be careful around vulnerable individuals, wear a mask if you suspect exposure, and stay home if you have symptoms. This approach acknowledges their endemic nature without creating mass hysteria.
16. Prioritize Lifestyle for Health
Incorporate lifestyle modifications such as diet, exercise, and addressing metabolic syndrome as foundational strategies to improve overall health and potentially reduce vulnerability to infections.
17. Focus Beyond Antibody Titers
Understand that an intense fixation on only antibody titers for immune strength can be misleading, as antibodies naturally wane over months. Cellular immunity (memory B-cells and T-cells) is also crucial for preventing severe illness and should be considered for a more complete picture of immunity.
18. Rethink Frequent Boosters
Given that booster efficacy against symptomatic COVID can wane significantly within 10 weeks (e.g., to 35-45% for mRNA vaccines), and cellular immunity still protects against severe illness, constantly chasing high antibody titers with frequent boosters may not be an effective long-term strategy.
19. Space Out Vaccine Doses
Consider spacing out the first and second doses of mRNA vaccines as much as possible, as some immunologists suggest this could be more beneficial for immune response and potentially reduce the need for vigorous booster campaigns.
20. Evaluate Vaccine Risk for Young Males
Parents of young males (15-25) should be aware of the myocarditis risk associated with mRNA vaccines, particularly Moderna (potentially 3-5 times higher than Pfizer), with rates around 1 in 7,600 after the second dose. This warrants a nuanced discussion with pediatricians, especially given the ultra-rare death rate from COVID in healthy children.
21. Align with Global Health Guidance
Consider international health guidance, such as the WHO’s recommendation against universal booster programs (to avoid prolonging the pandemic and increasing inequities) and their advice against masking children under six, or the European CDC’s stance on primary school masking.
22. Question Perpetual Boosters
Be critical of the potential shift towards perpetual or annual booster recommendations, especially if the language changes to ‘up to date’ like software, and consider the long-term utility of frequent boosting for mild illnesses.
23. Beware Anecdotal Amplification
Be cautious of anecdotes, especially when amplified online, as they can distort data and influence fear and policy decisions. Prioritize well-designed scientific studies to understand true risks and probabilities.
24. Acquire Vitamin D Naturally
Instead of relying solely on supplemental Vitamin D, prioritize getting outside, exercising, and acquiring Vitamin D naturally through sun exposure, as the evidence for supplemental Vitamin D improving COVID outcomes is weaker and correlative.
25. Avoid Hospitalization When Possible
Recognize that hospitalization inherently carries risks due to medical errors, infections, and complications. Prioritize strategies to stay out of the hospital whenever safely possible.
26. Distinguish Fact from Opinion
When consuming information, especially on complex topics like health, actively differentiate between what is presented as fact or knowable data and what is personal opinion. This helps in critically evaluating the information received.
10 Key Quotes
Omicron is not infecting lung cells... it's about 90% less efficient in replicating in those lung cells. This is a more mild virus.
Marty Makary
Omicron may be nature's vaccine.
Marty Makary
Always know the difference between science and advocacy.
Peter Attia
This is probably the greatest lesson we should learn from the pandemic... we've got to openly talk about the corruption of science itself, how there has been a shutdown of scientific discussion, how you cannot talk about certain things.
Marty Makary
Natural immunity was 27 times more protective, adjusted for age, than vaccinated immunity.
Marty Makary
The therapeutics we have today have cut COVID deaths to zero in the clinical trials.
Marty Makary
We've moved to a second pandemic after COVID-19, which is a pandemic of lunacy, which is this overreaction to mild illness.
Marty Makary
We've got to get past the heavy hand of government. We've got to treat people like adults. We have to move from a culture of mandates to a culture of responsibility.
Marty Makary
As a general principle, I have no trust in people who can't change their opinion.
Peter Attia
The best investors will tell you they have very strong convictions loosely held.
Peter Attia