You can also listen to this episode on Apple Podcasts or Spotify—or wherever you get your podcasts!
Confused about how to handle COVID this fall and winter? Wondering how to think about masks, boosters, and reducing your risk of getting sick?
On this episode of Beyond the Prescription, Dr. McBride talks with Monica Gandhi, MD, MPH, who became one of the most prominent public health experts in the country during the pandemic. Dr. Gandhi is a Harvard-trained physician, expert in infectious diseases, and professor of medicine at the University of California, San Francisco (UCSF). She is the director of the UCSF’s AIDS Research Center and the medical director of the San Francisco General Hospital HIV Clinic.
Dr. Gandhi’s career centers on the principle of harm reduction, born out of her decades-long work in HIV. Harm reduction is the belief that public health policies should consider not only the pathogen (i.e., HIV or COVID) but also people’s basic needs for social connection, intimacy, and agency—and that public health’s job isn’t to shame, stigmatize, or even to eliminate risk (that’s impossible) but rather to arm people with information and tools to mitigate the inevitable risks we face.
Her new book, Endemic: A Post-Pandemic playbook, published in July 2023, aims to reckon with the country's present condition: comprehending and living with a new respiratory disease and how to face the coming variants and next pandemic with reason, science, courage and compassion.
Listen to hear Drs. Gandhi and McBride discuss where we have been, where we find ourselves now, and how we ought to manage the virus this season, and in the coming years.
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of our conversation is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go beyond the prescription. Let's talk about Covid. Joining me today is my dear friend, Dr. Monica Gandhi. Monica is a physician and professor of medicine at the University of California, San Francisco. She's the director of the UCSF AIDS Research Center and the medical director of the San Francisco General Hospital HIV clinic.
[00:01:21] She studied at Harvard Medical School and then at UCSF where she focused on infectious diseases, specifically HIV. She holds a master's in public health from UC Berkeley, with a focus on epidemiology and biostats. During the pandemic, Monica became one of the most prominent public health experts in the country.
[00:01:42] National and local political leaders, medical professionals, and the media often turn to Monica for her thoughts and recommendations on how to handle the constantly shifting dynamics and demands of COVID. She has now put her thoughts together in a new book, Endemic: A post pandemic playbook out in July 2023.
[00:02:02] It aims at reckoning with the country's present condition, comprehending and living with a new respiratory disease back in 2020, and how to face the coming variants and the next pandemic with reason, science, courage and compassion. Monica is not only an accomplished physician and public health star, she's also a dear friend.
[00:02:24] I got to know Monica during the pandemic when I started noticing that patients were suffering not only from COVID, but also from the sustained fear, anxiety and social isolation of the pandemic. I was immediately drawn to her straight talking, evidence based and compassionate voice.
[00:02:42] It was a rarity in a sea of COVID experts. She seemed to consider the whole patient, to value the importance of human connection as much as guarding against an infectious disease. So we became fast friends. We've written op eds together. And we started a group text of seven women in medicine and public health who now have communicated multiple times a day for over two years today, Monica and I will discuss where we have been, where we find ourselves now and how we ought to manage this virus this fall and in the coming years, Monica, it is so fun to have you on the show today. Thank you for joining me.
[00:03:21] Dr. Monica Gandhi: Thank you so much. It's so good to see you.
[00:03:23] LM: So tell me about your book, let's start there. What are the lessons learned and then how can we move forward with COVID in our midst in perpetuity and the potential for new viruses coming along? So tell me about the book and what are the major themes in the book?
[00:03:40] MG: Yeah, so thank you. It starts out with an introduction to the concept of why I was so interested in infectious disease and I went into it and that really had to do with my interest in HIV, even from a very young age, my interest in social justice, my interest in disparities, and my interest in the fact that people are stigmatized for infectious diseases, which I always found completely shocking in the world of HIV.
[00:04:04] It's kind of Lehman's language on the whole pandemic and where we are with vaccines and therapeutics. And then it goes into harm reduction. And what that means is really that you have a pathogen. Let's say we had HIV which we did and we still do. And the way that we dealt with HIV, at least those people who are expected dealt with HIV is they dealt with this kind of whole person aspect of care.
[00:04:29] So you have a person living with HIV, but you also have their mental health and their sexual needs and their needs for companionship and their needs to have hope and it to become an HIV doctor became a really, I think, a doctor that sees the whole person and doesn't just see the disease or the pathogen or just the virus.
[00:04:51] And what I saw with COVID 19 is that we used the same bad stigmatizing language that we used with HIV with COVID. There were actually public health people that said, COVID idiot, or you're a bad person for getting COVID, which I still will never understand. And then I thought of harm reduction. What are the ways that we can absolutely fight the pathogen?
[00:05:12] In my mind, it's biomedical advances, but also minimize the harm done to society. And the three I think, or supposed mitigation, because I don't think they helped, that did harm, in my opinion, were prolonged school closures, were closing other medical care, not taking care of other medical needs, especially mental health, and then third is not letting people see their family members in the hospital.
[00:05:36] I think that's actually, frankly, inhuman. So I dwell on those for some time, chapter five is all school closures, then the subsequent chapters on around global equity, because if biomedical advances are your way out of a pandemic, you need to give them to everyone. And then the last chapter is a 10 point pandemic playbook.
[00:05:54] How do we go forward. If this happens again, and I hope it doesn't for 100 years and not get to this point where we are now, where there's about a 30% trust in public health. By the latest poll, a health affairs paper showed that in March of 2023, 30% of people trust the CDC. I mean, there must have been mistakes made for such a low number of trust.
[00:06:14] I don't subscribe to the view that Americans are anti science. I think they saw all the confusion. They saw the harm and they don't trust. And how do we get to a pandemic playbook that makes sense, that takes other people's needs into account, societal needs into account, outside is safer, therapeutics, vaccines. And then we're in the building of trust phase and we can go into that.
[00:06:36] LM: Yeah, harm reduction makes sense on a population level. It also makes sense on an individual person level, just for people who are listening and you don't know what that exactly means. It's rooted in the idea that risk is everywhere, that being a human being involves risk by being in relationships, by driving a car, by existing with bacteria and viruses, merely being a human carries occupational risk.
[00:07:08] And we cannot make risk zero. In the case of HIV, correct me if I'm wrong, the message never should have been abstinence only. Because what abstinence only as a message does... is it deprives people of their basic biological needs to have sex and intimate relationships, and it stigmatizes the person for having human needs.
[00:07:33] So, Harm Reduction's message to HIV patients and populations is, let's not tell you no, let's tell you here are the risks, let's arm you with facts and nuanced information, and give you the tools. Condoms, education, and a way to frame risk so that you can make your own decisions based on your risk tolerance, which you're entitled to.
[00:07:58] You can be very afraid of HIV and never have sex, and that's Up to you, you can be less afraid, but as long as you're aware of the data, you're talking to your partner, then you do you. So I think what I saw in my practice was people suffering from being shamed for going to their child's graduation, even after they'd been vaccinated.
[00:08:24] You remember those pictures of people. On beaches and media pundits were shaming them for being outside when we knew from get go that outdoors was pretty darn safe. And we know that people need to be outside. So somehow we lost the plot and we of course cared about death and dying from COVID, like that is a given, right?
[00:08:47] There's no question that human tragedy. I mean, zero question, but somehow people started moralizing human behavior. And then, if you spoke out, like you and I did, about trying to balance the harms of the virus with the harms of not living a life that is just meeting basic biological needs, somehow if you're talking about that, you're morally reprehensible.
[00:09:15] So, it's a really weird time in our country. I don't need to say that to you, but I just wonder, what do you think is that in inherent tension? Like, where does that come from? That this concept that like doing things, living your life, even if you've been vaccinated is morally reprehensible. I just don't understand.
[00:09:37] MG: Yeah, I didn't understand it until I really went back to the history of HIV, and then I think I made a connection, which is that in the history of HIV, 1981 was when these case reports were first described in the CDC, MMWR, and the President of the United States of, at the time was Ronald Reagan. And because of that, he and his wife also with Just Say No as a campaign for addiction, pushed an abstinence only approach.
[00:10:03] He actually didn't even talk about HIV until 1985. And there was a very like, just say no, there's just something wrong with you if you want these needs. And so the public health community. who tends to be left, as I am, completely pushed against that and said, no, that is a absence based only is an awful approach.
[00:10:22] And it's really unkind and not compassionate. And we can't tell people what to do. And instead we'll give you tools to stay safe. And we'll tell you about condoms and later prep and treatment, but really like it is up to you. You are a human being with your own needs, like you said, in your own risk tolerances and what happened during COVID, as Trump was president, so the public health establishment who's left, and so are ID doctors. They pushed against him no matter what he said, even when it was reasonable, like prolonged school closures weren't happening in Scandinavia and Europe. And he said, let's open schools in summer of 2020. And then people were all writing about opening schools, public health officials, and then they changed their mind when he said that.
[00:11:02] So I think it is actually a push against, it was not reasonable because it was clearly A reactionary pose against the right. And the problem with that reactionary poses at harm children. And it was completely topsy turvy from what we did with HIV. And I think there were two other reasons. One is the media thought that would with a lot of fear, they thought that would kind of scare people into compliance with masks or public health measures. But the problem with that is fear doesn't work. It makes people like paralyzed. I mean, that's what it does in nature. And so it doesn't make you say, oh, I completely understand that even though we have vaccines, they're still telling me to socially distance, even though Europe's gone back to normal with the vaccines.
[00:11:48] Instead of understanding that again, distrust came. And then I think that the third was that we just didn't celebrate the vaccines and no physician is really against vaccines in general. Like it's just a degrading 96% of physicians got vaccinated for COVID with the first two shots. Boosters I think have to be nuanced, but it was a celebration of the vaccine of the HIV therapies in 1990s and with the vaccines. At least the media still made it seem like it was really negative and that didn't unlock the key to normal life, but they didn't do that in Europe. They did. They unlocked the key to normal life. I don't know where anyone thought that normalcy wasn't an important human need, like being connected, being together, joy.
[00:12:37] Being around people, celebrations, church, synagogue, temple, these are part of the rituals of human existence. They're so terribly important for our mental health. So when the vaccines came we could have really celebrated them and instead there's been so much fear still.
[00:12:53] LM: And it's so funny how anti vax, like true anti vax sentiment, people who are saying that the vaccine, you know, alters your DNA and, you know, turns you into an alien, that messaging almost touched the messaging of let's have a vaccine that's life saving in some high risk populations, but it's not enough.
[00:13:15] Let's continue to mask and distance. It almost felt anti vax, as you just said, for me, the moment, I mean, there are many moments during the pandemic when I thought, golly, Baba, we are not messaging this Right, was Provincetown. So Provincetown was that weekend when it was rainy and cold up in Provincetown, Mass. There was a lot of people in intimate settings, post vaccine, and a lot of people got COVID. But no one died. A lot of people got colds, flus. To me, that should have been the CDC's moment to say, “Oh my gosh, this was the stress test for the vaccine. These people have been vaccinated, they got together, they had sex, they had fun.
[00:13:58] And they got colds. And they got flus and that's terrible and we don't want that.” But you know, what are you gonna do? And we should have said, “that's a vaccine success story.” But instead, that's when the CDC said, “nope, put masks back on. And that's when, among other moments where I thought, oh my gosh, we've lost the plot because we're moving the goalpost.”
[00:14:17] It's like kicking a soccer ball down the field and you're, you shoot for the goal and then the goal gets moved. And again, just to be clear to people who are listening, this is not to say, go get COVID, And you know, who cares? Not at all. We can do two things at once. We can be mindful of our risks for a virus and arm people with tools and information.
[00:14:38] We can also be mindful of the risks of living in a state of hypervigilance and fear where we aren't allowed to be ourselves and be in relationships and go to school and see the faces of our teachers. Like, we can do hard things. We can do many things at once. And I think it was this sort of paternalism from public health institutions, it felt very draconian and sort of condescending like that we know better when the vast majority of people who got COVID particularly after the vaccine did extraordinarily well.
[00:15:07] MG: I mean, I think that the interesting thing about what you just said and where I had a little different twist to the conversation was my history in HIV. And so if you look, people were saying a lot of people around that time was saying the same thing, actually, CDC's moment and they blew it, but I could bring in this concept that HIV.
[00:15:28] We never judged people, or what I mean is the people who judge people, we didn't like those people. We didn't like those public health officials who judged. We thought they were really out of line. And we used a harm reduction pro, in this case, sex approach. And so in the case of COVID, what happened with the Delta variant surge in Iceland is the Iceland prime minister came out and said, Look what's happening, everyone.
[00:15:55] You all got vaccinated, the hospitalizations are extremely low. This means the vaccines work. Go back, go forth, be with one another. This is an excellent example of how the vaccines work. And then everyone got vaccinated and the appropriate people got boosted, like older people, and everyone moved on. And they really did move on in Europe.
[00:16:14] So there was this kind of celebration of that moment, and I do write about this in the book. That was, I think, the moment. where the CDC really did lose its trust with the American people and we need to rebuild it, which is a lot of what the latter half of this book is, that the people who are talking right now, like the vaccines and therapeutics don't work are not actually rebuilding trust and certainly not rebuilding trust in technology and advances.
[00:16:42] Like we rebuilt hospitals. Trust in antiretrovirals with HIV to say that life wouldn't change after these advances didn't make sense. This is the other thing that's really important is that beyond bringing the HIV angle to it that I could because I've just thought about it for so long. [00:17:00] It's also important to say that respiratory viruses, cause I live, I'm an infectious disease doctor have always plagued humanity and I worry every winter about respiratory viruses.
[00:17:11] I worry about RSV, and I worry about influenza, and rhinovirus, and other coronaviruses, and adenovirus, and human metapneumovirus. But, actually the difference is, we have better tools for COVID than we do for human metapneumovirus in an older person, for example. I can give Paxilovir to an older person. There are boosters.
[00:17:29] There are no vaccines for human metapneumovirus. There are no treatments for that virus. RSV, we just got a vaccine. So, it means... That we really moved quickly, and we didn't celebrate that, that rapid movement, that incredible biomedical advances. But we did in HIV. We did. We said undetectable equals un-transmittable.
[00:17:49] You don't have to use a condom if you're on antiretroviral therapy. And we were just much more harm reductionist and sitting with the patient, making shared decision making. At least that's what, again, the good HIV doctors were doing. And here it was top down decision making.
[00:18:03] LM: And the MRNA technology that is so incredibly advanced is being deployed now for potential vaccines in HIV.
[00:18:12] MG: it's very exciting. Yes.
[00:18:13] LM: It's very exciting. I mean, I'm with you. Like, you and I got accused, both of us, for spreading hopium. It's so funny
[00:18:22] MG: It's a strange word. Yeah.
[00:18:23] LM: It's such a strange word. Like, you know, but it's sort of the way American medicine addresses patients in general. We think about health as this sort of set of boxes to check. It's about your cholesterol, it's your height, your weight. When hope, joy, and the sense of an end point to a crisis are really important for health. I mean, it's foundational. It's fundamental. The other thing is that hope and caution are not mutually exclusive.
[00:18:50] You can protect yourself like you and I did by getting vaccinated and boosted as needed and staying home when you're sick and celebrate the successes of the vaccine. Celebrate that. Now, as you just said, we have so many more tools to protect ourselves from COVID than we do for, um, metadenoma virus or para influenza virus, which every single year get many of my patients sick and in the hospital, because this is not a new concept that viruses tip people into crisis when they're particularly vulnerable.
[00:19:22] I mean, again, this is not new. We have done this before.
[00:19:26] MG: Well, I mean, I'll give you a good example of what you just said, what it reminded me of. Number one, my husband passed from cancer three months prior to the pandemic, and actually we didn't have hope fundamentally with bad cancer and we had moments of hope, but there wasn't. The thing about infectious disease is it's the other, unlike cancer, which is the self.
[00:19:48] I just wish, I kept in thinking as we were going through the beginning of COVID, I wish that I had someone to turn to during the worst parts of his cancer who would say vaccines work, therapeutics work. And so I wanted to be that person to help tell Americans that advanced therapeutics for an infectious disease, which is other. work. And it's not hopium. It's actually modern medicine technology. And then the second thing is it also could be that if you look at the world right now, I think there's a kind of a microcosm maybe on Twitter, but if you look at the world, I went to a large concert at something called the Chase Auditorium in San Francisco, which is like 20,000 people in an indoor space.
[00:20:30] And it was a large rock concert. And then later I went to Cirque du Soleil and. All these people, because I just was on the news a lot in San Francisco, came up to me at the concert and they said, Hey man, got vaccinated, rock on, you know, like, and they weren't, you know, distancing or masking. They were really living back with that joy that made life so meaningful.
[00:20:51] And I was really happy to see that is. It's kind of the point, right, of combating infectious diseases or combating anything that you're doing in medicine is the point is to infuse as much joy and normalcy into human beings lives as possible. And the other thing, and I really want to mention this, is my father was immunosuppressed during COVID. He was 88 and going through B cell lymphoma treatment. So this is as you know, when we talk about the vulnerable, this is really as vulnerable as we can get because he's not only vulnerable to a virus that is really age stratified in this risk. But he was on chemotherapy. And I kept on writing about how well the vaccines were working in my father.
[00:21:32] Trying to give people the personal anecdote. Because after vaccines and a booster, he had sky high antibodies during chemo. He sailed through his episode of COVID that he got at a family wedding, you know, very well. We did give him Paxilovid and I think that's very appropriate. I couldn't get at why... People didn't think the vaccines worked among the immunocompromised because the mRNA vacs, and I work with an immunocompromised population because I work with HIV, these mRNA [00:22:00] vaccines are so immunogenic. They're much more than like a whole virus vaccine or old protein based vaccine. So I'm really pushing the mRNA vaccines on my immunocompromised populations because they work so well.
[00:22:10] If someone wanted a Novavax, I was not encouraging immunocompromised, but Novavax was great for others. So it was just, again, like knowing that they really work. Even there was this idea that we would leave immunocompromised people out of the loop, but we weren't because we had this new technology that didn't leave them out and I kept on bringing my dad up to try to tell that I'm not just saying that even though I do work with an immunocompromised population.
[00:22:36] This is as bad as it gets and he's done very, he's done very well and he's back to normal life. He's, he went to the Shakespeare Festival in Utah the other day with his 92 year old friends. Yeah, he's 88, he's turning 89 soon.
[00:22:49] LM: It's amazing. I mean, you were always the champion of the T cells being cellular immunity, the arm of the immune system that protects against severe disease. So we learned pretty early on that it was post Delta that the vaccine could no longer block infection. That ship sailed, you could get 4, 5, 10 vaccine doses and still get infected,
[00:23:13] MG: Yes, exactly. T cells and B cells together are literally arming us from future protection from severe diseases. That's why it's so enduring.
[00:23:20:] LM: Right. And somehow that message just didn't get across, like the waning immunity conversation, it's like, I felt like, probably like you, I wanted to poke my eyeballs out because people thought waning immunity meant you were naked, like you're running outside of your house without any protection, when that just was never true.
[00:23:38] MG: These are basic principles of immunology that we learned in medical school. And I wrote a thread on Twitter just two days ago, cause I'd been thinking about it for a long time. How long does immunity last? Cause we've had some very nice new data about antibodies and it looks like it's going to last a long time for years actually.
[00:23:55] And so, and. The reason I thought about T cells so much is it's so hard to have seen an early AIDS and infection that HIV that hurt the very arm of the immune system, T cells that helped you combat infection. So I think about T cells all the time. I say the word T cells to my patients because what's your T cell count?
[00:24:14] But beyond the basic concepts of immunology, we've had a wealth of immunology information during the pandemic from really sophisticated groups in the UK and San Diego. They have done beautiful work that shows T cells cover all variants, and that's really important because I know we think we have to update the vaccine all the time, but they really do cover all variants because it's kind of a blanket of protection, and then B cells adapt their antibodies towards new variants.
[00:24:41] So there is really an adaptive immunity that we've shown both in this pandemic and from basic principles.
[00:24:47] LM: Monica, let's do a rapid fire Q and A. I'm going to ask you the questions that patients ask me every day About COVID and how to face the upcoming fall winter season. So there's a lot of buzz about these new variants, right? The BA
[00:25:03] MG: 286. Yeah. Yeah. I remember it because it's like 86, Ward 86. Yeah. Our
[00:25:09] LM: right. And the fear about this is that it has so many mutations that it may be, it may have escaped immunity from the vaccine. So when someone asks me, what should I do? Should I mask? Should I distance? Should I get another shot in the face of this new variant? What do I tell them?
[00:25:28] MG: So, there's two variants that keep on being talked about in the news, EG5 and BA286. And the one thing I will say is, actually, BA286 is not taking off like EG5 is. So we keep on saying, hey, there's a case in the UK, and there's a case over here. Actually, it seems extremely not very transmissible, and I think it's going to end up being one of those ones that go away.
[00:25:49] Because... If you're more transmissible, then you keep on rising in incidence. And the one that's rising in incidence is EG5. It looks like it's more transmissible than XBB1.5. These new variant directed vaccines that are coming out in mid-September are directed against XBB1.5, and they're going to very happily cover EG5 because there was just a paper on that. That EG5 and XBB 1.5 just differ by one mutation. So that's done with EG5. We'll know it's going to work.
[00:26:18] LM: But, let me ask you this. When you say cover, it doesn't mean you're going to, you can get the new booster and you won't get COVID. Right. So let's clarify that; it doesn’t block infection.
[00:26:27] MG: what's so important going back to BA286, which you were asking about originally, is that there's a concept of sterilizing immunity. What is sterilizing immunity? It's what we saw with smallpox infection or smallpox vaccine. And that was really the ability of Antibodies in the nose, which are called IGA to block all infections and the intramuscular vaccines that we get for COVID-19 do not produce that high of IGA in the nose.
[00:26:55] Guest: They did actually earlier on, or at [00:27:00] least the IGA was adequate to cover alpha. So there was blocking of transmission early on, but when Delta came along, 2 things happened. Number one, our antibodies go down with time and Delta had mutations across its spike protein and the vaccines didn't work as well against Delta, at least in terms of antibodies.
[00:27:16] But this is where our T and B cells are so important because there's never been a variant or a sub variant where the vaccines or your natural immunity don't work against at least in terms of cellular mediated immunity because T cell coverage is very broad so you can have lots and lots of mutations. But it still provides a blanket of protection and that's been shown again and again by Dr Setti's lab and other UCSD and then the second reason is B cells which T cells help produce more antibodies from those B cells are sitting dormant.
[00:27:50] Like you said they're in memory And then if they see another subvariant, even if it is BA286, they say, Oh, I, my job is to make more antibodies. I'm not going to make antibodies directed against some old variant in the past. That's not how these work. They're adaptive. I'm going to make antibodies directed against what I see.
[00:28:05] It will take a couple of days, but they will make, and you'll get infected, but you will be protected against severe disease. So there will be ongoing protection, even with both of these new variants with severe disease. If you've been naturally infected or had he vaccine before, and most people have had both, many people have had both. What about who needs boosters? That's the next question. I
[00:28:29] LM: Yeah. So as for boosters, so people are asking all about these boosters coming out at the end of September, early October, I remind people, cause most of my patients. I've had COVID and have been vaccinated. So they asked me, what's the optimal timing? I'm going to my daughter's wedding in November. What should I do?
[00:28:46] I remind them that again, you can get 10 shots and still get COVID. So they're not, these vaccines are not sterilizing. But if you wanted to try to time the vaccine to get a transient bump in your antibody levels before the wedding, which again, may not. It's like, if you jump into a freezing cold swimming pool and you're wearing a wet suit, aka vaccine, you're still going to get wet.
[00:29:11] MG: but it doesn't harm you with the severe disease. Yeah. Like it doesn't harm you.
[00:29:15] LM: Exactly. It's not, you're not going to have severe disease, but having had COVID and having had the vaccines previously is already going to likely protect you from serious outcomes. But if we're talking about the new booster, you might time it to get two weeks before the anticipated crowd you're going to be in.
[00:29:35] But, I mean, what do you think? Do you believe in like timing the vaccine to an event?
[00:29:37] MG: I don't actually believe them in timing them to an event because like you just said, I don't know if it's going to rise high enough to prevent infection at that event. What I actually really believe in and I wrote about this a lot of times is spacing the vaccines appropriately to get the best immune response.
[00:29:51] So I'll give you a good example that it looks like you should definitely wait at least four and likely six months since your last infection or last booster, whatever, they're the same thing. They're showing you the virus or parts of the virus in the case of to get another shot because you're essentially, you're going to interfere with that B cells trying to settle into memory, and this was data from the NIH.
[00:30:13] So, for example, my father, I would have encouraged him at 88 and going through chemotherapy to get the fall booster. However, he got, just got COVID, and it was in mid-July when he got COVID. So I'm going to ask him to please wait four months, regardless of events. So July, August, September, October, and then get the vaccine then. At least four months, maybe six so that he is doing exactly what vaccines are supposed to do, which is help refresh his immunity.
[00:30:41] Again, his immunity is more needing of refreshment than a young person's because young persons have very good immune responses to vaccines or infection.
[00:30:50] LM: It's a great point. And the other thing to remind people is that, you know, you can go to your daughter's wedding in November as planned. And if there's no one in the room with COVID, you know, it doesn't matter if you had the vaccine or the booster at all. In that moment, you can also be in any room anywhere because COVID is ubiquitous and it's not a wedding, but just because it's a wedding doesn't mean you're more likely to get it.
[00:31:08] That said, the virus tends to spread in closed Poorly ventilated spaces. It's just an odds ratio. It's not like weddings equal COVID and walking to the, the small boutique pharmacy, you're not going to get COVID. The virus isn't that smart. It's just different.
[00:31:24] MG: yeah, I think that's a really, not only is that a really good point, but the inoculum question, which I wrote about really early on. Oh, by the way, I was really mask focused very early on. In fact, when you say that I was on the, on the news, actually the first year and a half, it was all about masks, but I actually was talking about masks and this concept of inoculum.
[00:31:43] And there was just a recent paper that showed this is likely true, but it's amount, it's the amount of virus that you're exposed to. So that's why, yeah, dose. Right. And so, That's why in a closed indoor space, you'd be more likely if someone has COVID. Because the other important thing is not everyone has COVID all the time.
[00:31:59] That was the issue about treating people like they were vectors or something was wrong with them. Or we taught people to be scared of breathing. Actually, that is a thing that my patients said again and again to me. They said, I've been through one pandemic and I was told to stay. These are people living with HIV.
[00:32:15] And they said, I was told the way to stay. Stay away from people now. You're telling me to stay away from people and I can't even breathe like it was so hurtful the messaging a very soundbite messaging wear a mask save lives stay at home save lives Because it was not nuanced and spoke to the fact that It's really more likely when you have COVID that you're spreading disease.
[00:32:37] That was another interesting thing that changed with time is the degree of spread is really most when you're symptomatic and now we have really updated data around that But there was this idea that and I also wrote about that idea at the beginning but I changed my mind with time when I saw the data that you were spreading it when asymptomatic Just like most other infections. The majority of it is spread when you're symptomatic And that's good because that's what updating of data and recommendations means, right?
[00:33:01] LM: We have to have the epistemic humility to acknowledge that when we have new knowledge, we can change recommendations. That's not rooted in politics or ideology or, you know, who we vote for. It's, it's science change. It's iterative.
[00:33:14] MG: There was this idea that Americans needed simple messaging and I thought that was really insulting to the American public because I actually find Americans very pro science and very sophisticated. And I mean, just like everyone else. And so I didn't think they needed simple messaging, boosters for all mass for all. Like I thought they needed, you know, an explanation of the data instead of just say no.
[00:33:35] LM: Yeah. So there is sort of no more hot button. Issue than masking in this country, right? It became this sort of lightning rod and. It was just a fascinating sort of display of vitriol and science entangled with politics when masks are just masks. So when patients ask me now, should I mask in the fall?
[00:34:00] Should I wear a mask in an airplane? Should I mask when I'm outside? I tell people that despite searching for data to show that masks Reduce the risk for transmission. We failed to prove that they are that effective, particularly cloth masks and so even surgical masks. we do think is that a well fitted mask that is worn consistently and that is high grade can protect the wearer and whether or not to wear it is really up to you and your personal risk tolerance. Will I wear a mask when I'm sick with COVID? Well, I'll probably be at home in my room anyway, I wouldn't want to go to work sick or go to a social event sick. So first of all, I think there's no role for band aids because again, masks are for the wearer.
[00:35:00] But I also am trying to manage people's expectations because I think most people want to understand the reasoning. At the same time, there are some people who just want to be told. Mask up.
[00:35:10] MG: Yeah, I mean, so I will say that you're absolutely right, like I really go over the data on masks in this book. So it, because it was such a contentious issue, I really wanted to go over the data and it's kind of a vast section about all the studies, the Cochrane Review and negative studies in children. I mean, meaning negative harms in children, especially those who are learning how to speak.
[00:35:32] And so I really try to. comprehensively review that. And I agree with you that the only conclusion we can make as physicians and those who evaluate data is that if you all the time, we're a very well fit and filtered mask, like N95, KN95, KF94s, that you're going to protect yourself to a certain degree, but not always actually, cause it loosens, you'll take it off to drink something like it's not always, but that is all we can say. In medicine, putting all of this data together and I wrote the chapter actually for our infectious disease Bible on COVID and we really with another infectious disease doctor and we go over the data on masks. And that's what we conclude. You really mass mandates. It's not appropriate to put them back because of the different ways people are mass.
[00:36:16] And also because there is personal determination. If someone chooses to wear a mask or not, for example, my father. Again, I like to bring him up because he's high risk, except that I don't actually think he's that high risk because he's been vaccinated and now he's had COVID, but he doesn't hear very well because he had an accident 10 years ago.
[00:36:33] So masks are really, he doesn't like them because they interfere with his hearing. So it's when we think about people who are living with disability, um, it's a nuanced approach to what they would like to do. It has to be a personal decision, but I also reassure people so much about the vaccines that it's really interesting to see I don't think I have a single patient who's still masking. To my knowledge. They come in and they're like Hey, you convinced me. Like, you know, you got me to even take it sometimes if I didn't want to. And I, now I'm living with this risk like I've lived with other respiratory viruses.
[00:37:05] LM: At the same time, I, you wouldn't either shame anybody for wearing a mask if you want to wear a mask. That is your prerogative.
[00:37:13] MG: We are not very kind. Why don't, why are we so unkind? Like, we never, I don't know, in medicine the nice doctors are the ones who don't tell people how they have to be. I don't know, like, you just give them tools and then you let them...
[00:37:24] LM: Wasn't that the deal in medical school? I was, like, humility, empathy, compassion.
[00:37:30] MG: Not stigmatizing, not blaming, not people calling them idiots. So I can remember we treat lung cancer with compassion. If there's maybe an associate, you know, there is an associate of smoking. I mean, we'd never say, well, they don't deserve care. And in this epidemic, we were so unkind. We said the unvaccinated don't deserve care. Some people said…
[00:37:48] LM: Right. And we called children vectors of disease, grandma killers. I mean, you know, it's just not appropriate. It's not really in keeping with the sort oath of kindness that we take as doctors or
[00:38:00] MG: It really isn't in keeping with the principles of physicians.
[00:38:03] LM: it's also just not accurate. I mean, like, okay, let's talk about long COVID, which is real. I have a patient who has, I'm not satisfied with the diagnosis, by the way, like he carries a diagnosis of long COVID. But I look at the diagnosis of long COVID in this patient as a placeholder for when we actually get the diagnosis. I think COVID tripped a wire such that he has myriad. I mean, he has every organ systems on the fritz.
[00:38:30] He has profound dysautonomia. He has neuropathy. He has new anemia, renal insufficiency. I'm like a dog with a bone with my patients. We're going to figure out what's going on. He's going to have a bone marrow biopsy, a kidney biopsy. But my question is about long COVID. What is it? What is it not? And how did we get to a place where some of my patients and the general public are really afraid of it.
[00:38:57] MG: So I think that three and a half years and almost four years in, unfortunately we've done a disservice in terms of catching too many things into the long COVID diagnosis and not really being clean about our examination of data. So, What it looks like through all that noise and the WHO calls it an infodemic because you can put out papers that aren't very good and that's too much information and then you really look into it and you see that analyses were done improperly or it was observational confounded data or you didn't control for X or was ICD 10 not codes and it wasn't, you know, really understanding if they're inflammatory biomarkers.
[00:39:33] And if you put all the data together, it does look like any severe illness, sepsis. Influenza, COVID causes longer symptoms, but we knew that because as a specialist in infectious disease, I knew that from influenza. And that's why the incidence of this has gone down with the reduction of severe disease.
[00:39:52] So that's one good thing. That's good thing because we have the tools to prevent severe disease. Second is that we don't know all the contributors to. Why when you've had a severe infection that you get lingering symptoms, but in general, it has something to do with inflammation. We knew that for a long time in HIV and the anything that's even remotely promising or being tested as promising has anti-inflammatory properties, meaning like metformin looked promising in an observational study and it has anti-inflammatory. Property. So it's gonna go ahead and there's gonna be a study of randomized metformin, or a paxlovin study, like trying to kill the virus that actually closed early at Stanford. They are gonna study it more, but that would really imply that there was persistent R N A virus in multiple parts of the body.
[00:40:37] And we haven't seen that with other R N A viruses like hepatitis C, which is an RNA virus, does stay. But only with hepatocytes, only with liver cells. So we haven't seen that with other coronaviruses either and we do have six other coronaviruses. So that'll be studied but I'm more interested in the anti-inflammatory and I'm very interested, actually committed to preventing severe disease among, you know, the entire planet.
[00:41:01] And again, we have those tools to do that now with the vaccines and therapeutics. We need therapeutic access globally. We need something besides Paxlovid, which is Shinogi Protease inhibitors being studied. There's a Gilead nucleoside analog that's being studied. We're gonna have two more antivirals if they work.
[00:41:18] Hope they come soon because we need ongoing therapeutics and ongoing booster vaccination for people who are at persistent risk like older people and those on immunosuppressants in perpetuity for COVID because just like influenza, it will never go away.
[00:41:32] LM: Right. And we also need, as you talk about in your book, vaccine equity
[00:41:38] MG: Yes. It was so unfair.
[00:41:40] LM: The travel bans. I mean, as someone said early in the pandemic, that's like create it, trying to create a urine free zone in a swimming pool,
[00:41:47] MG: Oh no. Yuck. Yeah,
[00:41:50] LM: …until we vaccinate the world. First of all, that's just not, that's just not right. But secondly. Helping the collective [00:42:00] with immunity helps
[00:41:59] MG: It does. And that is, there's a long chapter on the book or like extensive on global equity and also how we should have learned more from HIV equity. And again, the same people who were urging HIV equity and of antiretrovirals weren't beating the drum. I thought for COVID vaccine and therapeutic equity, there was a lot of judgment being applied to human beings in this pandemic.
[00:42:19] I hope we get past this polarization, this politicization. I hope we increase trust in public health. We're going to have other problems in life and other pathogens, and we shouldn't be at this point.
[00:42:30] LM: I mean, if I were going to follow any guidance for the next pandemic, it would be your book.
[00:42:36] MG: It is a step by step, so I hope people do. The last chapter is a 10 point step by step.
[00:42:42] LM: It's a brilliant book. You're brilliant, Monica. And you kind of embody the humility and kindness that we hope other physicians and public health leaders adopt.
[00:42:51] MG: Thank you, but that's why I was drawn to you too, because I find you very compassionate, very kind and very loving with your patients. And that is the only duty of a doctor is to be kind, compassionate, meet them where they are and consider the entire patient. When I disappear into a room with a patient, it's just that patient and I, and that's, it is all about that person and it is holistic, every aspect of their life.
[00:43:16] LM: Monica, thank you so much for coming on the podcast and I hope to see you next time you're in
[00:43:21] MG: Thank you so much. I will.
[00:43:24] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at info@lucymcbride.com. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
Monica Gandhi on What's Next with COVID