Vaccine Hesitant? A Doctor Responds
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I'm Barry Weiss, and this is Honestly. Remember 15 days to stop the spread? Remember thinking that this COVID thing might mean just a few weeks out of offices? Maybe a few months of wearing masks in public?

Sometimes these days I just sit back and laugh when I consider how all of that has morphed into nearly two years of all of this and rolling lockdowns and at least two shots, but probably a booster every year going forward until you die. And yeah, masks indefinitely. And yes, that means at restaurants during moments where you aren't forking food into your mouth and also for kids. And yes, that includes kids in preschool.

I could go on, but the thing is, you already know all of this. COVID is one of the rare things every single one of us has lived through, or rather, is living through, together. And yet that sense of togetherness, the sense of unity that we had in those first weeks and months, remember the daily cheer for the first responders, the ritual banging of the pots and pans? Well, that's given way to pretty much exactly the opposite.

The same polarization and demonization that runs through our politics has come to infect our feelings about, well, just about everything regarding this virus: the origins of it, the response to it, the messaging around it, who's to blame for it, and the fact that it feels like it has no real finish line. Are vaccine passports an obvious and ethical measure to protect our health? Or are they a slippery slope toward a kind of social credit system?

Are masks protective or are they more so a talisman in our culture war? Is ivermectin an effective prophylactic or are those pushing it responsible for vaccine hesitancy? The bottom line here is that there is a lot of confusion about what's going on and where exactly we are right now.

And perhaps what's most frustrating is that a lot of that confusion comes from our public officials, public officials who have told lies, who have failed to abide by their own COVID restrictions, and not just in private, but have flaunted it, including by being unmasked at fancy restaurants or gala dinners while being served by faceless attendants who are still forced to mask up.

It is really hard not to be angry when you watch, let's say, a video of a wailing two-year-old. Fighting their teacher to free themselves of a mask soaked with their own saliva and tears. But it's especially difficult.

When you set that video next to one of the mayor of San Francisco, blithely announcing that she was feeling the spirit and not thinking about a mask. I got up and started dancing because I was feeling the spirit and I wasn't thinking about a mask. To justify her dancing maskless for hours in a nightclub in violation of her own city's public health orders. I desperately want life to go back to normal, but not just for those at the top.

And to help me cut through the noise and the confusion and the endless bickering over policy and public health, I turned to somebody you probably haven't heard from or about. That's because he's a doctor who has consistently avoided the blame game. He's kept calm and cool. And he's following the data wherever it leads and pushing for more wherever it's needed.

His name is Dr. Vinay Prasad. Vinay is an associate professor in the Department of Epidemiology and Biostatistics at the University of California, San Francisco. He's prolific. He hosts a YouTube channel, and his Twitter account has been one of my most reliable sources for information about COVID throughout the pandemic.

His positions are nuanced, well-considered, and shows exactly the kind of level-headedness and evidence-based decision-making that you'd want from someone that you're trusting your health to.

In my conversation with him, we cover policy questions like masking and vaccinating children. We talk about vaccine passports and whether or not the new Biden mandate is a good idea or a counterproductive one. We talk about side effects. And I think most importantly, we talk about vaccine hesitancy and why shaming and blaming and censoring the unvaccinated is a losing strategy.

And how Vinay has been so successful at opening people's minds who are nervous about getting the vaccine. And yes, we do talk about ivermectin. Stay with us. Hey guys, Josh Hammer here, the host of America on Trial with Josh Hammer, a podcast for the First Podcast Network. Look, there are a lot of shows out there that are explaining the political news cycle, what's happening on the Hill, the this, the that.

There are no other shows that are cutting straight to the point when it comes to the unprecedented lawfare debilitating and affecting the 2024 presidential election. We do all of that every single day right here on America on Trial with Josh Hammer. Subscribe and download your episodes wherever you get your podcasts. It's America on Trial with Josh Hammer. Dr. Vinay Prasad, welcome to Honestly. Thank you so much for having me, Barry. I want to begin with the big picture.

where are we now versus where we were a year ago today? Like if I'm thinking back to where I was a year ago, things seemed just way more precarious, way more unknown.

And today, as frustrated as I feel a lot of the time with public policy regarding COVID, I have to admit that things are so improved that I'm able to be annoyed with some of the irrationality of COVID. And, you know, for me personally, you know, I've been vaccinated for months. I'm back to having regular Shabbat dinners at my house inside and unmasked where my friends and I are

hugging and touching each other, and it feels amazing. Right. And it feels, to me at least, like we are rounding third. But then...

I turn on the news or I click to the news rather, and I see news about the Delta variant. I see that the EU is recommending that its member nations don't allow U.S. travelers in because of rising infections here. And of course, I see all of these tragic and viral stories about people on their deathbeds saying they wish they had gotten the vaccine. So it feels a little bit to me like I'm living in a

or schizophrenic or paradoxical world. So give me a sense of where we are. Give me a lay of the land. Right. My view is closer to your view, which is we're rounding third. What do I mean by that?

We're not rounding third everywhere. So I think one thing to say right off the bat is globally, a lot of places are still extremely vulnerable. Vaccine uptake is quite poor in a lot of places around the world. And it won't be long before one day you turn on your TV and it might be India, it might be Brazil, it might be another nation that is really facing healthcare system collapse. So I think we should remember that. But here in the United States, I do agree with you. I think we're rounding third. And what do I mean by that?

I mean, I think we have a good number of people, I think I last checked a couple of days ago, about 63% of Americans who had gotten at least one dose of vaccine. We have a number of pockets in America, including California, where both you and I are, where a lot of the cities, a lot of the places have very high vaccine uptake.

We have other parts of the area, as you point out, that were recently hit by Delta wave. I think Delta wave is cresting. It's going to be subsiding. But those places have a little bit lower vaccine uptake, but they do have a good chunk of natural immunity now. And so I think where we are is we're in a position where

We're realizing and we're having anxiety about the end game. And what is the end game? I think we're finally coming to terms with the fact that this virus, SARS-CoV-2, it is going to be intertwined with human beings for the next thousand years. I mean, we're going to have this virus forever. There are going to be outbreaks of this virus. There are going to be people who get sick. It's going to continue to happen. There'll be another few more waves, I think. But they'll be smaller in magnitude, I suspect, than they have been in the past.

I think we are going to someday in the next year or two start to think of this as something like seasonal influenza. Yeah. But I do think we're rounding third in the sense that for most Americans, we are very soon getting back to those normal human things that we put on hold for all this time, like you talk about. I love to even hear you use the word endgame here. And the endgame is essentially being ushered in by the vaccines, right?

The big change between where we were last year and the reason that I'm now able to host people inside my house is because of all of these vaccines. And the numbers, like the original reporting on the efficacy of these vaccines were astonishing. You know, the Johnson & Johnson shot was shown to be 85% effective at preventing severe cases of COVID. Pfizer and Moderna were like 95% effective at preventing symptomatic cases of COVID. Right.

But I think those numbers, and correct me if I'm wrong, have gone down somewhat since the trials were complete. And I think there's this new concern that's emerging that the protection that the vaccine can offer is a little bit less effective, or maybe the word would be longstanding, that we had been promised. Can you give us an update on sort of what the promise of these vaccines were?

in terms of keeping the disease at bay and what it actually looks like in practice?

Okay, so I guess I will agree with you wholeheartedly that when these vaccines debuted, you know, our jaws hit the floor. I had never seen relative risk reduction so large in randomized control trials. The effect size is huge. I mean, we often don't get something like this. I got to say that I suspect the people who made these vaccines will someday win the Nobel Prize because the time span in which they developed such an efficacious vaccine is truly heroic.

Over time, there have been many different reports trying to quantify this thing you're talking about, which is vaccine hesitancy.

effectiveness, how well does the vaccine work over time? And it's really tricky, Mary. It's really tricky in a couple of respects because one, you're looking at the rate of people who are vaccinated getting sick compared against the rate of people who aren't vaccinated getting sick. But one of the things that happens is over time, the people who aren't vaccinated, that increasingly has a group of them who have already had the virus and clear the virus, they have natural immunity.

So if you have natural immunity, your chance of getting reinfected is lower than if you had never met the virus at all.

And so that fact alone will make a vaccine efficacy over time look like it's falling just because people in the arm that you're comparing it against, they're getting sick and overcoming it. So that's one of the kind of biases here. The other bias is that a lot of these nations, we didn't deploy our vaccine to everybody right away on day one. We obviously started with the people who are most vulnerable, the oldest people in our communities. And so when you look at some of these data sets, you're really asking,

How well does the vaccine work in people who are 70 or 80 nine months out? Because those were the people in whom you gave the vaccine first. So I guess I do think that we should take with a little grain of salt that this vaccine efficacy is diminishing. I do concede that I suspect it is a little bit, um,

especially against having a symptomatic infection. But what about severe disease and hospitalization? I think it's still a really terrific vaccine, even this many months out, and protecting you from the thing. Let's not forget why we actually feared SARS-CoV-2. It wasn't that it caused a cold-like symptom. It's that in a small group of people, it makes you really, really ill. And the vaccines still work marvelously, I think, at lowering that rate.

So that's kind of how I think about vaccine efficacy. And right now, as we're talking, the FDA is meeting to discuss the need for boosters, which is a controversial space in older people, average American people spurred on by the Biden administration. It's weird. I mean, just anecdotally from my own life, I know people who have gotten COVID, of course, as we all do over the past two years. But I know more people that have gotten COVID in the past few months since they have taken the vaccine than I did from before the vaccines were available.

Now, the case I'm talking about aren't super severe. They're not ending up in the hospital, but they're sick and they have COVID. And I want to understand, is that because breakout cases are just very common with this vaccine? Or is it because ending lockdown inevitably led to people getting it? And also the fact that testing just got way more available and reliable than it did, you know, in the first six months of the pandemic. Yeah.

Yes, you're onto it, all those things. I mean, yes, it is almost surely the case the vaccine is a little bit less protective against getting this virus than it was the moment, you know, the few weeks after you had gotten it when you had like the peak antibodies in your bloodstream, sure. But it's also that now that we've had widespread vaccination and also that we have put life on hold for so many months,

There is an outpouring of behavioral change. People are behaving differently, going to bars, going to restaurants, going traveling, doing these sorts of things, which I think is a thing that challenges the vaccine. And then the other thing is there is a strain of this virus, Delta, which is highly contagious and much more contagious than prior strains. You put all that together and you're gonna get breakthrough infections. And if I might, I do think the thing that

as part of the end game is realizing something which I've sort of come to terms with, which I think there is a high probability that over the next seven or ten years that every single person on this planet is going to have a meeting with SARS-CoV-2, the virus. This virus is not going to go away, it's what we call endemic, it's part of circulation now, it has a number of animal reservoirs, it will never be sort of eradicated like other viruses.

And what that means is that perhaps in the next year or the next year after that, you know, we're going to encounter SARS-CoV-2. The best way to encounter it is after you've gotten a couple doses of vaccine in you if you're an adult. But I think avoiding it forever is no longer tenable. And that also kind of ties into some of our policy decisions in this moment, what we ought to be doing on college campuses, et cetera, which we can talk about.

I want to sort of get into a conversation about vaccine hesitancy. One of the things that I think has made people skeptical of the vaccine is the gap between what the vaccine promised and the fact that all of these people who have the vaccine are getting COVID. Can you help square that for me?

Yes, I mean, I do think that there is a group of people out there who say, "Why should I get the vaccine? I still have a chance of getting COVID anyway." And the way I would say that to them is, "Look, when this all set out,

Why were we fearful of COVID? We were fearful of COVID, not that you'd get it and get a runny nose and that would get better. I mean, nobody wants that, but we've lived with that for a long time. But we're really fearful of COVID because you get it and you don't know, but you might end up requiring oxygen, having to go in the hospital. They might have to intubate you, put you on a machine to help you breathe. And some people...

unfortunately might not make it. And what I would say about this vaccine is that although it is true, the breakthrough rate is non-zero, the rates of all those fearsome complications are dramatically reduced. And we're not talking about like, of course, they're reduced in an 80-year-old and a 70-year-old and a 60-year-old, but they're even reduced in people who are 20, 30-year-olds. They're reduced in adults. And so I think...

you know, in my mind, it's not, let's not let the perfect be the enemy of the good. Of course, we wish we had some magic inoculation or pill that would make this virus vanish altogether and you could never get it. You'd be invincible like a video game character. But the truth about biology is it's not that, but just because it's not perfect doesn't mean it can't be good or terrific. And I think it's important to be able to talk about that honestly as you are. So

When you say that, you know, this thing will never go away, that we're sort of needing to learn to live with COVID-19 the way that we live with the flu. How much of that is just inevitable? Is just the nature of this disease and the nature of pandemics in general? And how much of that sort of endless nature of it, the idea that this thing will never go away, how much of that is due to vaccine hesitancy?

If everyone now has the opportunity to go to their local pharmacy and just, you know, get the vaccine, at least the public health messaging that's coming through to me is that this thing would be over. But I'm hearing from you that that's not entirely accurate, that maybe the thing that makes it endemic has to do more with the nature of the disease.

Yes, I think this is an endemic virus because of biology. But I also think if everybody who is persuadable and able did get vaccinated, it would be a different narrative on TV. So how do I reconcile these things? So there are places in this country where the hospitals are getting overwhelmed. There are places in the South where a lot of people, even young people, are getting hospitalized in record number. There are places where the doctors who work there are feeling fatigued. They're feeling overwhelmed. They're looking for space to put somebody who's coming in on a gurney.

That would be a lot better. That would be a lot better if people were vaccinated because a smaller fraction of them would be getting ill and a smaller fraction of them would be severely ill and the hospital might not be overwhelmed there. And the cases would be fewer and there'd be fewer kids who get exposed to virus because there'd be fewer cases from which they could be exposed. So I think that narrative, that visual would be different. And to some degree, what is a pandemic? A pandemic is this superhuman,

social construct of all the things we're seeing and hearing and feeling about it, in addition to, I think, the real biological truth. That's really interesting. Tell me what you mean, Bort, about how the pandemic is a social construct. I mean, the pandemic is a real thing in the sense that it is a real virus that really makes some people sick. But so much of it is a social construct. I'll give you a couple examples, Barry, how I think it's a social construct. You took the same virus, SARS-CoV-2, and you dropped it in 1998. What would have happened?

I think we would have had a very different policy response in 1998. Here's why. Some of the things that have changed our policy response are in part our extreme political polarization, which you've covered marvelously on this show and throughout your writings, that make...

make it so that America is almost two Americas. If one America says go vaccine, the other America says no vaccine. If one America says, you know, try some new pill, the other America says that's a pill meant for animals, even though of course, you know, that's not the case. So we're so polarized on this issue. We can't get behind anything. The next thing, the advent of technology and Zoom.

So were it not for Zoom, I think we would have had a very different policy response. We would have had to make peace with some compromise of living with the virus earlier because Zoom has permitted a huge chunk of upper middle class workers, and I know you've talked about this,

to really continue to have gainful employment while really being sequestered from society. And in 1998, there was no Zoom. There would have been widespread layoffs if people were to stay home for a year. And I think what would have happened is upper middle class people would have found that untenable and we would have struck some compromise. We would have ventilated workplaces. We would have said, "Barry, you go in on Monday, Tuesday, I'll go in on Wednesday, Thursday." We would have alternated, something like that. And all those little differences in how we lived our lives over the last 18 months

that would affect our anxiety, our mental health, it would affect the way in which we view the news, the way in which we consume media, it would affect our discourse, and I think it would have been a very different pandemic, same virus, same biology in 1998. And that to me suggests that some of it is the human side of it and not just the biology of the virus. The other example I would give you is like the same virus in different countries had different responses. Western Europe for the most part

kept schools going throughout most of the pandemic. But the United States, we really closed schools at a lot of places. The places we ended up closing schools, it also took on a left-right political valence. Trump came out in favor of school reopening. So it was the most democratically leaning cities, cities like San Francisco, like Chicago, like Washington, D.C., that ended up with the most prolonged school closures. Places like Florida and Texas, they pushed school reopening. Now, that is a product of the human response to the virus, not the virus itself. If you look across Western Europe,

places like Sweden actually never closed elementary school, and other countries may have closed but briefly for six weeks or eight weeks or 12 weeks, nothing like what we'd seen in the United States. So different countries grapple with the same biology, the same virus differently, and that to me suggests that to some degree it is a social construct, it's a political construct. So you're saying to me that if we didn't have the ability to go to school from home, if we didn't have the ability to work from home,

anywhere in the world, like that everything would be different because we would have just had to get back to life much faster. Yes, I think that's true. And I think that if you read pandemic guidances from prior to 2015, that's what pandemic guidances said. They never thought that these sorts of interventions would be sustainable, particularly for this duration, because they couldn't imagine a world where you could work remotely, where you could do school remotely, where you could have this technology that permitted this response.

Now, to some degree, maybe it was good, but to some degree, I think it has hurt us because one of the realities of pandemic response is the more you disrupt someone's day-to-day life, the more you make them emotionally and mentally anxious and afraid and resentful

resentful and hateful, it feels increasingly, Barry, that the enemy isn't just the virus, it's those people and what they're doing, no matter where you are, those people who are recommending something that they think is a false promise or those people and their reckless behavior. And I think we see ourselves more as enemies. And that would have been a little bit different if we had to go in person and meet each other face to face, even if it was in some limited capacity with masks, with ventilation, with distance.

Thinking about the idea of the pandemic as a social construct, which I think is brilliant, I hadn't thought about it this way. Let's just take even the example of first responders, okay? People that delivered food or worked in bodegas or worked in restaurants, the people that aren't included in the we of my former question, the we that are able to, you know, work from home, the sort of largely upper middle class people who are able to do most of their work from behind a laptop screen. Right.

It seemed in the beginning of this virus, those people were praised and venerated, the people that worked in places like Rite Aid, et cetera. And now it seems like, and I don't want to overstate this, but it seems like those people are being treated almost like second class citizens. In other words, when I go into a restaurant, okay, I am able to sit there without my mask on.

Right.

Do you think that that is going to become our new normal? And I'd love to just hear about your personal experience with what feels increasingly to me like an almost two-tiered America, or perhaps it's just revealing the tears in a stark way that's impossible to ignore, that we're already there.

Yeah, I agree with you. I guess the only thing that I would say is that I think although we applauded them in the beginning, I don't think we defended them and fought for these people. These are the people who are necessary to keep society going, the people who cooked our food, who worked in our slaughterhouses, who continued public transport. These are the people that made society run, and they are essential workers as essential as a doctor is, as I would be. So what do I think how we have mistreated them?

Yes, we applauded them and we celebrate them, but our policies didn't protect them. For instance,

Some of the most highest risk occupations in California throughout the pandemic were line cook at a restaurant. So we talked a good game about how you should sit at home, order Uber Eats, get takeout, support local business. But we didn't think about the fact that the people who work there who are cooking in the kitchen are often in an unventilated space with poor masking. Maybe they need an N95 or a respirator type mask. Maybe they need a policy that if they were to have a fever or feel ill, they could call in sick and still collect a day's wage. But we don't have that policy.

In California, we have a lot of immigrant populations who does a lot of the labor throughout this state. They're often living in households where many, many people are living together. If one of them were to be sick, do we have policies that provide them a free place to stay so you can recover and not infect the other people in that home? I think to some degree,

As you point out, this two-tiered society, it led to a poor pandemic response. Wealthy people, people who could live by Zoom, they increasingly did. Uber Eats and Amazon Prime and Zoom and Netflix, you can live a comfortable life. And we forgot that pandemics, they always prey upon the more vulnerable people of society. They've always done that for thousands of years, and they will do so for another thousand years. But

many of us could disconnect ourselves from that. We didn't see it, it didn't affect us, and we could shield ourselves. And to some degree, we became removed from the political conversation about what to do, policies that would provide resources to prevent spread in these communities. One of the things that strikes me as being

I don't know what the right word is, ironic or just an uncomfortable reality, is that a lot of the people who are regarded rightly as our most essential workers, let's say, for example, nurses or people who work in the health care industry, there is...

Data that has come out, surveys and such, that show an incredible amount of vaccine hesitancy among those people. I'm sure you're aware of that, and I can't help but ask you about it. Yeah, I guess what I would say is that I think...

At first blush, vaccine hesitancy seems about information. It seems to be about, you know, are people aware that this is a problem? Are they aware that this is a very good and safe solution? It seems to be about information. But I think the roots of vaccine hesitancy are far deeper, and they are cultural and they're societal roots, and they're roots that people like you have done a lot better job of probing, which are the roots of vaccine hesitancy are wealth inequality, income inequality, tribalism, division,

political discourse that doesn't seek middle, doesn't seek consensus, that seeks to eliminate or silence views that don't fall into our world. And so I think for a lot of people, vaccine hesitancy is a small space in the universe where you can seize autonomy in a world that's increasingly out of your control, that seems unfair and cruel. And I think that a lot of what we do, we don't get at the root of it. And I'll say one more thing. I also worry a little bit, you know, I'm

I'm incredibly pro-vaccine. I've given so many vaccines because I used to take care of bone marrow transplant patients and you'd have to re-vaccinate them like an infant after the procedure. But I'm also worried about people on the flip side. I think there's some well-intentioned pro-vaccine people who've become too much of a zealot. They're too uncompromising. They're too unable to consider that vaccines are marvelous, but you know,

there can be room for nuance. Does every 12-year-old boy need two doses at the adult dose? Is there a risk of myocarditis? You need some space to discuss these issues. Not everyone who's opposed to vaccine is ignorant or problematic or many people are well-intentioned and well-motivated and approaching this from a different cultural lens. So I do think that we are contributing to the polarization and some of the most ardent pro-vaccine people are contributing as well, I hate to say it, and some of the most ardent

Okay, let's dig in to vaccine hesitancy because

I think oftentimes in the mainstream media, people that are vaccine hesitant are caricatured, they're demonized. And frankly, even, you know, you see these sort of like celebrations when people who haven't gotten the vaccine die. Something that I think is just ghoulish and very disturbing. And at least from where I sit, the primary responses to the vaccine hesitant have looked like this.

First, intense and frequent reiterations of how safe and effective the shots are, but without really engaging with the particular fears of people who are vaccine hesitant. The second is just

expressions of rage and anger and fear at vaccine skeptics for the persistence of COVID. So shaming them with like, you know, this is now a pandemic of the unvaccinated. This is the response that's just really all about public shaming, which I think you would agree is not very effective. Right. And then,

like I said before, just open mockery of unvaccinated people who die of COVID saying that the unvaccinated don't deserve to be treated or that they should be lower priority in terms of hospital beds. And,

A lot of public health experts have come out and said that these sort of shaming and blaming responses just aren't effective at addressing vaccine hesitancy. And it often actually has the opposite effect. It entrenches people in their preexisting beliefs. I wanted to share, well, first of all, let me stop there and allow you to respond. And am I missing anything in terms of what the

broad public health response is to people who are vaccine hesitant. I think you're right. I think everything you said is right. I'm deeply concerned when I see people who seek to promote vaccines say things like unvaccinated people should be denied care, they should have to pay higher premiums. We forget that many of these are the same people that realize we have the Affordable Care Act for a reason. We don't discriminate on the basis of whether or not somebody was a smoker, what somebody ate, what somebody chose to do. You know, as a progressive,

If somebody comes to you and they are addicted to drugs, your view is not that they're a bad person, but rather the system is broken that led to this. And how can we fix the system and also treat them with compassion? And so I find it antithetical to my philosophy.

I think you're right that that is a knee-jerk response. I think in this world where we're living as avatars on social media and not having in-person interactions, we can become more disinhibited. We can stop seeing them as human beings and seeing them as problems. And I think that is contributing deeply to this challenge. I think as a physician who sees people face-to-face, it's hard to describe, but...

I wonder if some of these people who spend their time predominantly on social media websites trying to use rhetoric to make their point can imagine what it's like when you're actually sitting at a table with somebody who has some real questions and

as we do in the doctor's office. And you want to address their questions, answer their questions, you never get far if you're going to make fun of them, if you're going to demean them. And you really need to see that sometimes questions about vaccines are perfectly legitimate, very reasonable, highly rational, and you got to meet people where they are if you want to encourage them. And sometimes you don't do it all in one conversation, somebody comes back a few weeks later.

I've gotten many emails from people who watch my lectures and such and my public statements, but I've also had a lot of in-person in my clinic, people who were initially reluctant who came around when I explained it in a way that it hadn't been explained to them before. And so I think you're right, we don't gain a lot of mileage if we demonize people. Let's break down some of the reasons that people are hesitant and have you address them from a medical perspective.

One of the biggest concerns of vaccine hesitant people I know is side effects and the fact that

public health officials and public health organizations are not being fully honest about the extent of the side effects. Obviously, there are side effects. I was sick in bed for a few days. My wife's knuckles just had a tremendous amount of inflammation. So we experienced them in our own household. They weren't severe, but they were there. Tell us what

Yeah.

I think you're right that this vaccine, especially often for most people, dose 2 comes with some side effects and we're talking about 60% of people... So your question was how do we know the side effects? We know we have randomized controlled trials with tens of thousands of people where we've looked at these side effects and they are real side effects. I mean this certainly appears to me to be a vaccine that is more immunogenic and has more side effects than say the flu shot.

Now, I guess one thing worth stating is that they're idiosyncratic. Like who has side effects you don't always know before they get the shot. And so we all have stories of the person in our lives who's like, oh, you had all those side effects they tell me in this. And then they say, well, you know, I actually didn't feel anything. And so I think that has to be acknowledged too. But, you know, we're talking about 60% of people with like fatigue, severe and then different percentages, but...

even up to half of people, severe arm pain. Some people have fevers or mild fevers. They feel chills, they feel nauseated, they feel weak. They can require a day or two, predominantly taking it easy in bed. And then there's a whole gamut of things that occur less frequently that people may experience.

I think you have to be honest about that. I think some good policies would be to provide paid sick leave or a free day off for people after they've gotten the vaccine, maybe after dose two, to provide some way that people can recover and feel good about it. And I think the other thing is, as part of the implicit contract of these side effects is that when you recommend the vaccine,

You know, for adults, we do know, I think with some certainty that you are much better off having gotten it than not gotten it. By that, I mean the vaccine. You're much better off getting the vaccine despite these side effects than not getting it.

But I do think that we need to be honest, and this is a place that I've been pushing on, is, well, what about if you're 12 and 15 and 16 and a boy? Do you really need two doses? And what about if you've had the virus before and recovered, do you really need two doses? And I do think there are places that we could have some compromises that might make people feel better about the process. And that's what I've been trying to push within the profession. Do you think that one of the mistakes that's been made in the public messaging has been

to not be as forthcoming as an honest, honestly, about the side effects. Like, and also just to the data, you know, I didn't report my side effects to anyone. Neither did my wife, neither did tons of people I know that had side effects. So how do we even know that we have accurate data about how widespread these side effects really are?

Oh, I think you're hitting on a couple of big points. One is that I think we must admit that our vaccine surveillance systems, they are passive and they are limited. We are good at finding some signals. For instance, the Johnson & Johnson vaccine

and the AstraZeneca vaccine which was not approved in the United States but used in Europe is associated with a very rare particular type of blood disorder where you have runaway clotting and it can be clotting in the great vessels of the brain. That was something that took a while to find but it was a very unusual constellation of events and we found it.

But things like myocarditis in boys, the first reports of myocarditis came from Israel where they have better surveillance and they knew about it as early as April. The EMA instituted an investigation and the US finally got around to looking into it. I do think we need a federal sprucing up of surveillance systems. When you deploy large-scale public health interventions, you need a better system to find and isolate and figure out if it's linked

different side effects and different adverse events. And you've mentioned it a few times now, what is myocarditis and how does it particularly affect you?

12-year-old boys, which has also come up a few times. There are many side effects, like the ones you described, like you can feel unwell for a short period of time, but one side effect I think has emerged as particularly noteworthy and sort of something that we wish weren't there, which is that it appears that men between the ages of 12 and let's say 26 have an elevated risk of heart inflammation, inflammation of the muscle of the heart, and that's called myocarditis.

And that appears to be, and I don't think there's any doubt about it, linked to the vaccine. And it's many, many more times what you would otherwise get the baseline rate. But it's still very, very infrequent. We're talking about maybe one out of 7,000 to one out of 20,000, that kind of ballpark range. So it's still very rare. But why does it matter so much in this age group? SARS-CoV-2 is such an interesting virus. One of the most interesting things about it is the risk of bad outcomes by age.

it doesn't just go up with age a little bit, it goes up a lot. It's what we call log fold increase in risk. So as you get older and older, it's going up by a factor of 10 and 100 and even 1,000. And so it's 1,000 times more deadly in an 80-year-old or many thousand times more deadly than it is in an 8-year-old. That risk gradient you don't often see in biomedicine. And so why it matters is when you start getting to these younger ages, I do think you need to have...

much more of an open mind and be much more focused on the numbers to really tease out who benefits. And so other countries have approached this differently. The United Kingdom has decided that people between the ages of 12 and 18, they're only going to get one dose of the vaccine for now because they're concerned about this safety signal. Norway has done one dose for 12 to 15 and Hong Kong just announced they're doing one dose for 12 to 15. And so I do think this is a place that there is some global uncertainty. And

In this country, we often downplay that. We don't talk about that openly. The more openly you talk about it, I think the more reassured people feel that you're taking it seriously and that you are considering it.

So just to say it back to you, your approach to the question of side effects is to tell people you're not crazy to be concerned. And yes, there hasn't been perhaps the level of frankness and openness about side effects in the public conversation. And that's made people more paranoid and skeptical. But the side effects that we are seeing, especially in adults, are

are not so concerning that their risk is greater than the risk of not getting vaccinated. Is that right? That's all right. And I'll just add one more thing to that. I mean, I agree with everything you just said, that that's exactly right. And the one more thing I'd add is that there is also a double standard. So what's the double standard? You know, if somebody were to have SARS-CoV-2, and then there was a report later that, you know, of a thousand people with SARS-CoV-2, two people developed Parkinson's disease.

that's gonna get covered by all the major media outlets as a potential risk of the virus. Even though it might not be linked to the virus. It might just be the two people were gonna get Parkinson's disease, whether or not they had COVID or not. And in fact, I think that's probably more likely in that case. So we cannot have a double standard for covering

long-term symptoms and consequences of the virus versus acknowledging the possibility of side effects. It has to be the same scientific standard, which is that, yeah, after something happens to you, lots of things can happen in the future. Some of them might be linked to what happened. Some of them are not linked. There are common side effects. There are common things that COVID does, like you lose your sense of smell and taste that can last for weeks. And then there are rare things like something happens to you

A couple months later, you get a cancer or you get a Parkinson's disease diagnosis. Was that linked to the vaccine? Was it linked to COVID? And I think when people see a double standard in the media around the long-term sequela of COVID itself and the long-term sequela of the vaccine, I think they are naturally skeptical and we could do a better job of showing the standards that we use.

In addition to the question about side effects, the other major subject that comes up in conversations that I've been a part of with people who are hesitant to get the vaccine is essentially

the problem of newness, right? Like they'll say, these were produced really quickly. We've only had them for a very short time. They haven't been sufficiently tested. Some of them use this mRNA technology, which is new. How do you personally address people that have this concern and bring it to you? Yeah, it's a terrific point. I guess the first thing I do is kind of walk people through how I think about an issue like that. And I guess in my mind,

There are constantly new drugs that we are coming out with all the time. And in my opinion, new is not the thing that makes me uncertain, what makes me uncertain. One of the things that concerns me is just how many people you've studied it in. If you study something in a sample size of 40,000 people, like some of these initial vaccine studies, you have a lot of power to find events of a certain frequency. You know with some confidence that...

If there is something out there that you haven't yet encountered, it's going to occur less often than, you know, one in a 40,000 sort of rate. It's going to be less than that. And you have some confidence that common things are excluded. And why is that so important? When the virus itself has...

outcomes that are so bad, you can say, "Look, we don't know about all the possible things that this vaccine could lead to, but we do know there's almost no chance there's anything out there that's bigger than the problem that we're dealing with, which is the virus." The second thing I would say is that

For better or worse, most of the major side effects that we worry about with vaccines do rear their head early. We're not talking about something rearing its head three years from now, five years from now. We're talking about myocarditis, which happens just a few days after the second dose, for instance, or this blood clot disorder that happens a couple weeks after you've gotten the shot.

And so a lot of the things that you're worried most about happen early. So the fact that it's new and quick doesn't affect those two things. So I guess I think about it that way. How many people have you studied? How many person days of follow-up? We like to use terms like person years, person days, number of people multiplied by number of days of follow-up you have. And when you start to get 100,000, 200,000 person days of follow-up, you feel pretty good that you're excluding a lot of things. Now, what about the newness?

you know, the mechanism of action is new, but that is both a blessing and a curse. I mean, it's a blessing because had they not used the mRNA technology, they wouldn't have been able to do it so quickly. So the newness is kind of linked to the novelty of the mechanism because normally you have to kind of make that spike protein which is a trial and error kind of process and it can turn out not to go the way you want and you kind of have a vaccine that doesn't work. This leverages the bodies

own ability to make it for you and the body makes the protein that it learns to fight off. And so I think that it's both a blessing and a curse that it's new. And I'm not necessarily worried that a mechanism is new because the other thing about medicine is really almost every new drug is a new mechanism. We're just constantly innovating new ways of doing things.

So what did you make of those who opted to get the Johnson & Johnson shot, which at least where I was, was far less available, or if it was available, it was available after Moderna and Pfizer, who wanted to take that shot because it used sort of the old, you know, tried and true technology rather than this new mRNA technology? Yeah.

I think that's reasonable then. I mean, if there's an option out there that uses a different technology and for whatever reason you're more comfortable with it, if you're more comfortable with something because it's one rather than two doses so you know you're one and done, I think those are all legitimate reasons to choose the other option. I guess...

The part I would kind of push back on is if there was only the mRNA option and you chose to do nothing instead, then I think I would say something like, you know, I guess my concern is that you're just taking on much more risk than the vaccine because you're taking on the risk of coming into contact with the virus and being unvaccinated when you do. So let me say it back to you to make sure that I'm understanding. You're saying, you know, historically, new drugs, including new vaccines...

can be concerning because they haven't had enough patients involved. But A, this vaccine has been out in huge numbers. And at this point, we have many people, millions of people who have had the vaccine for months now. And the side effects that they would show or the pitfalls they would have are already obvious to us.

Yes, that's well put. And I guess I would say like I was thinking about in the beginning, but at this point, yes, we have hundreds of millions of people, billions of people who've been inoculated

as adults. And I think your ability to find really rare and unusual constellations of adverse events is tremendous. We've found most of what we're going to find in adults. Now, that's not to say that, you know, right now we're working on randomized control trials in five to 11, and we're working on things about the adolescents. Is it possible we're going to learn more about young kids and adolescents and this

group of boys? Are we going to think about one dose in boys or change the dose a little bit in younger people? Sure. I think those are all possibilities, but are we going to learn anything for a 50-year-old person or a 40-year-old person? I think at this point, there is almost no chance we're going to learn anything different about the side effects in a 40 or 50-year-old person. We just have hundreds of millions of people who've been dosed with these vaccines.

Another thing that comes up a ton among people who aren't getting the vaccine, and for me, this is maybe the most understandable concern of all, and that's the why should we trust them issue.

One way that this will be expressed is, do you really trust these pharmaceutical companies? These are the same companies and people that Bernie Sanders, for example, has been railing about for years. These are the same companies that just lied to us for decades now about how addictive opioids are. And so now you want me to trust them and take this vaccine? How do you respond to that, Vinay? Okay, here's how I would put it. I guess I would say that...

I agree with the premise that these companies have been guilty of egregious problems in the past. In fact, I've written two books pretty much on those themes of how drug companies manipulate evidence and the problems in the drug approval process. What I would say is, similarly, both you and I, I think, didn't always agree with the former president. We thought he said a lot of things that struck us as odd. But every once in a while...

An organization that has done things you disagree with does things you agree with. For instance, the former president said, you know, it probably would be a good idea for these kids to get back in school. And I guess what I want to say is you can't throw the baby out with the bathwater. When he said that, he was right. I think he was right that we should have pushed really hard to reopen schools. That was a policy blunder we made. And I think in a lot of people, it was just they were irrationally opposed to the president because they didn't like other things he said. And

And similarly, I can be critical of Pfizer and their marketing practices around other drugs, but I have to also give them credit and celebrate that this mRNA vaccine was a massive human achievement. It goes against my priors because I was critical of the pharmaceutical industry. I didn't think they'd pull it off, to be honest with you.

So I guess the answer is that, you know, no entity from a pharmaceutical company to even this president we loathe is all good or all evil. Sometimes they do get some things right and you got to give them credit when they when credit is due. And so, you know, Tucker Carlson, I think, is wrong to say everything Pfizer does is bad, just as we'd be wrong to say that every single thing Donald Trump did was bad. In fact, he he did the Operation Warp Speed that led to this rapid approval of vaccines. So I think he should get some credit for that.

So you have to sort of evaluate each claim on its merits. But then you have the strange phenomenon that I think we're living through in which, you know, the random, you know, mom or dad in Pittsburgh, which is where I'm from, or Cleveland or LA or wherever, you know, it feels like they need to become some kind of public health, scientific medical expert. Right. Which is untenable. This connects me to...

to me, the thing that is most egregious that has happened in this entire pandemic. And that's what the noble lies, the admitted noble lies that people like Anthony Fauci told, how that eroded the public trust in institutions like the CDC or, you know, in the case of Chinese capture by the WHO, institutions like the WHO. Yeah.

Once it was revealed that these institutions and the people leading them were either craven or corrupt or telling a lie for the sake of all of us, you know, ignorant, unwashed masses, it's very, very hard then to get people to then turn around and trust them because they've just blown up their trust. How do we...

do we deal with that? I mean, I'm asking that honestly from a very personal place because on the one hand, I'm left incredibly skeptical of an organization like the CDC. But on the other hand, I'm aware that we can't live in a liberal democracy and get back to normal if we don't have some public health authorities that we all agree basically to trust. Right.

Help me figure out how to live in that space.

Gosh, I wish I had a perfect answer for you, but I agree with all your premises, which is one, the average person just cannot be expected to do their own literature review on every single drug product that's coming out, I mean, it's just not penable. Even the average doctor. So we have to trust in institutions, we have to trust in other entities. We do, that's what we need, but then how do we do that when they've so eroded their trust in such obvious ways?

I mean, I think that the answer is that the noble lie is just not doable going forward. I mean, I've written about it. You know, I wrote that piece in Slate about it, which I think that these noble lies were a problem. They were a big problem. And what is a noble lie? A noble lie is the person who's lying to you. They do know they're lying to you. They're telling you something that they in their heart believes is untrue when they're telling you it, but they're doing it

because they want you to behave a certain way that they think will have a broader societal good. And my point is, you can do that, sure, but you do it once and then you're done because no one will ever trust anything you say again. And even now...

when I know that noble lies have been told to me, every time that speaker says something else, my first thought is maybe it's true. But my next thought is, hmm, if it weren't true, what might they be really after? And I start to kind of deconstruct it in my mind. And you just don't want that as a situation. And so I think the only solution going forward is we live in a world where

The average person has access to a lot of the information. The average person can do digging. Whether the issue was lab leak or should you wear a mask, these are issues that you just can't

ever deceive anyone. You just have to be totally frank about what we know, what we don't know. Don't curtail discussion. Don't put bans on what people can talk about on social media. Don't gild the lily. Don't exaggerate evidence if you don't have the evidence. Just be honest about what we know. And you can say things like, look,

I don't know this works for sure, but we want to give it a shot. Or I know really confidently this works, but I'm worried about these subpopulations. Maybe it doesn't work so well in them. And I think that's something that public health is going to have to work on. The old model, I think, where there were just a few sources of news and you could kind of control what people are hearing, that's over. Now people can look at all the primary data themselves.

I think the noble lie that has been most covered, obviously, is Fauci and Fauci in the beginning of the pandemic suggesting that masks wouldn't stop the spread of COVID. And then also how he admitted to sort of deliberately raising the herd immunity threshold. Right. That's been discussed. The noble. Exactly. So.

The noble lie that is now being, I think, promoted most aggressively is this idea that mask wearing actually helps young children learn. There was an op-ed in the Times in August that argued something to that effect. And, you know, the thing that I can't stop thinking about is that

the American Association of Pediatrics, they were sort of deleting research about the importance of children looking at other faces to learn things like social cues and mirroring and all of the rest. Yes.

The first thing to say is that when you're faced with a pandemic, it is reasonable to implement things that you don't know for sure work because you are nervous and concerned and you want to err on the side of precaution. I also think you need to revisit the science. And when you get it more than a year into something, you need to ask yourself, is it really doing what we think it's doing?

On this topic, when it comes to masking very young children or whether or not babies should see faces, there is some difference of opinion globally. In the United Kingdom, for instance, they've never had a mandatory masking policy for kids less than 12.

Whereas our American Academy of Pediatrics says anybody over the age of two ought to do it. The World Health Organization says don't mask a kid younger than six, but again, our CDC says over two. So there is some global differences. We are more aggressive at masking very young ages. The other thing is the United Kingdom, if you...

put your child in daycare in the United Kingdom throughout the whole pandemic, they would see the face of the caretaker who's taking care of the baby, whereas in the United States, they would not in most places. And the American Academy of Pediatrics had a tweet saying, you know, there is something, they said something to the effect of, there is no clear data that shows it's detrimental for a baby not to see a face.

You're right that they pulled down some document that was about the importance of seeing faces. They say they're migrating it to a new website. That's a problematic thing. Do you buy that? No, I don't think that they're migrating it to a new website in the peak of the biggest divisive argument. I mean, I think it's okay to come here and say something like...

To just be honest. And be honest, what does it mean to be honest? It's like, you know, we have no really pertinent data for the pros and cons of doing this. Kids who are very young, kids in general, we've never really done good studies in kids. We really don't know what the side effects might be in babies being deprived of seeing faces.

I think it's a bit ridiculous to think it makes them stronger, like that New York Times op-ed argued. I think that kind of runs counter to people's common sense and run counter to pretty much the thinking of every European expert on this topic.

It is okay to say that, you know, there's a lot of uncertainty here. We can try to learn more about the policy. Different places can do different things. But I do think you're right. This is a place of noble lies. We're living in a time in America where it's not enough to say there are tradeoffs, there are pros and cons of doing something. You start to take the cons and spin them as if they were pros as well. And that's ridiculous. I think no one with common sense will believe you.

Why do you think it's become so hard to have an honest conversation about just trade-offs? Let's go a little deeper there. What is at stake for both sides? I hate that phrase, but you know what I mean. In just being able to say, yeah, you know what? This is terrible. This is hurting small businesses. This is helping, you know, giant companies like Amazon and the rest, but we need to do it because X, Y, Z.

Like even saying that became so difficult. Right. I agree. Why? I wish I had the answer for you. I mean, I wonder if...

you know, to some degree Americans are religious people, but we don't have religion anymore. And so what happens is some of these issues take on religious proportions. It's not enough to say something like, you know, what might be a compromise? I mean, a compromise on this issue might be saying something like, you know, some kids actually, even when they're very young, they can mask just fine and they get along just fine. And it doesn't appear to bother them that much. And maybe it slows the spread of the virus. We don't know for sure, but maybe it's worth doing. There are other kids who struggle a bit more. There are other kids who may have some

sluggishness in their language acquisition as a result, and maybe we need some compassion and some flexibility in our policies at these young ages, I think that's kind of a reasonable middle ground position. But instead you see two sides. You see one side saying that it's child abuse to put any kid in a mask,

I think, you know, for those of us who've seen the horrors of real child abuse, I think that's a bit of an exaggeration. There are other people who say that babies never need to see faces. Why? I mean, can't there be anything in between these two polar positions? And I think to some degree we approach it with this religious fervor. We don't have religion in our lives. So our politics become our religion. Our Twitter tribes become our religion. I think it's very caustic.

Speaking of religious fervor, I was in synagogue for Yom Kippur and I was in LA and the weather was beautiful and we were all outside and we only could be there if we were vaccinated. And still we had to wear masks. And I have to tell you that...

I had to kind of contain my anger at this. I just, it feels very frustrating to me, again, as a non-scientist, non-doctor, just normal American, to think like we're two years into this, we're outside, we know so much more about how this virus is transmitted, we are all vaccinated, and yet we still have to wear the mask. And that's when you start to lose confidence.

I guess a person like me. And I feel like at least maybe in the places in America where I live and travel and socialize, that kind of sort of paranoid response is the norm and not the exception.

Yes. Let me tell you a little story on this. I went for a run on the coast of San Francisco. The sea breeze was hitting me maybe 10 miles an hour. It was a weekday in the middle of the day. There was literally no one out there. And I heard a strange electric sound and I didn't know quite what it was. And all of a sudden somebody passed me on a Segway scooter. Okay. And they turned around as they passed and they said, where's your mask, asshole?

And I had been vaccinated in the sea breeze outside and there was no one around. And I, you know, I felt like shouting back. I was like, actually, there's no data that that mask would work. But he's gone. Amazing comeback. Amazing and concise medical comeback.

But yeah, the data is quite limited about this purpose. I don't know why you're so angry. But in that moment, like, don't you just feel so annoyed at the irrationality of it? I mean, the number of people that I see in the middle of the day walking on a sidewalk alone wearing a mask, it's like.

Maybe this is just a really good substitute for sunscreen. I don't know. It just seems, it just seems irrational to me at this point.

It's so irrational. And I think the other thing about it is like, you know, this is one of the things that people have pushed back in me about because I've been critical of a lot of these things. Like when it doesn't work, I want to point out it doesn't work. And people say, why are you spending all your energy pointing out these things that don't work? Focus your energy on what people should be doing that does help. And what I want to say is like, there's only so much juice you have. There's only so much energy people have to put up with the restrictions. And what you want to do is pick and choose the things that actually help and eliminate all the things that just don't

are virtue signaling that don't help anything because people are going to get fed up with you if you keep wanting them to do everything. And so I think it's important to point out that, yeah, you're vaccinated, you're outside. Absolutely. You don't need to wear a mask. I don't see any, it was, it was debatable if you needed to wear the mask before you were vaccinated outside. It's certainly not debatable now. You don't need to, but yet, you know. But do you think, do you think that just, you know, civility requires us to comply? I guess practically. Yeah. Yeah. I mean,

The reality is, like me, actually, like I do comply. Why do I comply? Because I just don't want to have a conversation with anybody. I mean, I just want to go about my business. You know, I'm in San Francisco where people are going to wear double mask outside after vaccines and boosters. I mean, it's just the culture here. And so I just comply to fit in. But I don't think that's right. And I do think it drives a wedge between...

you know, San Francisco and the rest of America. I think it is problematic for meaningful progress here. I wish I could talk to people, but I do comply just because it makes my life easier. But I'm not sure that's the right answer. Yeah, it's hard, right? Because a lot of the times the forgetting the guy that ran by you or rode by you rather on the Segway, a lot of the times the people that are in the position of having to

enforce what I think are redundant or irrational rules, you know, are doing it because that's what they're required of in their job. It's not because, you know, they have any dog in this fight. And I don't know, I, I, I'm sort of catching my disdain for the group of people or the tribe of people rather who choose to double mask, you know, by a 20 mile an hour breeze on the coast of San Francisco. And, and,

want to maybe bring the same level of empathy that we're bringing to people who are vaccine hesitant to them. In other words, maybe they're doing it because they're traumatized by what we've all just lived through. Well put. And maybe, you know, it's very easy to look at those people and say, ah, ew, they're just virtue signaling. But maybe it's an expression of a much deeper wound.

That's well put. I mean, I think that's probably why I actually just comply because I think, you know, maybe it does bother them. Maybe it's hurting them. And I think you're right. They're wounded too. And maybe this is another policy thing is that,

When people are wounded, you got to give them something to do. I mean, when people feel like they've got the energy, they want to help and pitch in. And what did we tell the average person they can do? I mean, we told them, stay at home, order takeout, and wear as many masks as you can. You know, that's what we told them. And maybe we could have told them to do some other things instead. I have to think about that more. But, you know, I think you're onto something that, yeah, to some degree, they are a victim of a culture, just like the people who are reluctant to mask are a victim of a culture. Yeah.

Vinay, I was really moved by a message that you shared on Twitter from a vaccine-hesitant person who decided to get the shot after listening to you talk, and I wanted to read it.

Back to you. A note went like this. A small note of encouragement here. As a result of Dr. Prasad, and then he named two other doctors, I decided to get vaccinated. It is because of the honesty in this group and your medical conservatism that was the deciding factor for me. I'm a university-educated individual, and I've never been an anti-vaxxer, but I wanted rational, truthful, nuanced conversation, which is not happening from our public health officials.

By being honest, you've done more to promote vaccinations. My trust in public health is gone, but please keep up the courageous work. Many of us out here owe you a debt of gratitude. That sort of reaction is just amazingly rare. And I think it's because, as you've noted, we're living through a time where the value of talking past your tribe, talking across the aisle, to use the old cliche, is

is, feels like it's dead. And the art of sort of open public debates and persuasion has just been so devalued. Without, you know, putting you too much on the spot, I would love to have you just reflect a little bit on why you and these sort of medical conservative colleagues have been successful where others haven't. What kind of strategies do you feel you've deployed that might be useful to others to deploy as well?

Yeah, that's really a kind note, and I was appreciative of the person who sent it. And I just want to clarify one thing about that label, Medical Conservative. That was a paper that we had written many months ago about...

the practice of medicine has nothing to do with the liberal or conservative political labels. And if anything, I'm probably on the liberal side of the spectrum on the far left side politically. But I grew up in rural Indiana and I believe it's important that doctors reach everybody, whatever their political philosophy is. But I guess what I would say is, what does it mean? Like, what is it that I think we embody, the people to whom that note refers? I think...

we're out there on social media we're talking about these issues but we're not talking about it we're not sorry let me say that again we're out there on social media we're out there on social media we're talking about these issues but we're not talking

down to people. We're just being absolutely transparent in how we think about these issues, which is, why did I come to believe vaccines are very effective for adults? Why do I still have questions around how many doses you ought to give 12 to 15-year-olds? And we're just really open about our own thought process. We're open and transparent. We're not engaged in noble lies. We're not

elected officials who are trying to persuade anybody of anything. I'm not a public health official, I'm just a university professor who sees patients. So when I approach these issues and I talk about them, I'm just talking about it through my lens of how I think about science and evidence. And I try to do that on a podcast I run, on videos that I make, and when I talk to other people. And so I think some people, a lot of people, are just looking for someone out there to be very honest about what they think and believe and why they think and believe it. And they gravitate to that.

I'm grateful to have gotten this note and I'm grateful to have gotten many such notes, actually. A lot of such notes have come in. And I think we'd all be better off if people were just more focused on talking about these issues and acknowledging the massive uncertainty and the massive trade-offs, which you've done well to get into on this podcast, because that's important.

When you do unprecedented things to a population of people, it's not all good, it's not all bad, it cuts both ways. You see a lot of the benefits and a lot of the harms and there are a lot that we have not yet seen. We don't know all the harms of some of our interventions, we won't know for many years to come. But we have to acknowledge that and acknowledge the uncertainty. And if we don't do that, I think we're not scientists and I don't know what we become.

Well, here's to hoping that you are starting a major trend. And I hope that people are inspired from this conversation to look up your videos, which I think have been just unbelievably effective at addressing some of the concerns we've been talking about.

We'll be back after this with more from Dr. Prasad on what the pandemic has revealed about the state of science, about the dangers of censoring speech online, and the riddle of policies like vaccine passports. Stay with us. I want to turn now, Vinay, to the state of science as it was revealed by this pandemic, but also how the pandemic transformed it. One of the instances that

I was reading about most recently to choose one of many, many examples that we could choose was this Lancet article from February 2020. And the article dismissed the lab leak theory. And what was recently revealed about the scientists behind the article is that 26 of the 27 official Lancet scientists that made that report

had prior relationships with the Wuhan lab. What broader observations can we draw from that specific instance about how science or the field of science rather has been maybe rotted out in ways that are quite disturbing to look at? That's a great question. I guess the first thing I would say is

Early on in the pandemic, #followthescience became a mantra and I always felt it did a disservice because science is a beautiful tool. It's a beautiful instrument to figure out what leads to what and what caused what and what goes with what and how the world works.

But science will never be sufficient to tell people what they ought to do. And you always need to engage the body politic to figure out what people value, what trade-offs they're willing to accept, what trade-offs they aren't willing to accept. You can never follow the science as incoherent. You can only have science inform the policy and educate you. But these decisions are ultimately decisions that have to be made by people.

about this lab leak hypothesis, I think, and I'm not the expert on lab leak, and I won't be able to tell you if this virus was the result of a lab leak or not. But what bothers me a great deal was that very early on, before people knew, they came out forcefully in that Lancet paper and said, it absolutely isn't a lab leak, and anyone who says otherwise is guilty of spreading misinformation. And for a while, Facebook said, you couldn't even discuss the topic. We will ban it from this platform.

until Don McNeil and Nick Wade wrote those two. Medium articles. And that's the other point. They're publishing. They were on Medium. Right. They're not in the canonical press. And that broke the seal. And now suddenly we could talk about it. Well, that broke the seal. And then I think, you know, Jon Stewart being able to make jokes about it out loud on Colbert was like, you know, the breaking of the dam. Yes, you're right. And what do I think is going on here? I mean, you know, we've seen in some surveys now that even among people,

people who consider themselves progressives and liberals, that the appetite for these social media companies to censor our speech has reached the highest it's ever been. More and more people are comfortable with them censoring misinformation. And look, as any doctor out there, I don't like to read

things that I know to be incredibly false and erroneous about medicine. But I do think we're in a dangerous place where we have difficulty drawing the line between what is merely disputed and what is uncertain and what is really misinformation. And this lab leak fiasco suggests that we drew the line too harshly and we curtail dialogue where there ought to have been dialogue. And I worry that our appetite for censorship has reached a pinnacle and that's going to be dangerous in the future. When you learned that

all except one of the authors of that report in Lancet were connected to the Wuhan lab. What

What did you think? I'm still learning about it and I'm still concerned. I mean, I wonder, I still think we have not gotten to the bottom of the flow of grant money from the NIH to that laboratory. I still think there are open questions about what type of research they were doing. Yes. I think that people who argue reflexively that this research is necessary and useful, I think they're important questions that need to be asked and I'm not necessarily sold that that's true.

I'm concerned that there are these conflicts and these are deep conflicts. They are to some degree financial conflicts, but they're intellectual conflicts. They're the conflicts of identity. These people have poured their identity into doing this work. And so they're naturally going to be resistant to the idea that some of that work may have potentially leaked their laboratory and caused great damage. So I think that this is a place that there needs to be some independent pushback and

And again, you know, I'm somebody who is on the political left, but when I see Rand Paul ask tough questions, I think somebody needs to ask tough questions. You know, I am sympathetic to that.

Well, it seems pretty clear from that interaction that Rand Paul was the one who was telling the truth and Fauci was playing semantic games about what gain of function research really means. Having watched those videos in retrospect and now what we know with leaked documents through a FOIA request, I think it is the case that the NIH was funding that research. I think it was a semantic game. And so I think Rand Paul was right in those dialogues.

One of the things that has sort of shocked me and surprised me, although maybe I was just naive, is the extent to which cutting edge American medical research and scientific research is knitted together with science.

China. For me as an average person, when I'm reading about how we're funding this research into novel coronaviruses in a lab in a province in China, I'm thinking to myself, wait, why the hell are we doing that? Help me understand that. And is this a more regular feature of scientific research at the highest levels than most people actually realize? Like, was this revealing something that, you know, to people in the know is actually quite mundane? Or was this an exceptional case?

I mean, it is certainly the case that some portion of NIH funding has always gone to global endeavors and global laboratories.

But I think that the salient features here that are very concerning is this particular type of research is very high risk. There are laboratory safety standards that need to be strictly adhered to. There appears to be some indication that it was known that these standards could not be strictly adhered to in this location, and yet the research will continue to be funded. And I think that those are all recipes for a problem. And I think that there needs to be a full-fledged independent investigation of this with

some force of cooperation from the Chinese government. And I don't think we've gotten that. I think we've only gotten insufficient investigations to date. You know, we talk about how we need to have trust in our scientists, trust in our public health officials. At this point, given what we know about the Chinese Communist Party and the

the way it functions especially has been revealed over the past two years with disappearing research and disappearing scientists that would have alerted the world to the fact of this pandemic much earlier and probably saved millions of lives

Am I crazy to come to the conclusion that we shouldn't trust any lab working in China just as we wouldn't have trust any lab, you know, in the Soviet Union? If they're working with a contagious disease, I certainly my trust is low. If they're working with something that's not contagious disease, I still always trust

trust but verify, I still always verify, I still always, whenever I read a scientific paper, whether it's cancer research or rheumatology, I still ask myself, is it possible that what I'm seeing is not an accurate representation of the science that was done? But when it comes to contagious diseases with implications for the global population, I think the answer is we need to be seriously concerned about the laboratories around the world

especially in China. The big public policy question that we're facing as we speak at this moment, it's about vaccine passports. And I think there's a lot of confusion about what a vaccine passport is. Maybe it's a lot of different things. How do you define what a vaccine passport is? I think a vaccine passport to me is some proof that you were vaccinated.

Some way to link it to your identity. So often you have to show your vaccine card and your photo ID. And then three, some gatekeeping that you can't go or do something without those first two things. And so I think a passport to me is one of those, all those three things.

So in cities across Europe, it's just completely normative that if you want to go on a train, you want to go on a plane, you want to go into a restaurant, you got to show identification and you have to show evidence that you've been vaccinated or somehow immunized from COVID. And that's completely normal. And aside from some protests that have been really interesting to watch in places like France, it seems like most people are really compliant.

Here in the U.S., I think the conversation's been really different around it. And I'm not sure if it's because, you know, we're Americans and we never want anything to infringe on our liberty, or if it feels like, hold on, like this could become the beginning of the slippery slope towards some kind of non-government but tech-organized social surveillance system. How do you think about the question of vaccine passports?

Do you think that they're on balance a good thing that will help us get back to normal, whatever normal means? Or do you share the worry of the people that are already pushing back strongly against them? I guess my two cents on this issue are, I think that the more adults who are both unvaccinated and have not recovered from the virus that you can get vaccinated, the better off we'll be as a country.

I think that the issue of passports is a tricky issue because, as you allude to, the political will to do it. The places that I know that have done it, for instance, San Francisco, if you want to go to a restaurant here, you got to do exactly that. You got to show your passport. LA too, yeah. But these are the places that have the highest vaccination rates already. You know, those are the places that have the political will to do it. The places in the South, the places with low vaccination rates, they just don't have the political will. And look,

I do worry, of course, that the more information you give these tech companies, the more problematic it is. But the San Francisco passport is you literally just show your card and you show your photo ID and you can go in the restaurant. It doesn't involve big tech. But what I do think is I wonder how much juice you're going to get from the squeeze because I

I just don't think realistically there is a path to doing it in a place like Texas or Alabama or Mississippi. You can do it in the San Francisco's and the Brooklands of the world, but those are places where you already enjoy 80 plus percent vaccination. And so I just think just as a pragmatist, I'm not sure how much we're going to get from that. And we can talk about Biden's plan, but it looks like Biden is also going in a different direction with his proposal.

Okay, one more break, and then we'll wade into the wonderful and not at all controversial world of ivermectin. Back in just a moment with more of Dr. Vinay Prasad. I'm curious what your views are on alternative treatments that have at various times been advocated for COVID and also debunked and then promoted again, most notably an older drug like ivermectin. Do you have feelings or thoughts about ivermectin?

Yeah, first let me put my feelings about all these drugs and explain to you why I think about all drugs really the same. Because I think like ivermectin has taken on a lot of importance in the minds of many people but I'll just walk you through how I think about all drugs.

The pharmaceutical industry and doctors, we've been trying to develop drugs for hundreds of years now, and we're always looking for drugs that help us in all sorts of ailments, from cancer to heart disease to infections. And the reality is that for many drugs, you can find some molecular reason why it ought to help. You can tell yourself a story that there's a pathway in the cell, there's a pathway in this process, that this drug can abrogate, it can hit the right target, it can do some good.

And the reality is when you tell yourself a story like that based on laboratory science, you can even get a mouse or you can get an animal and you can kind of do some work that supports your claim. But what's the probability that that work will someday translate into an effective and safe drug in a person? And the answer is it's really, really low. It's almost like lottery-like odds. And that's why the pharmaceutical industry, of all the drugs they've got in their pipeline, just a tiny fraction actually get approved. And the

And the reason I say all this is just to say that this is what doctors call pre-test probability. In other words, without having definitive proof that a drug works, what's your baseline pre-test probability that it's going to help? And I guess what I'm trying to portray to you is that it doesn't matter to me whether it's ivermectin or hydroxychloroquine or whatever, my pre-test probability in medicine is generally low because I know about all the failures that happen along the way.

And so when I heard about ivermectin, which is-- I want to be clear about a couple of things. It is not a horse paste as some people disparagingly refer to it. It is a real and important drug globally. It is a drug that's used against worms or helminths, which infect many people globally and it is a drug that has improved the well-being of countless people. So when I heard that it might be useful as a COVID therapy, I thought to myself,

Okay, this is something that's reasonable to pursue and study in well-done randomized studies. And my understanding is that there's at least four that are still ongoing.

What I was hesitant about, as what I'm always hesitant about, is before you do those studies, should you just debut something and just start using it? And it's not unique divermectin. I was hesitant about this even early on in COVID. Doctors were throwing the kitchen sink at people. They were trying all sorts of drugs that we just didn't know a lot about. And most of our efforts were in vain. Most of the things we tried turned out didn't help. And so I guess...

Right now, where I'm on ivermectin is that I think it's something worth studying. It is being studied, but I wouldn't prescribe it to anybody until I see those results in my hand that it actually helps.

Joe Rogan most famously got COVID and was treated with ivermectin. And this led to this like giant conversation about whether or not ivermectin was, as you say, an effective drug or whether or not it was simply a horse dewormer. I think the two most prominent people in the country other than Joe Rogan that have been

made waves about ivermectin are my friends, Heather Hying and Brett Weinstein, who of course are evolutionary biologists who famously used to teach at Evergreen State College until they were forced out. And they basically say that the data...

shows that the current vaccines are, and these are their words, narrow and leaky. And that if we use these vaccines in the way that we're currently using them, it's going to lead to the virus evolving into variants faster than we can squash them. Sort of like what people warn about what's happening in the world of antibiotics with superbugs and the rest. And they argue that because we have better ways to treat COVID-19, we should hold off on going all in on the current vaccines. And in the meantime, we're

focus on getting the right treatment medications, especially ivermectin, into the hands of healthcare providers around the world. What do you make of their argument, which I'm certain that you have been hearing and confronting? I guess I would probably disagree with their argument in a couple of respects. I mean,

I think the evidence for vaccination is clear. They've had multiple randomized studies showing a massive benefit on those severe outcomes. I think that one can always wonder about which ways the pandemic and the virus will evolve, but I don't think they're on solid ground by claiming that by debuting vaccination, we are more likely to get the

deadly variant in the future. I just think that's very speculative. And I don't think that that's supported. And then I guess I think the other part I would challenge that is that I just don't think ivermectin has the data that supports its widespread use right now. In COVID-19, when you test a drug, I think we have this misconception that either works for COVID or it doesn't work for COVID. But COVID is not a monolithic thing. There's many different parts to it. So one is

If you and I would have dinner together and later you were to call me and say, "By the way, it turned out I had COVID when we had dinner," well, I might be looking for a drug that prevents me from acquiring the virus or having it rear its head, a prophylactic medication after exposure. Imagine I wake up one day with a runny nose and a cough, I might look for a drug that prevents it from getting worse, from becoming severely symptomatic.

Imagine one day I got COVID and I got severely ill, I went to the hospital. I might look for a drug that improved my odds of surviving that hospitalization. If I got even worse and I was put on the mechanical ventilator, I might look for a drug that would help me survive. And so a drug could work for one of these things but not the other ones. It could help you survive on the ventilator but not help you if you've been exposed. And a good example is steroid, dexamethasone. If you require oxygen in the hospital, it's life-saving. But if you don't require oxygen, it may even be deleterious.

And so I guess my point is that no one at this moment knows which of these scenarios, if any, ivermectin works in. And so I think it is not a substitute for vaccination, which we do know works. And so I guess I would disagree with those premises. There are some pooled analyses of very limited and flawed studies about ivermectin, but every day that goes by, there are increasingly reports of retractions and some questionable data in that data set.

So I think I would say that claims of ivermectin's benefit are highly uncertain and most likely to be spurious or incorrect at this moment.

The big question I want to end on is, I guess, a bit more personal, which is how are you living your life right now beyond running along the coast and getting yelled at by a guy in a Segway to wear your mask? What do you think of, you know, vaccinated events like weddings? Would you attend one? Would you go to a baseball or football game? Give us a little bit of guidance about how someone who's extremely well-informed is making choices like that right now. I can tell you my answer, but I also want to point out that

Should you put more stock in my answer because I'm well informed? I'm not sure. I think all of us have our own internal barometer and threshold for risk and benefit. We're all very different people. And the way we make policy decisions and the way we make these individual choices are fundamentally different. There might even be different parts of the brain.

And so I guess in my case, I'm somebody who has been working in the hospital for most of the pandemic in person. We were wearing surgical masks, yes, but we didn't always test people coming into our clinic and people we'd see on the wards weren't always in universally tested where I've been working. So I guess I've always tolerated some risk of getting the virus. Now that I'm vaccinated, I feel a lot better about my odds.

I'm 38 years old as I feel good about that having been vaccinated. And so what I would say is that I would personally be willing to do many of the things you mentioned, but that's just me. And I think different people will have to approach it differently. And there might not be a right answer for every individual. And the best we can do is to kind of think of policy that balances benefiting everybody and also allowing people to do, I think, what they want to do.

But next time I'm in San Francisco, we'll go for a walk on the Land's End Walk in the breeze without a mask? Of course, of course. If you see me outside, yeah, it'll be without a mask. Unless too many people are looking and then I'll just wear it to make them feel better. Vinay, thank you so much. I really, really appreciate you and everything that you're doing in this moment. Thank you so much for having me, Barry. Thank you.

Thank you to Dr. Vinay Prasad. If you're still brave enough to be on the 4chan for elites that is Twitter, you can find him at vprasadmdmph. Let me spell that for you. That's V-P-R-A-S-A-D-M-D-M-P-H-A. And over at Common Sense, our newsletter, we have a fascinating debate about the question of vaccine passports.

Dr. Prasad is there, but so is Glenn Greenwald, Francis Suarez, the mayor of Miami, an Australian who says that the mandates are a horrendous violation of his human rights, and yet he supports them, and others. Please check it out, barryweiss.substack.com. And thank you, as always, for listening. If you want to send us a tip or drop us a line, you can find us at honestlypod.com. We'll be back soon.