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All Podcasts It’s OK to Be Optimistic. Really. (with Monica Gandhi)

It’s OK to Be Optimistic. Really. (with Monica Gandhi)

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Description

Dr. Bob calls up Monica Gandhi, infectious diseases and HIV doctor at UCSF, to talk about why she’s feeling optimistic at this moment in the pandemic. They discuss why her optimism hasn’t waned despite the fourth wave, the variants, and the CDC Director’s feeling of “impending doom.” Plus, why it’s so hard for places like the CDC to balance optimism and caution in how they advise the public.

 

Follow Dr. Bob on Twitter @Bob_Wachter and check out In the Bubble’s new Twitter account @inthebubblepod.

 

Follow Monica Gandhi on Twitter @MonicaGandhi9.

 

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Transcript

SPEAKERS

Dr. Bob Wachter & Dr. Monica Gandhi

Dr. Bob Wachter  00:09

Welcome to IN THE BUBBLE. I’m Dr. Bob Wachter. Well, it looks like we’re starting something of a fourth wave. We feared this might happen. We hoped it wouldn’t. If you remember, we talked for the last several months about March being this race between vaccines and variants. And it looks like the race is sort of dead heat with vaccines winning in many parts of the country. The number of cases here in Northern California is really quite small. 35 today in all of San Francisco, we have three patients with COVID at UCSF Medical Center today, in January, there were about 100. We’re doing staggeringly well. It’s true in many parts of the country, but unfortunately, not all. And we’re seeing surges in the northeast, we’re seeing a very large surge in Michigan. And of course, we’re all aware of the surge in most of continental Europe, what’s going on?

Dr. Bob Wachter 

Well, the variants have gotten ahead of the vaccines in some places. And also people have started letting their guard down too quickly. And the combination has led to an increase in cases in certain areas among people who are unvaccinated. And although we are seeing some cases in vaccinated people, those folks are likely not to get sick and not to need hospitalization. But for the unvaccinated people, I am quite worried, because they have nothing to protect them. And there are a fair number of them are getting sick with the UK variant, which we now understand as not only more infectious but perhaps more deadly. So there are some real problems out there.

Dr. Bob Wachter 

This is a, it’s a big bummer. But much of the news is quite good. The vaccine rollout continues to go well, the real-world data that’s coming out of many parts of the us a lot of new studies on the impact of the vaccines and studies coming out of Israel and the UK, are nearly uniformly positive, as good as if not even better than what we saw on the clinical trials. And the vaccine seemed to work just fine. Thank you on the major variants that we’re seeing in the US, the UK variant, the variant that we’re seeing in California, the variant that they’re seeing in the northeast, and some recent studies show that it works quite well on the South African variant as well, where we see in some cases.

Dr. Bob Wachter  02:29

So and the question that we were asking repeatedly in January and February, okay, the vaccines seem to markedly decrease the rate of severe cases and deaths. But how much does the vaccine actually drop the transmission has now been answered pretty well, and in a very positive way, certainly, by at least 80, probably more like 90%. So these vaccines, and I’m talking about all three of the ones in the United States, Pfizer, Moderna and J&J. The news is just better and better about how good they are. And the vaccines are rolling out pretty quickly. 2 million doses two and a half million doses a day, states opening up their lines and their priority lists, soon to everybody already to everybody, and in many, many states. So, and the government is doing all the right things, so much so that we barely notice it anymore.

Dr. Bob Wachter

The federal response was so much of the story in 2020. And to some extent, it’s faded to the background big week, because we can kind of just expect that they will do what they need to be doing. So there’s so many cross winds that it’s actually hard to sort out whether to be optimistic or pessimistic, and I’m guessing if you’re like me, you flip back and forth depending on the time of the day, or what the latest news that you just heard was. The person I go for optimism is one of my closest colleagues, Dr. Monica Gandhi, who’s a professor of medicine here at UCSF. She’s an active infectious disease physician and HIV specialist, she runs our Center for AIDS research. She recently directed the International AIDS Conference that was here in the Bay Area.

Dr. Bob Wachter  04:06

Monica is a rigorous and thoughtful physician-scientist. Through her speaking and writing in both professional and lay forums, Monique has become an articulate and persuasive spokesperson for a line of thinking that says that these vaccines are miraculous, that we should be celebrating more and bumming out less and that we should and can begin to message optimism, both because the data largely supported notwithstanding the fourth wave data that I’ve shared with you, but also because it’s pragmatic to do that if we don’t continue to message to people, how incredibly effective these vaccines are, and the things that you can do once you’re vaccinated. You remember those early days where you got vaccinated, that’s terrific, but you can’t change any of your behavior.

Dr. Bob Wachter 

She feels strongly that if you can message what you can now do how the world begins to open up to you once you’re vaccinated, that will increase rates of vaccination, which, of course, is how we get ourselves out of this pickle. She’s really a wonderful person, and I think you’ll enjoy my chat with Monica. We’ll talk about everything, including the fourth wave, but I think you will emerge as I did a bit more optimistic than you came in to the conversation. With that, let’s ring up Monica Gandhi.

Dr. Bob Wachter

Hi, Monica.

Dr. Monica Gandhi 

Hi.

Dr. Bob Wachter 

Long time no see.

Dr. Monica Gandhi

Thanks for having me. I’m ready.

Dr. Bob Wachter 

Alright, so, Monica you’ve begun to get a reputation as being an optimist. Did you set out to do that?

Dr. Monica Gandhi 

No, I actually didn’t. In fact, you know, I’ve set out with COVID-19, to think about masks as a barrier and what all they could do. And people didn’t love it. When I was talking about masks, actually, and people would get mad at me on my rare Twitter feed. But then when I, it was just November 9th, and you and I both felt this that same day, the first time we got a press release on any of these vaccines, it was November 9th, Pfizer, November 16, was the next week was Moderna. And these vaccines are amazing. And they I didn’t think we’d see 95% efficacy; I didn’t think it would look so good against such a diverse range of participants. And it was from that minute forward that I could see that trajectory, the pandemic. And despite terrible surges in between ups and downs, I am very optimistic.

Dr. Bob Wachter  06:35

How much of this flows from your personality? Are you kind of an optimistic person? Are you a glass half full kind of person? Or is this, you know, you’re a neutral scientist, physician. And this is just where you land. Once you heard about how terrific these vaccines were.

Dr. Monica Gandhi

I genuinely think I’m a neutral scientist reporting on the fact that as an infectious disease doctor, and anyone would know this, that, that you cannot get through a pandemic without developing immunity to the new pathogen that’s bothering your population. And these vaccines have enabled us to get immunity against the pathogen. So it’s true that I am an infectious disease doctor. So all I think about is vaccinations it’s been an incredibly important part of what I do. But I don’t think it was that I’m a glass half full person. I actually have had some things happen recently that are very unoptimistic to me. But I would say that I am truly following the data. And I when I tweet out, like how the hospitalizations per case are decreasing in the United States, and some very good statistics from Israel in the UK with rapid vaccine rollout, I truly I’m just trying to present data.

Dr. Bob Wachter  07:43

You know, you and I did have that same feeling of euphoria in early November when the Pfizer data came out. But since then, I don’t remember whether we even had heard of variants, obviously, variants, we knew about variants as a thing in general in virology. But I remember spending most of 2020 telling people the virus mutates, but it’s of no consequence. And then at some point, it became of consequence, I think it was probably after. Is optimism still the right stance in the setting of the variants being out there? They’re just a bunch of curveballs and this pandemic always seems to be, you know, one step forward, and then one or two steps back. So as you heard about the variance, did your optimism wane a little bit?

Dr. Monica Gandhi  08:23

It actually, my optimism did not wane for the following three reasons. So I’m an HIV doctor mostly and all HIV does is mutate it has a very leaky polymerase. So does influenza. So I didn’t think that mutations long despite protein were going very fast. And Coronavirus, has a pretty kind of strong what’s called proofreading mechanisms. So it didn’t seem like it was going very fast. It was inevitable when you see more transmission to see more mutations happening. So I was not that concerned about the rapidity. Second, is that the B117 variant, which the UK kept on saying, oh, this is going to be a disaster at the beginning. Didn’t dawn to them in terms of vaccination progress, meaning cases, and hospitalizations and deaths, all followed suit with mass vaccination, because they’ve gotten much faster than we.

Dr. Monica Gandhi

And in fact, today was the first date zero reported deaths in London from COVID-19. In 6 months, this is a very good day. So March 29. So and then the third is watching the Israel Pfizer rollout with a B117. And also seeing those increased cases in February as they were starting to roll out. So we were seeing increased cases across the country, because people were, they were still under restrictions as we are but people wanted to be together and they were being together and there was more transmissibility with the B117. And then the vaccines crushed it, it just they just did. The Pfizer vaccine crushed B117. And now I think they’re approaching a you know, where you could argue with 54% vaccination rate that they’re getting towards herd immunity.

Dr. Monica Gandhi  10:04

So, we watched the cases, going up with the variants and then come down with better vaccination rates, which we haven’t yet gotten near compared to those two countries. And then the third reason I’m not depressed is we think about immunity a lot in HIV. So I never have thought about antibodies as being the main line of defense against viruses. They actually play a role in stimulating T-cell immunity, but it’s actually T-cell immunity. That’s the most vital arm of the immune system against viruses, including SARS-CoV-2. And T-cell immunity is preserved across the variants, even B1351, which is the South Africa, even P1. So I do think our T-cells are going to get out to get us out of this mess by vaccination, and we’re going to have preserved immunity against them. So we got to get out of this. They are increased transmissibility, but I don’t think they’re going to evade vaccines. And that’s what really makes me happy.

Dr. Bob Wachter

So when you see the increasing numbers of cases in Europe, and some countries in Europe, not the UK, when you see Michigan, New Jersey, other states in the US, how do you process that? Does that worry you? Or are you in the mode of we may see some increased cases. But if people are vaccinated, they’re not going to get super sick and not gonna die. And it doesn’t sway you all that much?

Dr. Monica Gandhi 

Yes, I am not as worried about the increased cases in this country in the setting of us not yet getting to the speed of where the UK was before, we started seeing decrease in cases. So again, we have huge things playing out on the real-world stage that we get to look at, to try to inform our country. That’s the lucky thing. We’re not just doing it to nova. So two places moved faster than we did Israel in the UK. And we have these, they’re showing it to us in real time. So Israel went up, there cases went up as they started vaccinating, because people were mingling more, they’re feeling good, they’re excited. And that’s what’s happening in some places in this country, not all some places. And also peeling off restrictions slowly is, I think, a very important mode of how we should be rolling out vaccine, which we’re doing in California, we’re being really prudent.

Dr. Monica Gandhi  12:10

Whereas other places are peeling off more rapidly. But what I’m watching Michigan in New Jersey, about two things, Michigan, frankly, they’re not vaccinating quickly enough. And there’s some really nice analysis published in The Atlantic about the rates of vaccination in counties around Detroit, and they are lower than other regions in Michigan and other regions around the country period. New Jersey did not go to their long-term care facilities first, they just didn’t, they didn’t prioritize that population first. And remember, every state was deciding their own response. And unfortunately, more hospitalizations there.

Dr. Monica Gandhi 

So I think there’s explanations from anywhere else where there are problems. And then what I keep on looking at is what’s called the hospitalization per case rate. I don’t know, that’s just a rate. And I keep on doing analyses with this biostatistician friend of mine, and we’re looking at all the hospitalizations, all the cases and seeing the decrease in hospitalizations per case in this country, which looks so different than the surges 1, 2, and 3, when we didn’t have vaccines. The severity of disease is going down with vaccinations and we prioritize older populations first, and they’re not the ones in the hospital.

Dr. Bob Wachter 

Got it. Today, the CDC director, Rochelle Walensky spoke of quote, “impending doom”. What did you think when you heard that?

Dr. Monica Gandhi 

I thought that, that it’d be really hard to be a CDC director, I think. Because you want to tell people to still be cautious, because I don’t actually believe we should peel off restrictions right away, just because we got vaccines. I keep using this analogy that like the wood, you had to put down the veneer on wood have really strong vaccines that will protect us forever. And you want to peel off the protective layer. That was our protecting your layer, your wood before very slowly. So she has to message. You know, let’s keep our restrictions on and let’s still not realize we’re there yet. And so that’s how she was messaging today. I have a different role. I’m an academic, medical physician. Luckily, in your department of medicine, you are not no one is telling me that I have to message for the country. And I get to kind of do what I need to do what I want, but I’m putting out..

Dr. Bob Wachter  14:23

What I’m doing what I want. So it’s worked out okay, We are not as I’ve said to people, we are not state media, we are academicians. And we’ll tell people what we think is true. So your senses that Rochelle is, it may very well feel the way that you feel but also is quite worried about people letting their guard down and so is going to message on the pessimistic side to get people to do that.

Dr. Monica Gandhi 

Yes, I think she’s messaging on the pessimistic side. If you watch the White House Task Force meeting the same day though, Dr. Fauci was messaging extremely optimistically and really pointing out what was profound about these vaccines is that they decrease, let’s just say almost completely cease severe disease in individuals who are vaccinated. And he showed, he showed a graph today that was 00000 severe disease in those who were vaccinated with any vaccine. And it reminded me of 000 cases undetectable equals on transmittable HIV. When you see a whole bunch of zeros that is, that is an effective strategy.

Dr. Monica Gandhi

And that’s how low your rate of severe disease will be after vaccination, almost impossible. So I was focusing on not in the White House taskforce meeting and thinking that how do you motivate people to get vaccinated who are reluctant? I think from our experience from HIV, using doom and fear and scare has not actually been as motivating to be very fair as using really optimistic messaging about PrEP. You don’t need to use a condom. Actually, we talked about this all the time. You don’t need a mask after vaccination, if you’re around other people who are vaccinated. And I think it could be, that could be a way of a message that would be more motivating, because I’m worried about vaccine hesitancy.

Dr. Bob Wachter  16:05

Just explain what PrEP is.

Dr. Monica Gandhi 

So PrEP is Pre-exposure prophylaxis. And this is just giving you know, people who are a risk for HIV a pill every day, and it will prevent them from getting HIV so effectively, the Do you have to use condoms? No, you do not. And that is really important. So is taking medication, if you’re HIV positive, and you take medication every day, if you can get your viral load to undetectable, the CDC message this very phrase undetectable, equals untransmittable, you don’t have to use a condom if you have an incredibly effective intervention. So I think of vaccines like that they’re not another tool. I don’t like the CDC messaging that are another tool in the toolbox. I don’t find vaccines a tool I find them the solution. I think these other things mass distancing, ventilation, contact tracing and testing are tools. Vaccines are the solution.

Dr. Bob Wachter

Strikes me as a just the way you describe Dr. Walensky and Dr. Fauci his comments in the past day, what an incredibly difficult messaging problem. On the one hand, trying to be incredibly optimistic about the vaccines and how miraculous they are and get people excited and motivated to do it. On the other hand, getting people not to believe that it’s 2019 yet and take their masks off and party. Boy, that’s tricky to get right.

Dr. Monica Gandhi 

It’s so tricky. I’m so glad that we get our have our jobs. And I don’t have to be CDC director. I think it’s very hard to message I think it is. And I think it was actually in they were almost playing kind of two sides of the equation there in the press conference.

Dr. Bob Wachter

Do you think that’s a strategy? Do you think that they’re doing a good cop, bad cop thing?

Dr. Monica Gandhi 

I do think they’re doing good cop, bad cop thing. I was actually talking to NEAD this weekend about it and how we were going back and forth on some slides for the vaccines and just how incredible they are. And then I think it was kind of they were playing two sides of it. Let’s stay still cautious. Let’s stay restricted. But then let’s please get out the message that these vaccines work incredibly well. And I think it was hard and any criticism directed towards them. We have to remember we’re not in that position. And it is hard to be in that position.

Dr. Bob Wachter  18:23

So let’s talk for a second about what one can do when after someone is vaccinated. I think your feeling was, at least, you know, what you wrote was that we were not kind of permissive enough and optimistic enough after people were vaccinated. We were telling people for a while, you know, you can’t change anything. And then at some point, maybe a couple weeks ago, we did begin getting a different message out there. So how do you think that rollout has been through with the post vaccine messaging?

Dr. Monica Gandhi

You know, I think I was really excited by the CDC guidelines that came out on March 8th, that were more permissive of what vaccinated people can do. I probably would go further myself based on the actual data around these so they said vaccinated people in vaccinated people can hang out, unmasked and undistanced. I don’t actually see how the size matters in a way of that group if you’re all vaccinated, given the data that Dr. Fauci shared this morning,

Dr. Bob Wachter 

So let me just clarify when you say the size so they said you can do that, but only with a small number of people and not a larger group?

Dr. Monica Gandhi 

And they didn’t, right. Exactly right. And they didn’t say what larger small was. So it says open itself up to interpretation. And the reason I think about that is I think about mass vaccinated settings to places that are most mass vaccinated, healthcare worker settings. Many people are vaccinated who didn’t decline and long-term care facilities. They got vaccinated first and of all the places of loneliness long term care facility where residents have kept away from each other and not been able to eat together, play together, play games together, watch TV together, I hope that it wouldn’t matter what size if you’re all vaccinated, you should be able to be unmasked and distanced in that setting. So I don’t know what small medium large meant in their definition, but I wouldn’t put a size on it, though I understand again, I’m not in the position of being CDC director.

Dr. Bob Wachter  20:05

So is what you think going on there that just the larger the group, the more likely it is that there are people you don’t know. And those people you don’t know may in fact not be vaccinated that if you could sort of guarantee that everybody’s vaccinated wouldn’t matter whether it’s 5 people or 100 people, but it’s the unknown that might get you.

Dr. Monica Gandhi 

It’s the unknown. And that’s why it’s actually fair to say, of course, outside the home, still mask and distance from others, because you have no idea who’s in the store vaccinated or unvaccinated. And also, I think it’s tremendously unfair for some of us to be able to rip off our masks and run around and some for not in less, we’ve gotten vaccine equity out there that we’ve given everyone a chance to get a vaccine. That’s why I don’t think vaccine passports are fair, except for some conditions. And we can talk about those. But I wouldn’t do it on mask right now. Like you can only come to this restaurant, if you have a vaccine passport, like the green passes in Israel, because that’s so unfair. There’s so many people who desperately want the vaccine, April 16th is when in this state you can get it.

Dr. Bob Wachter 

Right. Does that change in a couple of months when everybody has had access to a vaccine, and some people have chosen not to be vaccinated?

Dr. Monica Gandhi

I think it could change in a couple of months. And why would I say that? Well, we have precedent for this. You, as the Department of Medicine chair knows very well that I’m not allowed to decline the flu vaccine. If unless I wear a mask all winter, so I can decline the flu vaccine as a healthcare coworker. But it’s highly encouraged of me. And if I choose not to I will be asked to behave differently, which will be prior to this. We weren’t universally masking in health care centers, but I’d have to wear a mask all winter. Second to schools. There have been schools who have chosen to say because of herd immunity means herd immunity, your immunization protects me.

Dr. Monica Gandhi

My immunization protects you. You had to show documentation prior to coming as a freshman of your meningococcal vaccine, for example. I think that’s fair, and it’s been used for many years. And the third example is travel. Travel. This has happened since 2006. That we can’t go to certain countries without showing our quote yellow card, it was called yellow card because of the yellow fever vaccination. But I’ve been India many times I can’t go without documenting that I’ve been vaccinated against certain infections. So I can see travel is one way.

Dr. Bob Wachter  22:23

So you’re saying that you thought the CDC REX for vaccinated with vaccinated was okay, maybe the group size thing is a little off. How about the other two categories vaccinated with unvaccinated and then unvaccinated with unvaccinated? What do you think of those recommendations?

Dr. Monica Gandhi 

So I thought the vaccinated with unvaccinated. What I really loved with what they said is that they said if you are vaccinated, and you’re going to go to a household where there’s an unvaccinated member, but there are low risk for severe disease, then you may be unmasked and undistance. That just opened up the fact that my parents are literally visiting me right now. They’re 87 and 80. And being around my unvaccinated, 11- and 13-year-old children, and they’re just hugging away. So I love that that really gave that opportunity. Again, it is a little conservative to say, but there couldn’t be two households together, where the unvaccinated children were together because then you could see a brother and a sister and they’re vaccinated.

Dr. Monica Gandhi

Parents and the brother and sister are vaccinated. But what to do with the four children. They’re all unvaccinated because they’re less than 16. I think putting these kind of arbitrary restrictions on things have undercut some of our public health recommendations. In California on December 4th, it was messaged that you’re not allowed to be outside with anyone outside your household. Wow. Like that really didn’t work out well, because it’s arbitrary, right? It’s totally arbitrary. And so I think arbitrariness can undercut our recommendation. So I would have said, if you’re around unvaccinated people of low risk, then I wouldn’t put like a one household commentary on it.

Dr. Monica Gandhi 

And also, importantly, children aren’t going to be vaccinated yet. And they are low risk for severe disease. And then the third thing is, they did say that if you don’t have to quarantine, if you’ve been exposed, that’s pretty much opening to me the question of, you know, they’re bringing in this data that it’s very hard for you to transmit an infection after you’ve been vaccinated. And I think that really needs to be updated in their guidelines, how hard it is to transmit after you’ve been vaccinated. We have a lot more real-world data on that.

Dr. Bob Wachter  24:28

So where are we with that? Because that for the first couple of months was this, this big uncertainty looming out there? We can’t say for sure that you’re vaccinated, we know you’re not going to get sick and die. That’s good. But we can’t say for sure that you can’t catch the virus harbored your nose and give it to somebody else. And I think then they hedge that a little bit and said, we’re pretty sure you do that less. But we just can’t say whether you do that 10% less or 40% less. So it’s just brings up the issue of how you do with these uncertainties while you’re trying to make public health recommendations.

Dr. Monica Gandhi 

Yes, I think is really fair at the beginning to say we don’t know if they’ll decrease transmission, I probably would have said it in a different way, though, which is that they’re likely to decrease transmission because all biological plausibility would have said that. I know that’s a long thing to say. But we don’t know for sure, because the clinical trials, you know, didn’t swap people regularly. But now we have a lot of data, including a CDC study that was just published this morning. From healthcare workers, first line responders. Across the country, this was 3950 people. And some of these healthcare workers first responders were getting swabbed regularly, and decrease in both disease and infection was 90% after two doses.

Dr. Monica Gandhi 

And you can even quibble that they used to person day outcome. And little on the CDC data from just this morning, we have this CID, Clinical Infectious Disease study that people at the Mayo who are going in for pre surgical appointments, they swab them before their pre surgery appointments, and they had 80% less likely to have COVID-19 in their nose. If they got vaccinated than those pre surgical who weren’t swabbed, then we have a lot more data from other real-world settings, healthcare workers in England, health care workers in Israel, and also the Pfizer real world data for the Ministry of Health in Israel.

Dr. Monica Gandhi  26:17

That shows anywhere between 85% to 94% reduction in transmission, meaning asymptomatic infection in your nose. And then one nature medicine paper, I just want to mention just published this morning, that even if you get it in your nose after vaccination, your viral load is extremely low. Your CT values are very high. Just got published this morning, March 29th. So we think we’re showing a lot of evidence that it’s hard to transmit after vaccination.

Dr. Bob Wachter 

Is the evidence so persuasive that you would rethink that third category of vaccinated person hanging out with a moderately to high-risk unvaccinated person? In other words, someone going to visit, for whatever reason the grandparents aren’t vaccinated.

Dr. Monica Gandhi

You know, I would, because I’ve really convinced by real world data. And actually, I have to say, boy, real world data used to look worse than clinical trial data. And anything that we’ve ever grown up with, like a drug always looked better, or a vaccine always look better in a perfect clinical trial. And I don’t know what’s going on with these vaccines. But the two new England journal studies from March 23, that swabbed health care workers, and looked at the effectiveness of vaccines in University of Texas and Southern California, the CDC study from this morning, these vaccines are so effective, they’re more effective than the efficacy in clinical trials. So yeah, I’m pretty convinced that we should be looking at our data after data point coming out about real world transmission reduction. And I would be happy if I were the person making these recommendations, I would change that recommendation.

Dr. Bob Wachter 

So what would you change it to? So it would you say that for a fully vaccinated person, they can hang out with anybody with no masks and or not quite?

Dr. Monica Gandhi 

See this is where we’re super tricky, because I also am very interested in fairness. And I don’t think it’s fair that half of us can run around without masks and half of us can’t, I just I don’t think it’s fair and I would change in the public sphere. We drop our masks and our distancing all together, it just didn’t seem fair to me. So when you’re out in public, you have to mask and distance whether you’re vaccinated or not, however, in the privacy of one’s own home, or a small gathering, I’m so convinced that you can’t it’s very hard to transmit if you’ve been vaccinated, that you’re fully vaccinated after two weeks after your second dose would be comfortable with vaccinated people being around unvaccinated family members who still hadn’t gotten vaccinated and they were still more risk for severe disease to private versus public sphere. It’s hard.

Dr. Bob Wachter  28:48

Yeah. No, I understand. I’m on clinical service now. And I noticed something interesting here at UCSF Medical Center, you may notice the same at Zuckerberg San Francisco General where you work, which is all of the healthcare workers are vaccinated, that have chosen to be vaccinated and essentially all of the doctors have, all of the patients are tested for COVID. And we know if they’re positive or not, and yet, all of the health care workers are wearing double masks. Many of them are wearing a N95’s and double masks, N95 at a cloth mask on top of it. And goggles. And I think when you ask people why it’s a little bit of habit, and then it’s a little bit of you cannot prove that I cannot possibly get asymptomatic COVID that will turn into long COVID and I will regret it and wearing a mask is no big deal. What do you think about that?

Dr. Monica Gandhi

Okay, well, you’ve gotten in some really hard territory for me to answer because.

Dr. Bob Wachter 

that is my job.

Dr. Monica Gandhi 

Because if I were in charge of our medical center. Or if I were in charge of the SFDPH, I would say that I’m so comfortable with the very conservative CDC guidelines from March 8th, that when healthcare workers are gathering with each other, they should drop the masks and they should eat together because we haven’t seen each other for so long. And what am I doing behind closed doors with my mentees, or with my colleagues, were all taking off our mask, because we’re all vaccinated, and we feel really comfortable with the data. But we haven’t been told officially that we can do that. So we closed the door.

Dr. Monica Gandhi  30:34

So I would be this comfortable with the data about the 100% efficacy against severe disease, there was only one person in six clinical trials that went into the hospital with who had gotten a vaccine, and they did fine. That’s what Dr. Fauci showed us this morning. So I’d be so comfortable that I would drop the mass and when we’re around each other, however, were in a twilight period. And this was a super scary virus. And we all saw a lot of illness and we are human beings who feel fear and feel residual fear. And I am sympathetic to anyone who is still fearful.

Dr. Monica Gandhi

There are all these stories in the newspaper now about people saying, why are people going outside and meeting with other people who are vaccinated, I’m not gonna leave my house for a long time. And I understand that, that is, that is someone Dr. Lucy McBride that who I know, had coined this phrase fear of normal, FONO, and we are fearful of dropping those masks. And it seems easy to wear a mask. And so I do understand why we’re in this Twilight period. And I will do whatever my medical center tells me do right now, by the way, but I do. I do want to say one thing, there was a study from JAMA surgery, that said that patients didn’t like looking at masked people all the time.

Dr. Monica Gandhi

And actually the recommendation eventually, for surgeons who wear masks a lot, because I doubt I don’t think we need to universally mask as medical people in the future. But surgeons do a lot of universal masking. This JAMA surgery article said it was very hard for people going into surgery to never see the full face of their surgeon. And the recommendation was actually for clear masks or for counseling without masks. And this is surveying many patients, we should not also reduce the implications for our patients of how frightened they are, and how much they need that face-to-face interaction with their doctors.

Dr. Bob Wachter  32:43

What do you think about the long COVID risk? I’d say that’s the one that gets to me a little bit. I’m fully vaccinated, I’m comfortable with all the recommendations. But then there are situations where I say, you know, this feels a little risky in terms of being exposed to COVID. I know I’m not going to get super sick; I know I’m not going to die. But I don’t know with 100% certainty what the effects of getting a mild case of COVID might be over the long haul. So I’m still going to tilt toward the very careful side in terms of masking and distancing. Is that crazy? Or do you think that, you know, the evidence is clear enough that we don’t need to worry about clinical consequences of a mild case of COVID?

Dr. Monica Gandhi 

You know, I agree with you that long COVID is still being worked out. I think I look to the data just from my own San Francisco General Hospital, because I talked to them in the hallway and the COVID symptoms that linger are more associated with severe disease or symptomatic, quite symptomatic COVID. Why? Because there’s sort of a biological plausibility to the innate immune response that you generate to severe disease and then having that linger for you. So mild or asymptomatic infection, at least from our medical center has not been associated with long COVID symptoms. And they haven’t  meta-archive article on this. This is Dr. Stephen Dietz and his group.

Dr. Monica Gandhi  34:03

And we’ll be publishing a very high-profile journal since and other groups have published that in nature. However, I would also say to people, you know, what you should do whatever you feel comfortable with in terms of your masking behavior, even after mask mandates are dropped. Why? Because what the vaccines are going to eventually do for us is not only decrease severe disease massively decreased prevented almost, but they are going to reduce cases they we see these in the two places that are ahead of us incredibly nicely in Israel and the UK. And we’re seeing this in in places. I think like California, I think our 42% vaccination rate in the city of San Francisco is contributing to our low cases.

Dr. Monica Gandhi 

So you will be exposed to COVID-19 in the future, if we can keep everyone vaccinated. And then that gets us to low cases you can definitely wear your mask and I think everyone should be comfortable. But when we have supremely low cases in the city, you’re not around someone in the store. Once mask mandates drop that would even have COVID. So a lot of our conversations right now, we’re still persisting with our understandable anxiety about it. And that’s very understandable. We’re in a twilight period, we’re in a time of history, that’s amazing. We’re emerging from something horrible; things will get better. And we won’t even have these kinds of questions that sit for months.

Dr. Bob Wachter 

Let me underline that point. Because I think it’s really important. It’s not just the vaccines and the level of protection, it’s how much virus is there in the community around you. And as more and more of us get vaccinated, the chances of the person standing next to you in the line at the store has COVID goes way, way, way down, as it already is, is way, way down in San Francisco.

Dr. Monica Gandhi

In San Francisco, there was five cases diagnosed in the city yesterday. I mean, I don’t think I’m gonna see those five people when I go out today. So to the hospital, I think that’d be very, very unlikely

Dr. Bob Wachter 

820,000 people, that’s a small probability. How do you think the media has done on not to generally covering over but on this specific issue of toggling between optimism and pessimism, and messaging, messaging optimism in the right places, but also not pushing people let their guard down to soon. You said it’s tricky for the CDC, but it’s tricky for the media, as well. How do you think they’ve handled that responsibility?

Dr. Monica Gandhi  36:18

I think it’s very tricky for the media. So I sympathize with anyone who’s a journalist or CDC director, you know, again, I I’m allowed to just look at numbers and I don’t have to message to a bunch of people. I’m only have the people I talked to. However, I will say that you know, David Leonhardt article last week in New York Times about how much more bad news, we messaged in the United States, about COVID-19 compared to the international media, it was so much higher here really got me thinking. And the reason it does is I’ll tell you a sort of personal anecdote is that I get a lot of people emailing me personally about HIV over many years of being an HIV doctor who would say, Hey, I’m in a store and I like got a paper, could I get HIV? And I always write them back.

Dr. Monica Gandhi 

I always say this is low risk. I’m now getting a lot of emails from people around the country just de novo, saying, I got fully vaccinated, I had two doses. I’m so scared. I’m so scared about the variance. I’m so scared, I’m going to die. And I guess it’s because it’s very easy to find my email and you can just write anyone. And then I do it takes me probably 20 minutes a day, if I choose to respond to all of them to reassure people, I don’t think instilling fear right now, as much as we are in the media is as indicated, especially about Marion’s with what we talked about T-cell immunity. And I want to say one other thing about that point. Today, the CDC released this enormous study about how vaccines work in the real world across the us healthcare workers, first responders, firemen, all these places around the country.

Dr. Monica Gandhi 

To put it really simply, if there if you had I mean we’ll use really easy numbers. of 1000 people, there would have been 161 infections of COVID. If there have been no vaccinations among 1000 people after vaccination, there is one infection after vaccination. And that’s the way to boil down that study readily. And when you looked at the media coverage, even from today, they were like, ah, but you can still there’s a couple people who can still get COVID after vaccination. I don’t know if they’re asymptomatic. I don’t know what their viral loads were in their nose. We need more detail about that. And you can spin it, right? And it was amazing news, and I would have just been all over it excitedly in the media. So I think would it be great for us to do more of a balanced towards good news. The vaccines are going to get us out of this.

Dr. Bob Wachter  38:39

Yeah. You’ve been talking mostly about Pfizer, Moderna, does the J&J and that lower, you know, top line efficacy numbers that bug you at all? Are you put it in the same ballpark?

Dr. Monica Gandhi 

You know, a lot of people wrote today, saying, well, hey, tell us about Johnson&Johnson real world effectiveness. And I had to say couldn’t because the two new England journal studies from last week and the one CDC from today, we’re just done over December, January. And so that was before Johnson&Johnson was authorized in this country. So these are the only the mRNA vaccines, I suspect the J&J is going to have similar outcomes, though. Why do I think that because the AstraZeneca vaccine in the UK, which is its friend, its cousin. It’s like an antivirus. Shell with a DNA inside of it has amazing real-world outcomes that they’ve been publishing like crazy in the UK, like 94% reduction in hospitalizations after one dose in Scotland. And then there was a big study out of England that showed the same thing. So we’re going to need a little more time with our Johnson and Johnson to show the real-world effectiveness, a pretty confidence going to show the same thing as the mRNA’s. Despite the very wide clinical trial range of efficacy comes mild versus severe disease.

Dr. Bob Wachter

Let’s spend last few minutes talking about the kids and you’ve been a big advocate of keeping the schools open. Tell us how you think we’ve done on that question over the past year and where we should be landing right now.

Dr. Monica Gandhi  40:01

You know, I think, you know, I’ve really been working with some other pediatric specialists from University of Chicago, and others to really understand how I think this country actually kept schools closed more than other countries did, which are at least for favoring school openings over other openings of first like restaurants and other settings. And I don’t think we’re doing that. Well, California, still, I keep on looking at the rankings, we still have fewer number of children back in schools than any of the 50 states, we’re still at the bottom, Oregon and Maryland, join us at the bottom. So these are the three worst states in terms of getting children back to school. Children are not at risk for severe disease from COVID-19. Any more than influenza, it’s just a fact is just a simple fact. It’s not a political statement. And so because of that, and because they are at risk for so many more mental health issues when they’re out of school. Yes, I’ve been very much in favor of school openings with all this teacher safety data.

Dr. Bob Wachter 

And why do you think we got it wrong?

Dr. Monica Gandhi

I think that we over messaged fear about this pandemic. We were not nuanced in our reporting. This is what David Leonhardt talks about. I think Democrats went too far one way and Republicans went too far the other way, Republicans underplayed the virus, so did the former President Trump, and there are people on our side who overplayed and said that it was not there was not gradations of risk across age groups. And that ultimate overplaying of fear leads to residual fear of teachers and parents that their children will get sick if they send them to school. And again, it takes a long time to shake fear, we should just be fact based, very clear and very database when we message period, just look at the numbers.

Dr. Bob Wachter 

Yeah, you have a couple of kids. So how’s this year been for you?

Dr. Monica Gandhi

They are 11 and 13. And they have been in private school. And they have been kind of half in half out. So it’s been hybrid. And with a lot of convincing, they are going back full time, both of them on April 30. For the first time in a year where they’re both going to be five days. And I’m so happy. So happy

Dr. Bob Wachter  42:09

Maybe last question, you know, people sometimes look at you and say is she just she accomplishes so much and she’s an optimistic can-do person. I wonder if she’s experienced any hardship, and you obviously experienced an incredible hardship this year. So can you just share that and what it’s meant to you and how it influenced the way you live this year?

Dr. Monica Gandhi 

Yes, on November 29 2019, my husband, who was on faculty at UCSF died of cancer after a really, really prolonged battle with cancer, and he was diagnosed two years after my second child was born. And then the pandemic community transmission was first reported in San Francisco on March 5th, so there wasn’t much breathing room between those two events. And I know that hard things happen. And I know that any death is an including the 550,000 Americans who have died of COVID-19 means a huge amount to the family. I know it personally with every fiber of my being what the loss of your main family member means to your household. But it doesn’t mean that we still can’t be optimistic about the truth. Believe me if on November 9th, there was a cure for cancer that had been released in a public health in a press release from Pfizer. And I had seen that on November 9, before he died, I would have been in a much better position. So, let’s we can still be optimistic even if terrible things happen to us.

Dr. Bob Wachter

And he’s an amazing person as are you and I couldn’t be prouder of everything you’ve done.

Dr. Monica Gandhi 

Thank you so much for being my department chair.

Dr. Bob Wachter 

Not only your profession, the way you’ve lived your life, if you want to say anything wonderful about me as department chair now is your opportunity.

Dr. Monica Gandhi

That you took a pandemic, you informed it I don’t know how many Twitter followers you have, like 200,000, I only have 1/10 amount of log reduction. And you’ve informed the pandemic and you’ve given a lot of people hope and cheer and optimism. I remember how excited you were on the day that the vaccine trials got released. And it’s important what you’ve done. It’s important it means a lot

Dr. Bob Wachter  44:16

You as well. Thank you for doing this and keep up the spectacular work.

Dr. Monica Gandhi

Thank you. Thank you for having me.

Dr. Bob Wachter

Well, I hope you enjoyed that as much as I did, and also were struck by the poignancy of it Monica’s optimism comes in the face of he really singularly hellish year as she not only was dealing with COVID professionally, but lost her husband just before COVID hit and I knew him quite well. And Rakesh was a very special person. And I think you got a sense of how special Monica is as a professional and as a human being so really grateful to her for being on and for all the work that she’s done in COVID. Well, we have a number of other great guests coming up on in the bubble on Wednesday, we’ll do a special toolkit with a frequent guest, Dr. Paul Offit, who is one of my go to people when we talk about vaccines.

Dr. Bob Wachter 

But sometimes we forget that Paul is also a pediatrician at one of the great children’s hospitals of the world Children’s Hospital of Philadelphia. And so the entire episode will focus on the kids with a special emphasis on vaccines. There’s some new data that just come out on vaccines in younger kids and much more testing being done. So there are lots of questions about vaccines in kids, and then other questions about what to do with the kids as adults are vaccinated, but kids are not. So you sent in a lot of just terrific questions, and we will pose them to Paul, on our episode on Wednesday. We have an upcoming episode where we’ll talk about equity. But we haven’t talked about equity. much in the last few months. We’ll do it in the context of vaccinations about the 4th wave. I’m sure talk about things like vaccine passports and other things, and how they impact different communities.

Dr. Bob Wachter  46:17

We’ll have three guests one Rhea Boyd, who has been a wonderful spokesperson on issues around equity, particularly in the Black community. And we’ll also have Diane Havlir and Jon Jacobo. Diane is a colleague of mine and a colleague of Monica’s, an infectious disease doctor, at Zuckerberg, San Francisco General and UCSF. Jon is a community activist in the Mission District, which is the Latinx district in San Francisco and Diane and John have worked together to roll out really world class testing programs in the Mission District, as well as now vaccination programs. And I think they are a model for what can be done through a really effective academic and community partnership working also closely with the San Francisco Department of Public Health.

Dr. Bob Wachter

It’s an inspiring story. And so as we talk about equity in that episode, we’ll be talking about in the Latinx and in the Black communities, and have some really wonderful examples of what can be done to make things better. Finally, if you find yourself feeling a little too upbeat after listening to Monica, we will dedicate a whole episode to the 4th wave, which I do not want to minimize is definitely a source of some concern, particularly in those regions that are beginning to surge, haven’t sorted out who our guest will be, but it will be a world class epidemiologist talking to us about what’s happening, why it’s happening, and what the prospects are for us as we head into the late spring and into the summer. So we have plenty to talk about and some wonderful guests. Please get vaccinated as you have a chance. Stay safe, and I look forward to speaking with you soon.

CREDITS

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. Our theme was composed by Dan Molad and Oliver Hill and additional music by Ivan Kuraev. You can find out more about our show on social media at @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening.

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