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Harm reduction, as so clearly described by our guest Monica Gandhi on this podcast, began as a public health approach that guided management of HIV. Harm reduction represented an alternative to an abstinence-only approach, which clearly did not work. In the harm reduction model, you acknowledge that people will take some risks, and that the goal is to decrease risk, not eliminate it.

And yet, here we are with a fear-not-facts approach to the COVID-19 pandemic. Some are advocating for the use of masks in schools, hospitals, and nursing homes in perpetuity. As in, forever. Sounds eerily like an abstinence-only approach, right? Science would dictate that now that we have vaccines, which Monica describes as “the solution,” we don’t need to engage in masking (with a few exceptions).

Monica Gandhi, an infectious disease doctor at UCSF, has advocated strongly for a fact-based approach to school opening, early masking and now dropping masking, and global access to vaccinations (and temporarily dropping vaccine patents), among other things. You can and should follow her: @MonicaGandhi9

And from Ashwin Kotwal, geriatrician and palliative care doc-researcher, we hear about experiences caring for patients who are afraid to return to normal after a year of masking and forced isolation, despite the toll these experiences have taken on them (documented in his recent paper in the Journal of the American Geriatrics Society).

It’s time to get back where we once belonged (song choice hint).

@AlexSmithMD

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, we had to re-record this intro since I forgot to press record because I am such a huge fan of the person that we have on with us today. Who do we have on?

Alex: Once again, we are delighted to welcome to our GeriPal podcast, Monica Gandhi, who is an Infectious Disease doctor, Professor of Medicine at UCSF and who Tweets @monicagandhi9. Welcome to the GeriPal podcast Monica.

Monica: Thank you so much.

Eric: And Alex, who else do we have with us?

Alex: We are also welcoming back to the GeriPal podcast a geriatrician, a palliative care doc, a researcher in the USCF Division of Geriatrics, Ashwin Kotwal. Welcome back to the GeriPal podcast Ashwin.

Ashwin: Excited to be here.

Eric: Before we get on the topic about re-integrating post-lockdown with COVID and how to talk about this with our older adults and those with serious illness, Monica, do you have a song request for Alex?

Monica: I do. I want to get back to no restrictions with the incredible effectiveness in the vaccines, so I want to hear Get Back by the Beatles.

Alex: All right. Here we go. (singing).

Eric: That was awesome, Alex. Thank you.

Ashwin: Awesome.

Eric: Monica, before we dive into the topic, we always talk about how people got interested in this subject. Before COVID, you had a focus on HIV. You’re an Infectious Disease physician. Now you are an international expert on COVID-19 and an advocate for what I think is evidence-based discussion about first advocating for things like mask use and then vaccines and now advocating for what a new normal would look like? Can I just ask, what motivated you to really jump into the space which, especially on social media could be very hard to do because there’s a lot of voices out there?

Monica: I actually hate social media and I didn’t want to do it and I’m going to get off as soon as I can, but it really had to do with taking an approach from my knowledge of HIV of harm reduction. So the principle of harm reduction is very simple. You actually want to decrease infections from a pathogen, but you want to do that using real world conditions, keeping in mind the real world conditions that may make people take some risks. They have to go to work. They have essential work. They want to see friends and families, but decreasing their risk within the context of humanity in a way.

Monica: And that is what HIV has always done, except at the very beginning. At the beginning of HIV, we said we didn’t use harm reduction. We said, “Stay away from each other. Everything’s risky. Oral sex is as risky as other sex.” And that’s not true, actually. And all of that led to this absence-based only approach. And then we quickly realized this is not the way to face a pandemic and so we used harm reduction, which is, I’m going to tell you how to stay safe, but I’m not going to completely keep you away from each other because I’m going to tell you about masks, distancing and ventilation.

Monica: But there are consequences of completely keeping away from each other which is loneliness, learning loss, closing schools, thinking about nursing homes with complete isolation. Instead, I’m going to tell you how to keep safe within the parameters of what we know. And since I didn’t see that voice so much, at least in our cities being out there, I wanted to talk about this approach and that’s what made me enter the dialogue.

Eric: Can I ask what the heck happened with that? I feel like we’ve learned an abstinence-based approach from a public health perspective doesn’t work. We learned that decades ago, right?

Monica: We learned it in, it’s actually the 40th anniversary of the first description of AIDS coming up this Saturday. So yes, we learned it 40 years ago.

Eric: Why did we forget about that?

Monica: Because of fear. Because we used what we say is a fear-not-facts instead of a facts-not-fear approach. Because there are facts. There are facts that with mitigation procedures, schools are safe. There were facts that people could see one another who are older in long-term care facilities with those protections in place. Those were the facts. The fear is that the best way to do this is just to completely cut off all human contact because that is the most sure-fire way to get us safe. And that’s inaccurate and in fact, the collateral damage of using that approach, we are seeing now.

Monica: We are seeing that with mental health effects in children. We’re seeing that with mental health effects in humanity, in adults and in older adults. So it can have damage. I think we did it because we thought maybe it would take two or four weeks. But the minute that we actually realized that lockdowns were going to go on for a while, that’s when we should have incorporated harm reduction.

Eric: Yeah. I guess, too, initially there wasn’t enough PPE to keep people safe. We saw huge outbreaks in nursing facilities, nursing homes, where I think 40% of deaths in the US occurred, so really devastated that community. Things have changed a little bit now since the introduction of vaccines and that we have PPE, but we’re now also seeing a significant shift in reopening some of these institutions to loved ones, family members, outside visitors.

Eric: Ashwin, is it okay if I turn to you? Monica also talked about some the negative effects of COVID-19 and the lockdown. You recently published a paper in the Journal of American Geriatric Society, looking at loneliness in San Francisco. Do you want to briefly discuss that?

Ashwin: Yeah. Absolutely. One thing that Monica mentioned is that there are harms that are associated with really strict precautions. I think with every preventive medical intervention, we in geriatrics often think about what are the short-term harms here? Because especially people who live in nursing facilities or those who are seriously ill might experience more of those short-term harms than the long-term benefits in terms of infectious precautions.

Ashwin: And so what we were finding in our study, which was started early on in the pandemic, just a few weeks after shelter-in-place orders were started, people were actually adapting pretty well to the restrictions. They understood the need to stay safe, to protect their community and to be responsible. So we actually found that loneliness levels were high initially, but then started to come down over the next few months.

Ashwin: But what we found more recently when we surveyed people in the last few months is that people are experiencing fatigue. They are tired of all these restrictions. Many people, they just need to see the light at the end of the tunnel, especially people who may be in the last years of life, last months of life. And so I think they felt like they’ve done everything right. They’ve adopted new technologies. They’ve been really patient and waiting to see their grandchildren and their children for over a year now. And I think people are really hoping that things will start to open up and that they’ll be able to reform some of those really important social connections.

Alex: And at the same time, Ashwin, we’ve talked a little bit, you and I, about how for some of your older adult patients, it’s tough to reintegrate. It’s tough for them to feel comfortable going back out there and that’s partly the residue of all this fear-based approach to our public health control of the epidemic.

Ashwin: Absolutely.

Alex: I wonder if we could hear a little bit about that?

Ashwin: There is a lot of fear. A lot of these restrictions have become almost second nature to people. It’s almost more normal to have a mask on than to have it off at this point when you’re with others and similarly, I think, people have just gotten really used to focusing mainly on digital or virtual interactions with others rather than going back to their community groups or hanging out with their children. So I think it takes a lot of proactive encouragement to follow the signs here, as Monica is suggesting, to get people back out there and back in the communities.

Eric: Monica, what does the sign say? Where are we now as far as where should we be as far as restrictions, lockdowns, face masks in the US in particular?

Monica: The science after vaccines is incredible. The one thing about older populations is there’s been two studies now. I think of the clinical efficacy studies of the vaccines as so very 2020, because we have now study after study after study in 2021 showing the real world effectiveness in the vaccines in the context of circulating cases. Even in those real world studies, actually the vaccines look even better than they did in the efficacy trials, the clinical trials because they work that well.

Monica: In terms of older populations, the two papers that really stand out for me is the one in the CDC MMWR that looked at those over 65 who had received the vaccine early on because we prioritized older populations first and hospitalizations decreased by 95% across the entire United States from the vaccine. And then there was a study that was published in the Lancet from Israel that stratified … This is the general population in Israel. It stratified the effectiveness of the vaccines by age and even up to 85, they stopped at 85, the vaccines were extremely effective, just as effective in that population of 75-85-year-olds than they were in the younger population.

Monica: So really shows these were the right vaccines. They’re really effective and they massively reduce the ability for you to get severe disease or hospitalized or die, which is fundamentally why we closed off society to begin with because it was so frightening that this was such a terrible virus. And if that goes away, if that ability of the virus to cause severe disease goes away, it actually, you stop monitoring cases because virally monitoring noses and checking for virus in the nose to make sure that we didn’t pass it on to others, but after vaccination, your ability to transmit is almost nonexistent after you’ve been vaccinated.

Monica: So keeping a screening in nursing homes, for example, for nose swabs in nursing homes when we know that we’ve already seen nursing home outbreaks and there have been two now big studies published by the CDC MMWR that show you cannot transmit within the nursing home if you’ve been vaccinated. Transmission reduction was up to 96% to 100% in one study. It means that swabbing people for just the sake of swabbing doesn’t make sense. We should be only checking people if they become ill. If they have a respiratory infection, of course we should ensure that they don’t have COVID-19.

Eric: So those twice weekly Binax testing that I do to …

Monica: It has to stop. I really do mean that.

Eric: What about for unvaccinated nursing home staff? Should they still get the twice a week Binax or the whatever?

Monica: Unvaccinated, yes, should, even though there’s a couple of caveats about that. One is that I think this idea that we are going to mandate vaccinations for health care workers once the vaccines are approved, as opposed to under EUA, I actually think this is wise and UCSF is going to mandate that, for example. We’re all going to be mandated.

Monica: The second is that it depends on the incidence in the community. The way to think about the unvaccinated risk, the risk for the unvaccinated, that would be someone who chooses not to get vaccinated or someone who is still not eligible for the vaccine, a child less than 12.

Monica: The risk for that person depends on your case rates in the community with everyone else being vaccinated. For example, we have an 80% first vaccination rate in San Francisco, higher than any other municipality in the country. We have very low cases and we’re screening. Like you said, we’re doing these Binax tests. We’re doing a lot of testing and out of about 100,000 people, we have one to two cases at the most in a day.

Monica: We are at such low levels that CDC has defined that as the lowest level risk. It’s like going back to almost 2019. So when I think about an unvaccinated staff in the City of San Francisco and them being swabbed twice a day, they are very unlikely to have been the one that confronts COVID-19 because we have so little COVID-19 in the city.

Monica: So you do have to incorporate community incidence when you decide on swabbing, masking, continued restrictions on the unvaccinated, as well. I feel it’s really important to get that concept in here that we’re going to need metrics to stop all of it, masking and swabbing even of the unvaccinated, based on community rates.

Eric: Yeah. I feel like a lot of people are still swabbing all of our patients in the nursing home, all of the staff. Man, I’m getting pretty tired of somebody sticking something up my nose twice a week, too.

Monica: It’s not only that. As you know, base theorem shows us that when a prevalence of an infection goes down very low, any disease or infection, the false positive rate goes up. So you’re going to actually lead to quarantining and isolation and things are not necessary because no test is perfect. And so this is the point at which swabbing … And the CDC has been very clear about this. They are recommending swabbing and screening only if someone has disease. And so what we’re doing in the city right now and many places in long-term care facilities is not recommended by the CDC.

Eric: Could I ask, something? You said earlier, this is a contentious issue. Should we mandate vaccinations for nursing home staff? And I think you said earlier that once we’re beyond the emergency use authorization that we should. And this is … Reasonable people disagree about this. There’s some who say that if we mandate it, then we’re forcing staff members to get something. And if you mandate it, it may feel like this is … I felt so unsupported in the nursing home setting all along, which is true, right?

Alex: We prioritize hospitals far more than we prioritize nursing homes, especially early on in the pandemic in terms of resources, PPE, et cetera. And that’s just revealed the legacy of poor support for nursing homes and nursing home staff have to work multiple jobs, et cetera. And now we’re forcing nursing home staff to get something that they might be personally opposed to on top of all of this and that it might erode already fragile trust. Thoughts from you about that perspective?

Monica: I think that’s a very fair question, actually, and in general, I’ve been against really forcing, as opposed to giving people education and compassionate data on the safety and the effectiveness of the vaccines. I think the one thing I would say about healthcare workers, though, is that we have been asked yearly to get the flu vaccine, for example, or we have to mask. If we decline the flu vaccine as healthcare workers, we have to universally mask. I know now they want us to universally mask forever, but I don’t think that’s indicated by a respiratory infection that’s going away.

Monica: But I think that’s a very fair point, but I think then continue masking, which I know, again, is being done in nursing homes even in the setting of vaccination, which we can talk about later. Universal masking, then, should be required for the unvaccinated if people decline to get vaccinated during the season. But it’s a very fair point and I will say more about that.

Eric: All right. I’m going to ask about masks now. How should we think about masks when we’re talking with older adults? Maybe they’re hesitant about going outside with a mask or going indoors with a mask. Maybe they’re questioning the current CDC guidelines that loosened up mask restrictions. How should our vaccinated older adults think about this?

Monica: I would like to start by just saying of course everyone will choose what they’d like to do, what feels comfortable. And if a mask has felt comfortable for you because it’s something that was protective, then now we’re going to say that in terms of just being compassionate that we should … Harm reduction means whatever people want to do. However, I will say this, that I write one with my division chief, one of the first papers on universal masking actually before the CDC recommended it. This was in March 2020. We were actually writing the paper and it was in proofs when the CDC said we should universally mask.

Monica: So I’m really interested and [inaudible 00:19:18] and have now written multiple papers on masking. I think it’s a very important mitigation strategy for a respiratory pathogen and it was one of the pillars of mitigation prior to vaccines. However, vaccines changed everything and even though a mask is a visible symbol that we all know is your immunity actually to a pathogen is actually the most profound thing you can do to protect yourself. And immunity overwhelms mitigation procedures by a mile, so masking, distancing, contact tracing and ventilation were all the five mitigation procedures were had before vaccination.

Monica: After vaccination, it’s a force field. Even again, we talk 75 to 85-year-olds in the [inaudible 00:20:08], still even older patients have this force field of being protected. And so I have started to talk about I think we should be unmasking and I agree with the CDC guidelines that they released on May 13th that was controversial. I agree with it that we should try to go back to when it’s indicated, when case rates are low for the unvaccinated and when we are vaccinated, try to go back to that pre-pandemic life of taking of the masks. Why? Because I think there are detriments to masking.

Monica: I think of the extremes, older and younger people, but younger people facial expressions are actually really important and learning and in communication and learning how to talk, for example, in really young children. And older people, there is that facial connection when you’ve been isolated for so long and a smile means a lot. And it’s not just your eyes smiling, but a smile. And so I genuinely can’t stress enough that it’s not wrong to unmask after vaccination. It’s right. It’s the science.

Monica: And we are doing in the health community, I think, a little bit of disservice to ourselves by saying … By not catching up with the effectiveness of the vaccine. Purely science based. Vaccines are science. It couldn’t be any more sciencey than to make it a profoundly cool vaccine. And catching up with the science means accepting the effectiveness of the vaccine, accepting what they’ve done. We’re at 14,000 infections across the entire United States today. 10,000 was the number that Dr. Fauci had said on April 15th would mean we’re done.

Monica: And so we can catch up with that science and unmask. I really, I think we will see if we model that normality for each other, we will enjoy being around each other. We will enjoy seeing each other’s faces.

Ashwin: I completely agree, too. When I think about older adults in masks, I think about hearing impairment, vision impairment, cognitive impairment, all those things that can impact how we normally socialize with others that we’re as geriatricians really trying to target with assistive devices and masks just create one additional barrier to all of those typical social interactions. So definitely not something without downside, although I completely agree it’s up to people to figure out what risk they’re willing to tolerate and it’s not as simple of a decision sometimes when we’re thinking about improving socializing.

Eric: I guess the question is the risk that we’re willing to tolerate because the messaging has always been oh, this is not an individual risk issue, this is a public health issue. So we’re trying to decrease risk to others with some of these interventions like mask wearing and I think potentially, also, with kids wearing masks in school, right? The incidence of kids getting really sick from coronavirus is shockingly low compared to, let’s say older adults getting sick. But it was about trying to stop the spread, trying to protect others. Where are we with that calculus?

Monica: The best thing you can do to protect others is have your force field of vaccination. So I think it’s actually really important that there was discussions whether vaccines block transmission. I’m not sure why we had so much discussion about that in January because even though the clinical trials weren’t designed to swab people routinely after vaccination and see if asymptomatic infection went away that would make you be able to transmit even when you felt well, the clinical trials weren’t designed that way.

Monica: We were going to get that information from real world studies and there was always biological possibility that these vaccines would block transmission. They actually generated IgA, which is a type of antibody that goes into your nose, IgG which they generate goes into your nose and so do T cells. They actually go into your nose. So everything they generate will block your ability to keep the virus in your nose and pass it on to others. And now we have study after study after study that shows us if you swab your poor you and your patients getting swabbed twice a week after vaccination that the rate of asymptomatic infection is decreased by anywhere from 86-100% and depends, again, on incidence in the community.

Monica: So it’s very difficult to pass it on after you’ve had a vaccine. What that means is you’ve just protected everybody else by being vaccinated way more than a mask would to be fair. I do know masks because I studied them, actually worked with a physical scientist to really understand them. But there is no comparison between a mask which can leak around the edges, which doesn’t always fit exactly. We’re not wearing N95 in public. There’s no comparison between that and what you do to protect others by being vaccinated. And then those who are unvaccinated, again, they’re protected by all of us being vaccinated.

Monica: So masks, I know it’s a talisman. It’s a symbol in a way that we followed the science before, but it’s okay to follow the science into it’s new places and the new place with vaccines is we don’t need to mask and in fact, I think it’s fair for geriatricians and for pediatricians to talk about age and why sometimes it’s needed to have, with hearing impairment like you said, to have this ability to take away our masks and talk to each other.

Eric: I remember a couple of your Tweets and since I read them, I thought to myself, I’m going to role model not wearing masks outdoors.

Monica: I think it’s good epidemiologic behavior. I always say that. Everyone’s glaring at me and I’m like, “I’m modeling good Infectious Disease behavior by taking my mask off.

Alex: I wanted to ask, we were joking with Monica at the beginning and maybe even in our first recording before we hit record, Monica was saying this family wanted to make WWMGD shirts and that they’re actually for sale out there. They’re out there. They’re out in the wild. But wouldn’t it be better to get those resources and diverted them to getting vaccines to India. And I think that there’s something important here that we should talk about which is that here, we’re on the latter stages and we’re dealing with how do we come out of this pandemic? And there are issues we’re grappling with and they are important and I don’t want to minimize the suffering and the persistent issues that we’re talking about today.

Eric: And yet, if you think in a global sense of where we should be concerned as healthcare providers in caring for others, caring for older adults, caring for people with serious illness, the need globally far dwarfs the issues that are continuing to happen in the United States. And I think, Ashwin, we’ve talked about what it’s like for your relatives in India and we had a staff member who lost a parent in India to COVID recently. I’m just thinking about what’s going … 2% of Africa, I think, has had one shot in comparison to half of the US and a third of Europe or something like that.

Alex: I wanted to just open it up and Ashwin, maybe start with you thinking about the global need here, where our priorities should lie.

Ashwin: Thanks, Alex, for creating the space to talk through this. I think it is really tough to experience the opening up or improvement here while watching what’s going on abroad and witnessing these global disparities and vaccination rates and also, just the acceleration of cases abroad. I think my hope is that this increased awareness and an increased push to have better and more equitable distribution of that seems … Also, just help with the day-to-day challenges and needs around the world will make a difference here.

Ashwin: I’ve been following Monica’s advocacy for India and elsewhere in the world pretty closely and I think as clinicians, we have a large responsibility, as well as potentially a lot of sway in helping to change policy to advocate for some of these equity issues.

Alex: And Monica, your thoughts on that.

Monica: I was an intern in 1996 here at UCSF, so I’ve been here a long time and in the history of HIV medicine, that was a really big deal year because that was the year that we had highly effective antiretroviral therapies for the treatment of HIV. So I was watching people at San Francisco General literally rise from their beds and become healthy with the antiretroviral therapy and at the same time because I’m from India, my family is from India, I was watching sub-Saharan Africa and India not get access to life-saving HIV medications for years and years and years after that.

Monica: I mean 1996, Europe and US was totally changing and 2006 is really when antiretroviral access became more available to people who are needlessly dying in sub-Saharan Africa because they didn’t have access to this medication. And that’s where, by the way, the HIV epidemic was most concentrated. And so I find it really ironic right now to be talking about the paradox of releasing masks and testing.

Monica: And actually, by the way, I want [inaudible 00:30:17] testing here because I want to save our public health dollars for other things. We shouldn’t needlessly test. I really do think it’s a public health resource that we shouldn’t test asymptomatic. But the reason that’s important is it’s incredibly ironic that we are doing over the paradox of this kind of we’re normalizing and India and other places are on fire. And we have the solution. We’ve had the solution in hand since December 2020.

Monica: India actually appealed with South Africa to the World Health Organization in October 2020, way before this horrible surge that started in March and they said, “You will have to await patents for these vaccines. We really need these vaccines. We have the manufacturing capability, give us the formula.” And the World Health Organization said no. And we could have averted this if we had more vaccines in India at the time.

Monica: So I totally agree with Ashwin that it is our role as clinicians, it is our role as clinicians to widely advocate for equity with vaccines because we have the solution to the pandemic. It could be over for everybody. We could all be discussing whether we want to wear masks or not after vaccines. The solution is here and it needs to be given worldwide, distributed and quickly.

Alex: Yeah. I like how you refer and you have referred in your … I’ve heard you on other podcasts to vaccines as the solution. For our listeners who might be interested in what they can do to help globally to address the tremendous equity issues in access to vaccines, are there things, steps that our listeners could take? Monica, any thoughts there and then Ashwin?

Monica: One thing is we have an open letter to the Biden administration and Congress asking for the donation of our surplus doses. We are getting so close to our 70% first dose rate, I think we will be there before July 4th. We have about 300 million surplus doses that we purchased, actually, above and beyond what our population needs. And I think the best thing we can do for quickness, beyond waving patents in the future, is advocating for donation of those doses.

Monica: If you just look on the internet and say open letter UCSF Biden, you’ll find it and you can sign it. And then, of course, there are ways to donate, as well, to South America, actually, India, Nepal and like you just said, sub-Saharan Africa will be next unless we can get vaccine equity.

Eric: Can ask something about the other side of people arguing around the patent issue is this is not going to be the last pandemic we’re ever going to see. What do you think about Pfizer, Moderna? They are for profit. The reason part of me … There are probably really good people working there, but part of the reason there was a profit margin in developing these vaccines and whether or not if you open up the patent will that decrease interest in making the future vaccine for the next COVID-25 or whatever comes next? How should we think about that?

Monica: That’s a very fair point and actually, I think the pharmaceutical companies will actually still make profit because this is what happened with the antiretroviral therapy, that actually the patents were eventually released short-term, short-term for India to get the capability to provide antiretroviral therapy for the world, this irony that India was the one who provided it for sub-Saharan Africa.

Monica: So it’s a temporary waiving and there is absolutely and as always happens the pharmaceutical companies continue as they should because you’re right, they worked on it to make profit. But it’s temporarily for a massive influx of vaccines right now to places that people could not be dying. And then we will go back to patents. That’s actually even President Biden has signed on to this and he is proposing a six-month waiving.

Eric: All right lightening round. I’ve got some lightening round questions. Alex, Ashwin, please jump in lightening rounds, too. Older adults or somebody with serious illness you’re seeing in clinic and they ask, “Is it okay if I’m vaccinated if I see my kids who just went to camp last week this summer?”

Ashwin: Yes.

Eric: Yes, Ashwin.

Ashwin: Defer to Monica on this, though.

Monica: Yes. Please. Please see your grandchildren because you’re still protected by the vaccines.

Eric: Yeah. But what if they’re not vaccinated and they’re just coming home from a sleep-away camp?

Monica: But the children being unvaccinated, you’re … Really the highly effective nature of the vaccines means you’re protected as the older person and so that’s what’s been so amazing, that even with circulating cases, vaccine effectiveness has been up to in real world settings 97-98%. So you are still protected as the vaccinated grandparent even if the child has it in their nose, which by the way, children are less likely to transmit because of virology in the nasal mucosa.

Eric: All right. Oh, Alex. Go ahead.

Alex: Okay. You’ve written quite a bit about how vaccine … We may not need boosters. This is building on the question that Eric posed before. I think one of the big companies has already come out and said they think we’ll probably need boosters. Could you explain in a lightening round fashion for our audience why you’re optimistic that this vaccine immunity will endure?

Monica: Yes. Two reasons. Briefly, it’s because in immunology, if a vaccine can produce what are called memory cells, memory cells actually go and sit in the bank and then they come out and protect you later if you ever see the virus, then you know it’s going to be long-standing immunity. And now we have two amazing studies that show that after natural infection they actually took people’s bone marrow biopsies and you could see memory B cells forming, memory T cells forming so that you’re going to be able to have those for a long time.

Monica: The same thing after vaccination, took lymph node biopsies of people and memory cells were forming. Those can last 90 years. And then the second reason is the coronavirus which this is actually doesn’t mutate like influenza. I know we hear a lot about variants, but it actually is … in ID talk, we say it’s a DNA virus wannabe and we think that’s so funny because we’re so geeky. But it really, it does not mutate very quickly like influenza does. So influenza is the only virus that we’ve needed yearly shots for because it’s a very mutable virus. That’s not at all what the RNA virus or coronavirus is.

Eric: All right, I feel like it’s going back to Hillary Clinton’s campaign, but the emails. Now it’s all about but the variants, but the variants. Memorial Day, oh my God we’re going to have a third wave because of the variants. How scared should we be about the variants?

Monica: Inaccurate predictions. Again, I think it is more because it’s hard to get away from that fear-based messaging because we thought if we’re fear-based that people would be cautious. Fear-based and caution was appropriate before the vaccines. With the vaccine’s incredible effectiveness, it’s not appropriate. And no, this has been shown again and again that you open up, there are variants circulating and yet the incredible power of the effectiveness of the vaccines are keeping those cases low.

Monica: And also really importantly, if you really think deeply about immunity, you can fight those variants with another arm of the immune system that you get T cells. So variants have been a little bit of a just scare tactic, I think, and things are going very well in this country, despite circulating variants.

Eric: And Ashwin, anything that you talk to your patients in palliative care clinic about reintegrating with society, dealing with loneliness? I know this is lightning round, so it has to be a quick answer.

Ashwin: Yeah. It’s all about reassurance right now. It’s actively encouraging people to get back out there and see their kids, see their grandchildren, try to do some of the social activities that they enjoyed prior to the pandemic and making … Even sharing your own personal stories about how you’re getting out there and it’s okay for them to do it, too. So I think as much reassurance that we can give, the better.

Eric: All right. Last question for you, Monica. Where the heck are the rest of the Infectious Disease doctors? Are they just burnt out because the year for them has been so hard clinically? How come a lot of the voices I see on social media, CNN, are not Infectious Disease experts? They’re others.

Monica: That’s an incredibly good question. I think that Infectious Disease doctors have a role to play because they do know virology, immunology, but they’ve also been seeing patients, which I actually think makes a huge difference in your response. An epidemiologist is not seeing the loneliness of people every day. We all as doctors have been seeing what it feels like to be in a pandemic. I don’t know. I think you can get attacked if you believed in masks before, but think that unmasking after is indicated and that attacks you’re awful and maybe people don’t want to put themselves out there. But they all write me and they say stuff like, “Yeah, totally.” So they agree.

Eric: I want a big, big thank you for joining us, but before we end, Monica, how about we get a little bit more of that song?

Alex: A little bit more of Get Back. (singing)

Eric: Monica and Ashwin, thank you for joining us for this GeriPal podcast.

Ashwin: Thank you so much.

Eric: And my family is very jealous that I had a chance to talk to Monica Gandhi today.

Monica: We’ll all hang out without masks whenever you’re ready.

Eric: We go on a walk every night now without masks outdoors. That’s role modeling, right?

Monica: Yep. Modeling good behavior.

Eric: Great. Ashwin, thank you for joining us and thank you to Archstone Foundation for your continued support and to all of our listeners at the GeriPal podcast, thank you for listening and have a wonderful night.

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