January 23, 2022


Why I’m for COVID vaccines, but against vaccine mandates.

In the heated debate over vaccine mandates, science and logic have often been lost amid politics and fear.

Read Time 14 minutes

Tomorrow we’ll be releasing a follow-up discussion with Drs. Marty Makary, Zubin Damania, and Monica Gandhi on all things COVID. This episode was put together in response to the overwhelming, if not staggering, response to our first episode, released on January 3 (Monica was not on that one, but she is a brilliant addition to part 2). In this episode we aim to address most of the topics that so many of you have asked us to expand upon.

On the heels of this podcast, I want to write about something that we discussed on the podcast, something that is sure to upset some reading this or listening to the episode, whichever side you find yourself on: Vaccine mandates.

The goal of this article is not to irritate you for the sake of irritating you. My hope in writing this, first and foremost, is to invite you to think. In the heated debate over vaccine mandates, science and logic have often been lost amid politics and fear. Ever-evolving circumstances – such as the emergence of variants with radically different levels of infectiousness or virulence – have only further separated opinion from facts. (After all, if facts are changing, why haven’t opinions changed, too?)

Of course, I’d like to convince you of my point of view (denying this would simply be disingenuous—why else do we write or argue a point?). But if that fails, I hope, at least, that this newsletter may serve as a reminder that exchanging rational decision-making for fear and blind partisanship is a recipe for injustice, discrimination, and policies that may do more harm than good. Scientific policy must be based on scientific truth — otherwise it will be ineffective in the present — and damage credibility for the future.

Let’s start with my priors: COVID vaccines save lives.

COVID vaccines absolutely save lives. Full stop. My opposition to vaccine mandates does not in any way diminish my belief in the data supporting the efficacy of vaccines in preventing severe disease and death, particularly in people over 65 and in those with comorbidities. So, I’m not going to spend much time extolling the virtues of vaccines beyond sharing some data that should always be examined for any medical intervention: what is the benefit, in different risk groups, in both relative and absolute terms?

Deaths of Unvaccinated vs Vaccinated (mRNA vaccines only, at least 1 dose). Data collected from the Veterans Affairs system between December 2020 and March 2021.

The data above show that for people over the age of 18, the relative risk reduction (RRR) of death is between 84 and 88%, regardless of age. This is very close to the 90% risk reduction that was touted at the time of vaccine approval a year ago. But if you’ve paid attention to anything I’ve spoken and written about for the past 10 years, you will recall that we should always pay attention to absolute risk reduction (ARR) also. If the relative risk reduction is 90% (to make the math easy), you still don’t know if the risk is being reduced from 100% to 10% or from 0.1% to 0.01%. And this matters greatly.

Consider the following example: Let’s say we faced a virus that killed 100% of those who contracted it. A vaccine with a 50% RRR (i.e., only “50% effective”), meaning it reduced deaths by half, would save over 150 million lives in the U.S. But if we faced another virus that killed 0.1% of those who caught it, even a vaccine with 99% RRR (i.e., “99% effective”) would “only” save about 300,000 lives (by lowering the death rate from 0.1% to 0.001%). In other words, in this scenario the vaccine that is 50% is far more valuable—and saves orders of magnitude more lives—than the one that is 99% effective that reduces deaths from 0.1% to 0.001%. How is it possible that a vaccine that is only 50% effective could save more than 150 million lives, while one that is 99% effective can only save 300,000 lives? Because of absolute risk reduction. The 50% effective vaccine is up against a virus that infects and kills every single person in a given population, so in absolute terms it is wildly effective, literally saving one out of every two lives of the people who take it. Conversely, the vaccine that is 99% effective is up against a virus that only kills 1 out 1,000 people who encounter it.

Returning to the actual data for COVID vaccines, take a look at the absolute risk reduction column. Here, two things stand out. First, the absolute risk reduction (ARR) increases with age. Why? Because the older you are, the more likely you are to die from COVID, so the benefit from the vaccine is greater. Second, the ARR numbers are very small, especially for people younger than 65. A quick way to get an intuitive understanding of this is to take the reciprocal of the ARR. This number is known as the “NNT” or number-needed-to-treat, which tells you how many people you need to treat to save a life. If the ARR is 50%, the NNT is 2 (1/0.5). If the ARR is 0.1%, the NNT is 1,000 (1/0.001). Based on this data set from the VA (which I chose because of the age stratification), the the number of people you need to vaccinate to save one life in the 18-64 group is 10,000, versus 2,857 in the 65-74 group , and 1,370 in the over-75 group. By comparison, the NNT for a statin is between 50 and 200, depending on the study and patient population studied.

This is not to imply that COVID vaccines are ineffective or somehow useless. Far from it. A quick glance at the recent CDC data, covering more than 1.2 million people who completed their primary vaccination between December 2020 and October 2021, bears this out. In this broader group, 0.015% had a severe case of COVID and 0.0033% died. Not surprisingly, the risk of death was highest among people over 65 and among those who were immunocompromised or had significant comorbidities. But overall, the risk of death among people who were vaccinated was infinitesimal.

In fact, the rate of death from COVID if you are vaccinated is on par with, and likely less than, that from influenza. According to  CDC data from 2017 to 2018, there were approximately 41 million symptomatic cases of influenza that year. This resulted in over 710,000 hospitalizations and nearly 52,000 deaths, which means a fatality rate of 0.126%. Looking at the same data for 2018 to 2019, we can see the death rate was 0.095%. It is abundantly clear: If you are vaccinated, your risk of severe illness or death from COVID is very low, even compared to influenza.

So, why not mandate vaccines, then?

There are many reasons I have heard put forth for why vaccines should be mandated, but one dominant argument stands out: Mandating vaccines will protect vaccinated people from unvaccinated people. This argument assumes three things:

  1. Vaccines DO NOT provide complete protection to the vaccinated (or else why would we care about what the unvaccinated do),
  2. Prior infection DOES NOT confer immunity on par with vaccination, and
  3. Vaccines DO prevent transmission of the virus (which is why we want the unvaccinated vaccinated, even if we don’t care about their health, per se).

Well, we’ve largely addressed the first point in an effort to get our facts straight on vaccine efficacy, and as we’ve seen, the basic assumption fueling this concern is valid at its surface: vaccines do not provide complete protection to the vaccinated. That is, they are not 100% effective at preventing infection, hospitalization, and death. In fact, although vaccines significantly reduce risk of detectable infection in the few months after vaccination, this protection drops precipitously once circulating antibodies decline, though protection against severe infections and death persists. Still, the protection isn’t absolute, and some risk of death remains even among those who have been vaccinated. However, the good news is that the risk is very low today. This was not necessarily the case 18 months ago, but three things have evolved over the past year-and-a-half to compound the risk-reduction of vaccines:

  1. Novel therapeutics have been developed specifically to treat COVID, including monoclonal antibodies, paxlovid, and molnupiravir, all of which reduce the risk of hospitalization and death by anywhere from 50% to 90%.
  2. At least one existing drug (fluvoxamine) has been repurposed to treat COVID successfully, reducing both hospitalizations and deaths by 66% and 91%, respectively, based on per protocol usage.
  3. Far more sophisticated critical care knowledge has evolved, specifically, to address COVID, including the use of dexamethasone and better strategies of ventilation.

The net result of these advances, layered on the benefits of vaccination, imply that a vaccinated person infected with COVID today is in a far less risky position than they were a year ago. And this says nothing of the fact that when it comes to the Omicron variant, which today accounts for >99% of document cases in the U.S., the risk goes down much further. Why? Because the data are unambiguously clear that Omicron is much less virulent than Delta and Beta and Alpha.

How much less virulent is Omicron?

Well, if we look at the most up-to-date information at the time of this writing (still in pre-print), analyzing data from Kaiser Permanente in Southern California between November 30, 2021 and January 1, 2022, there were a little over 52,000 documented cases of Omicron in the patients in their medical system, compared with nearly 17,000 cases of Delta (today these numbers skew much more to Omicron, of course, based on the current distribution of Omicron in the U.S.).

  • 235 (0.5%) of these Omicron patients required admission to the hospital, compared to 222 (1.3%) of the Delta cases;
  • of the 235 Omicron cases, zero required mechanical ventilation, compared to 11 patients with Delta;
  • one patient with Omicron died, compared to 12 patients with Delta; and
  • 84% of patients hospitalized with Omicron left the hospital in less than 2 days, compared to 31% of patients hospitalized with Delta.

Of course, none of this should be surprising given what we know from the data out of South Africa, where Omicron originated, which demonstrated the reduced severity of Omicron relative to Delta, even in a country with very low vaccination rates. Omicron is a very mild infection, compared to Delta, Beta, or Alpha, and based on the emerging data I’ve presented above, it seems to be mild even compared to influenza.

Therefore, we can conclude that while the vaccinated are not immune to COVID infections, their risk of severe illness or death is very low because of the following:

  1. The vaccines greatly reduce hospitalization and death, and
  2. We have a slew of novel and repurposed drugs that are very effective at treating COVID, and
  3. Our hospitals and ICUs are far better equipped to treat COVID patients based on nearly two years of empirical and trial data, and
  4. The dominant variant, Omicron, is a very mild virus (even to the unvaccinated).

How does natural immunity stack up to vaccines?

Next, let’s examine the assumption that prior infections do not provide immunity on par with vaccine immunity. Of the three sub-arguments in the case for mandates based on protecting the vaccinated, I find this the hardest to understand. I am not aware of any other virus from which a recovery does not confer immunity (and yet a vaccine does). In other words, the null hypothesis around this point, at the outset, should be that natural immunity is indeed as good as vaccine immunity, pending data to prove that assumption false. Looking back at the close coronavirus cousins of COVID, SARS and MERS, the data are overwhelming that patients who survived those infections had lasting immunity, even 12 years after infection. Do data exist to suggest natural immunity doesn’t exist for this particular coronavirus? No. To the contrary, there is ample evidence that natural immunity is robust and durable. In fact, the data suggest that recovery from COVID provides longer lasting and stronger protection against subsequent infection, symptomatic disease, and hospitalization caused by the Delta variant, compared to vaccination.

A quick examination of this figure from the CDC data released on January 20 shows that there is virtually no difference in hospitalizations from COVID between the vaccinated and unvaccinated, if a prior COVID infection took place.

In fact, if you look at Table 1 from the paper, and run the calculations yourself, you’ll see the risk of hospitalization is lowest in the group that was not vaccinated, but previously infected. I’ve summarized the data here for the fraction of each group that required hospitalization following a COVID infection:

This simple table, based on data from nearly 22 million COVID positive cases in California between May and November 2021, makes three points so abundantly clear, it’s hard for me understand how there can be any vestigial ambiguity:

  1. Vaccines unquestionably reduce the risk of hospitalization in previously uninfected people (by a factor of 16.5x), and
  2. In people who are previously infected vaccines offer zero additional benefit with respect to hospitalization, and
  3. In vaccinated people, being previously infected reduces the risk of hospitalization by a factor or 2.5x.

Can the case be any clearer, simultaneously, for both the efficacy of vaccines and natural immunity?

How do vaccines affect virus transmission?

Finally, let’s consider the rationale for mandating vaccines to prevent the unvaccinated from transmitting the virus to the vaccinated. A perfect vaccine would not only completely abrogate the severity of the virus on the host, but it would also completely prevent the host from transmitting it to another person, vaccinated or not. This is clearly not the case for any of the current COVID vaccines. In fact, it seems that they only slightly reduce the risk of transmission, and that vaccinated and unvaccinated persons with detectable infection have the same viral loads, despite the reduction in disease severity for the former group. Using a metric called the secondary attack rate (SAR), it’s possible to look at infection rates in household contacts stratified by contact vaccination status and index case vaccination status, and based on such analysis, it seems that vaccination only slightly prevents transmission. Vaccination does not reduce the peak viral load in the infected (though it does appear to reduce the duration of viral shedding, which may translate to the reduction in SAR). An important caveat here is that such analyses have been carried out prior to Omicron’s arrival, but considering everything we know about the mild nature of Omicron, the risk of transmission to vaccinated people is, again, likely much less.

What about mandating vaccines to prevent hospitals from being overrun with COVID cases?

It’s true that hospitals are stretched very thin right now with the n-th surge of COVID. But a few things are worth keeping in mind. During a bad flu season in the U.S. (recent examples would be 2017-2018, 2014-2015, and 2012-2013) it is common for 50,000 to 70,000 patients to be hospitalized at any one time across the country. This is not very different from what we see today (which says nothing of the fact that roughly half of the hospitalized COVID patients have incidental infections. That is, they are there for another reason, but also test positive for COVID). The difference, today, is that the hospital workforce is greatly reduced, relative to a bad flu season. Why is that? According to a survey by Morning Consult, approximately 18% of healthcare workers have quit their jobs since February 2020, while another 12% have been fired or laid off.

Furthermore, many people fail to realize that hospitals routinely function at 90% capacity in their ICUs. A reduction in workforce of even 10% is horribly disruptive to a system flying so close to the sun. It’s kind of like what happens when one of the OPEC nations, even if “only” producing 3% of the world’s oil, goes offline. Complete and total breakdown of the world’s energy markets ensues. It’s called a marginal supply problem.

Perhaps there was a rationale to mandate vaccines in healthcare workers 12 months ago, but given how many of them have quit or been fired for not being vaccinated, despite the fact that they undoubtedly have the highest rates of natural immunity of any profession, it seems illogical to continue to keep unvaccinated healthcare workers away because their immunity came from the actual virus, and not a vaccine.

So where does this leave us?

  • We have a virus that is far less lethal than the one that started the pandemic two years ago.
  • We have very effective vaccines that reduce the severity of illness and death by about 90%.
  • We have ample treatments to further reduce severity of illness in death (in vaccinated and unvaccinated alike) by another 90% or so.
  • We have better methods of providing in-hospital care to the infected.
  • For all their benefits, vaccines are not very effective at preventing transmission.

None of this is opinion. These are simply the facts upon us.

Politics and healthcare will always interconnect to some extent. So, the right question to ask at this time is not why are they’re intertwined, but rather: to what extent should they be?

As some of you heard me outline in my recent interview on Joe Rogan (#1735) and again during my podcast with Drs. Makary and Damania on January 3rd, there is an important distinction to be drawn between Science and Advocacy. Clear lines should be drawn between those two concepts. Vaccine mandates are a prime example of how those lines are often blurred.

Science is not a noun. It is not a person, or group of persons. It is a process. And it’s a process by which you perpetually adapt and evolve through the rigor of always testing your best guesses and seeking to disprove your own assumptions and firmly held beliefs. You welcome uncertainty in the interest of getting just one inch closer to the truth. Speaking in absolutes is not the aim.

Politics, one could argue, is radically different. Political leaders are criticized for speaking with uncertainty and punished for changing their minds. In that sense, politics is the antithesis of the scientific process.

None of the above is a new phenomenon, and little about this dichotomy is likely to change. However, the crux in which we now find ourselves is the present impact of this divide, manifested strongly in our current political policy and juxtaposed with our current scientific knowledge.

Another question that we don’t seem to be asking ourselves is, what, exactly, is the definition of unvaccinated? It’s becoming more and more subjective each day. Today, unvaccinated apparently applies to an 18-year-old college student who “only” received the full 2-shot vaccine dose, but did not receive a third booster shot. Such a student can’t attend a college for which their tuition has been paid. If they concede to the third dose, when will they require a fourth? A fifth? If we’re using circulating antibodies as our metric of immune success, we’ll need to give boosters every 3 months to keep antibodies high. And for what? Certainly not to help us avoid severe disease, hospitalization, or death. For that we can rely on the memory B-cells and T-cells we developed in response to an actual infection or to our first vaccination.

What is the impact of vaccine mandates?

Let’s consider the following examples of the impact vaccine mandates are having right now:

    • In my birthplace of Canada, an unvaccinated person cannot board a plane or a train, let alone go into a restaurant, gym, or skating rink. This is especially interesting, given that the rate of infections in Ontario is now higher in vaccinated than unvaccinated persons, a transition that occurred with the arrival of Omicron in late December. This finding presumably speaks to the low efficacy of the current vaccines at preventing Omicron infections.

  • A Canadian friend of mine, this week, was prohibited from seeing a medical doctor for a corneal abrasion because the doctor refused to see unvaccinated patients (including those with natural immunity from a prior COVID infection). Bear in mind that this is occurring in Canada, a country with universal access to healthcare—a hallmark of Canadian values.
  • A Virginia man in need of a kidney transplant was removed from the transplant list, denying him a life-saving procedure, because he was not vaccinated (though he was previously infected with COVID).
  • In September, Canada’s Prime Minister, Justin Trudeau said that the unvaccinated are part of an extreme group that also included misogynists and racists.
  • Here in the U.S. some are even calling for the deployment of the National Guard “to ensure that people without proof of vaccination would not be allowed, well, anywhere.”
  • A previous guest on my podcast, who asked to remain anonymous, was recently fired from their job as a professor at a very prestigious university for not being vaccinated. This person was fired with cause, which meant they were not even able to apply for unemployment insurance.

The bottom line.

I have been clear about my support for vaccinations. They are an excellent tool to protect us against severe infection and death from COVID. What they are not, however, is a monolithic tool to be used as a sword against our citizens, rather than a shield against a virus. When we call the unvaccinated misogynists and racists as Mr. Trudeau has, or when we make it our goal as a society to make the lives of the unvaccinated as miserable as possible, as French President Emmanuel Macron has said, what are we hoping to achieve? Is this a strategy to increase vaccination rates, or to exact a vengeance?

Even though the U.S. Supreme Court last week struck down the federal government’s proposed vaccine mandate for large corporations, hundreds of U.S. companies and universities are still putting in place mandates of their own, which come with stiff financial penalties and even job losses.

As you consider this thorny issue, I urge to consider the following questions:

Even if you felt vaccine mandates made sense one year ago, when the Beta and Delta variants were raging, when it was too soon to say how well the vaccines would work in the real world, when we had few excellent treatments for infected, and when ICUs were still struggling to understand how to treat COVID, can we really say with a straight face we’re in the same difficult situation, today, especially with the Omicron variant?

What is the scientific evidence to support vaccine mandates today? Today, we have vaccines that are very effective at preventing severe disease in the vaccinated. Today, we have many treatments to further reduce the severity of illness, if infected. Today, we have enormous expertise to treat infected patients in hospitals. Today, we have a dominant variant in Omicron that is nowhere near as virulent as its predecessors. If this were really about science, why would we not allow previous infection, which confers all the benefits of vaccination, if not more, the same rights? Does it not seem that mandates are having the opposite effect to what is desired? Instead of increasing vaccination rates are mandates instead hardening and alienating the unvaccinated further?

If we are being honest with ourselves, are the mandates truly for the protection of the vaccinated, or do they exist to punish the unvaccinated?

How will history evaluate these mandates?

How will history evaluate us for how we have treated the unvaccinated?

And as we look at future science-based policy discussions, even beyond COVID, we need first to agree on the questions we are actually trying to answer. From there, we can begin to explore different possible solutions and debate their costs and benefits in a rational and civil manner. And always, we need to ask ourselves honestly: are we picking sides based on assertions and talking points (Advocacy) or testable hypotheses (Science)?

injecting injection vaccine vaccination medicine flu man doctor insulin health drug influenza concept - stock image

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  1. I agree, it is time to allow prior infection the same status as vaccinated. In addition, CDC should update guidance on boosters to acknowledge age and comorbidity stratified risk-benefit analysis. Adolescents (especially males) should be advised about risks of myocarditis with mRNA vaccines which place them at risk>benefit from booster, and possibly from second dose. But the anti-virals are almost impossible to obtain, the pharmacies are EMPTY, and testing takes 4-5 days (PCR results), so the anti-viral argument is bogus, not available. You left out one important point, the high transmissibility overwhelms the lower mortality rate to the point that Omicron will kill more people than delta.

  2. I’m beyond believing any stats coming from the CDC anymore. It’s like believing the stuff coming from the AHA about cholesterol and statins or the ADA about BG control and carb recommendations.

    Agree with those who point out the evasion of addressing the risks associated with the shots. No mention of the re-defining vaccine in order to call the shots vaccines either.

    And what about “where other treatments exist”?

    This used to be a place where I could come to find the science, looks like not any more. I thought you used to do a lot of your own research.

    • I agree 100% When you have Dr Malone and Dr McCullough Or any one on the FLCCC group Dr Cory, Dr MariK to discuss the dangers that the vaccines have caused and potential long term dangers and treatments we have had from the beginning. I will be back but not until then.

  3. Thank you Peter for taking a stand on this important issue. We need courageous and knowledgable people like you to speak out against Sars-Cov2 vaccine mandates. I did notice some points that were missing from your post. The concept of freedom and in this case specifically medical freedom. It’s a concept that might only pertain to a US citizen but I’m grateful to be one. The other point you did not address is risk from SARS-COV2 vaccination. Your colleagues and friends act as if it’s completely obvious that the risks of vaccination or so low as not to even be discussed. If VAERS doesn’t concern you please let us know why. Maybe you think it’s obvious but many see huge issues. And that leads to the last missing point, Informed Consent. We have a right to know the risks of any medical intervention even it’s low and not severe. I can tell you I, as a lay person can’t really tell what the risks and severity are and unfortunately don’t trust my doc, my own government and certainly not the pharmaceutical companies as of late.

  4. Very disappointing article – the first time I have to state this about one of Peter’s articles. Without delving into the many flaws of the argumentation presented (many having been mentioned in other comments), our overall vaccination history including existing mandates and its positive impact speak for themselves. I guess Peter has joined the side which advocates for individual selfishness over societal responsibility. As I said, very disappointing.

    • Would you care to provide specifics to support your argument? You sound like someone who can’t adapt to new information. We have treatments and protocols in addition to an imperfect vaccine now. The pandemic has been over for months. Time to move on.

    • Give it rest with the responsibility thing. You are advocating for authoritarian policies. History will judge these actions.

      • It’s called public health law. Best analogies are our highway laws—they protect the driver and the driving public (from the negligent driver). Governance – good governance – requires creating and enforcing some unpopular rules to protect the masses from the ignorant and/or malicious minority. Sadly, in the case of COVID, we have both sectors, some overlapping, in our society.

  5. I’m an ICU nurse. I recently took a new job and did not have a positive titer for MMR. It was mandatory for me to get the MMR vaccine for my job. This has been standard practice for years – where is the outrage for this vaccine mandate?

    This article argues against the political forces that are for vaccine mandates, but what about the strong political forces that are totally against vaccination? The outrage that has been generated over the mandate is not equivalent to what is being asked of people. As I pointed out earlier, we have been mandating vaccines for a long time before Covid.

    Also, and this is just my personal experience, the number of patients admitted to my ICU are overwhelmingly unvaccinated. This increase in patients far outways the loss of staff that occurred from mandatory vaccines (which was 0 in the unit I work in).

    Love your work Dr. Attia but I don’t see eye to eye with you on this one. I think there needs to be more focus on the political forces that are keeping people from getting vaccinated.

  6. To coerce someone to take a medical intervention they do not want, or does not confer any benefit to the patient (previous infection) but with additional risk is evil.

  7. It’s been almost two years and you’ve finally figured out your personal opinion? How long have doctors studied viruses? The public deserves much better guidance from our health care system than they have been given. This feels like endless questions, discussion and mental indulgence but no actionable items for the public population as a whole.

  8. Well Said- now we can argue on a lot of points- but the fact that you are willing to discuss and respect the science comes out on top.

  9. I’ve had Covid twice and am unvaccinated. The second time, Omicron presumably, was even more mild than the first. Different people need different treatments. It’s unethical to require a medical procedure with nonzero risk to protect another. How can we cure the mental illness of people manipulated into hysteria?

  10. I am against vaccine mandates as well. I agree with almost every point you make here, however; it is NOT true that the number of people hospitalized with COVID right now is similar to the 50-70k flu admissions we typically see each year. There are 158,993 COVID patients who are hospitalized today with COVID! Omicron is causing severe disease in many people, including the pediatric population. My hospital system has never seen so many children admitted for COVID as we currently have now.

    You also failed to address two big issues in this article: masks as an effective mitigation measure, and long COVID. Hospitalizations and death are only part of the picture. You spent a lot of time in that podcast going off about the horrors of mask mandates without providing any data that refutes existing evidence that N95s and KN95s provide very good protection against SARS-CoV-2. The hospitals are overrun. Masks work. Each one of us, including children, should be willing to wear a mask indoors for a month or two, in order to reduce the spread of this infection that will be deadly for some and create long-term morbidity in many others.

    • Everything in your comment makes except the first sentence. What I mean is that the things you said that make sense seem to support the public health benefits of v, and you fail to explain why you oppose mandates.accines

  11. Thanks Peter. Love your work!

    However, you seem to be completely ignoring the adverse events / deaths caused by the vaccines in your analysis.

    Covid vaccines prevent covid deaths but they can also cause non-covid deaths. According to this analysis of Pfizer’s own trial data, more people died in the vaccine group (of non-covid causes), than the placebo group.


    Surely this needs to be taken into account, too?

  12. Long covid.
    Those whose lives are at risk because of compromised immunity.
    More variants developing.

  13. I have to disagree with some of the premises of your argument against vaccine mandates. Unvaccinated persons are much more of a threat
    to other unvaccinated individuals-think children under 5. I agree that unvaccinated persons should not be treated as lepers but it’s hard not to have scorn on those who willfully forego a vaccination that may save their lives and reduce the impact on our limited health resources. Yes Omincron is milder and more treatable but that isn’t a rationale for not vaccinating. There are many mandates in our lives-AKA laws. There are some laws I disagree with and I have the freedom to ignore them but still I’m responsible for the consequences and repercussions. I’m sorry but the betterment of society should always trump the rights of the individual. For the sake of brevity I won’t go into long Covid, whether natural immunity is better than vaccination(debatable) and whether measuring declining neutralizing antibodies is the best way to ascertain immunity. I hope you are playing the Devils Advocate. You certainly have sparked a conversation. All this being said Peter I love your podcasts and news letters. Keep up the good work. You’re the best.

  14. Listening to the podcast right now. Of note: Zubin was pointing out that natural infection generates a mucosal response. Ghandi suggested that Covaxin would provide this same benefit, but I don’t think that’s true.

    All of the vaccines will generate a monomeric IgA response. Additionally, an IgG response that circulates in saliva, but will generate little, if any secretory IgA (dimeric). The stimulation of the mucosa via infection through the upper respiratory tract is crucial, and unobtainable via intramuscular injection.

    The dimer form of IgA is required to exist in the tough environment of the mucosa. Also, studies have shown that IgG is twice as effective at neutralization as monomeric IgA, and secretory IgA is half again as effective as IgG.

    Not sure if the decay rates.

  15. Disappointed but not surprised by this article…

    The second to last question you ask in the piece really illustrates your mindset and who you think we should be looking out for in today’s society – “How will history evaluate us for how we have treated the unvaccinated?” – You never ask how history will evaluate the unvaccinated for how they have treated the rest of us, and that I believe is the real question considering we live in a SOCIETY, we are all partly responsible for each other and living together sometimes requires just the smallest of sacrifices to ensure our greater safety.

    Are the elderly and sickly people in our society not worthy of human kindness in your view, or working just a teensy amount to help protect?

    You consistently talk about thresholds and when do we change our mind, so I’ll ask you, at what point would you consider a vaccine mandate appropriate, and then let’s look at all of the vaccine mandates already in place for children to attend school and adults to enroll in the military, are those legit? Which of those mandates are you ready to drop?

    No discussion of Long Covid? But willing to make declarations on how virulent a virus is without looking at what might be the worst societal consequence of illness? Between brain fog, anxiety, heart issues, digestion issues and more, Long Covid could very well end up shaping a generation and doesn’t even garner a mention in your blog post.

    Speaking on the Joe Rogan podcast should be embarrassing and not something to brag about, certainly a large platform but you pay a price when showing up, covered with the stink of other fringe conspiracy guests and host spouting absurd and blatant untruths.

  16. What’s next, no child vaccines? Peter you jumped the shark.

    We don’t know how long natural immunity lasts. That’s especially true with new variants. We also clearly don’t know who has natural immunity. It makes no sense to state that vaccines significantly save lives and be against mandates.

    The great cost of the unvaccinated (in terms of lost lives, difficulty of treating other conditions during the pandemic and absolute dollars) to the health care system? Not considered.

    • George, there are over 100 studies showing that natural immunity is more robust and lasts longer than vaccine-induced immunities. Many other countries view it officially on par for their vaccine certificates. There are even studies coming out of Denmark and the UK that are showing after a few months, when the vaccine antibodies wane that those vaccinated multiple times against COVID are actually at higher risk of infection due possibly to immune system fatigue from over stimulation. In terms of the mandates, a vegan diet has been show to significantly reduce chronic illness (https://www.ahajournals.org/doi/10.1161/JAHA.119.012865) and yet people would be up in arms to have the government mandate that. Being overweight or obese greatly impacts your risk from COVID. Imagine people applauding companies who say they will no longer hire anyone with an unhealthy BMI? Soda, fast food, and other junk food create the obesity epidemic in this country, which reduces overall immune system function and greatly puts people at risk for all kinds of hugely expensive health procedures, yet we don’t outlaw it. Smoking and lack of exercise all have a huge impact on our health care system. Would you like to legislate around that? It’s a slippery slope to start picking and choosing what we allow people to do and not do in terms of lifestyle choices, especially now that it is clear the vaccines do little to hinder transmission with the newer variants.

  17. I enjoy the content of your posts and podcasts. This recent post about recommending vaccines versus mandating them made some good points, but I would like to point out that even healthcare systems that don’t have a Covid-19 vaccine mandate for their employees (the system where I work as a hospitalist being one, so far using the carrot of a bonus for vaccination rather than a stick) are still having staffing shortages. There’s a whole host of factors that are contributing to this. Economic motivators such as greater pay if one becomes a traveling/locums nurse rather than staying employed. Or the increasingly hostile environment as some patients try to mimic the hostile attitudes demonstrated by public figures on the media – those same people shouting at school board meetings are bringing that behavior in greater frequency to the healthcare setting, too, but hospitals can’t turn them away.

    I also would like to point out that vaccine mandates are not new to healthcare systems; every place that I’ve worked has mandated the flu shot annually for clinical staff. Exceptions were made, but not for “past flu” infection conferring immunity. There are plenty of people who get reinfected with COVID-19 after prior infection, and I wouldn’t be surprised if our approach to managing COVID mimics that of the flu as it settles into an endemic phase. The big question is, will annual boosters be needed? If they are, can they be spaced out further, and how long does natural immunity confer protection from reinfection?

    Given that prior flu vaccine mandates didn’t cause mass exodus of healthcare workers, I think it’s reasonable to ask healthcare workers who interact with medically vulnerable patients to do what they can to avoid nosocomial spread of infection, once again following the same approach used for annual influenza vaccination. Even if the employees are unlikely to suffer severe illness without vaccination, no hospital system wants to become the place where their employees are more likely to get their patients sick. It won’t be perfect – just like covid, flu evades prior immunity, and some years were bad flu years despite vaccines – but it will work some years at least. Also, even if most people only get “mild” illness with either virus, if a vaccine can reduce the number of employee call outs for febrile illness, then it certainly helps address some of these healthcare worker shortages.

    Would like to read more about other interventions that may work in place of mandates. After all, other respiratory viruses that don’t have vaccines still land people in the hospital. Do you all know of any data on interventions such as sick leave and testing policies that would help keep employees who are sick at home during their contagious phase? Ditto children/school? Can you review the data on how people who have mild illness (who otherwise would be fine to work but for the risk of infecting others) can still be productive if remote work isn’t an option? (i.e. does masking work as source control to protect others in these cases?).

    • Thank you for addressing these points, S.A.S. As a nurse working in a hospital with perpetual staffing shortages, due in part to repeat covid infection of unvaccinated employees (identified by routine surveillance testing of those who opt out of vaccination), I question those coworkers’ of mine and their responsibility to their profession. Great, prior infection confers some level of protection to unvaccinated individuals and essentially guarantees they won’t need be hospitalized. But at least a couple of incidents on my small unit alone show that unvaccinated employees are getting repeat infections and therefore having to ‘call out’ from work, perpetuating the already compounded staffing shortage. I acknowledge this point is anecdotal and there’s likely little to no data to illustrate the numbers of repeat infections. But as a vaccinated and boosted employee who hasn’t gotten covid (or at least a symptomatic infection), I’m showing up to work and taking care of patients, oftentimes with double the workload for the reasons stated above.

  18. Can you please address/break down your understanding of whether new variants are likely to be created in unvaccinated vs vaccinated hosts? Thanks!

    • More likely immunocompromised, although amino acid substitutions or changes (technically not mutations, although the word works in a generic sense) within any of the virus’s 25 proteins, could occur during any infection. Given the number of people being infected around the world, it is not important.

      What is important, is the environment in which the virus finds itself. What are the selection pressures, such as immunity within the populous? Or are there other fitness advantages that can make a strain the best competitor? Variants are being created all the time, but we never hear of them because their fitness, or lack thereof, in relation to the prevailing strain, doesn’t allow them to flourish.

      Delta probably gained advantage due to how quickly it invaded epithelial cells. It was less “mutated” than the Beta variant, yet came to dominate.

      It appears that Omicron’s primary advantage is partial, immune evasion.

      As immunity builds across the globe, immune evasion will most likely be a requisite, fitness advantage, but a variant could also possess additional advantages.

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