Contribute Try STAT+ Today

When major decisions must be made amid high scientific uncertainty, as is the case with Covid-19, we can’t afford to silence or demonize professional colleagues with heterodox views. Even worse, we can’t allow questions of science, medicine, and public health to become captives of tribalized politics. Today, more than ever, we need vigorous academic debate.

To be clear, Americans have no obligation to take every scientist’s idea seriously. Misinformation about Covid-19 is abundant. From snake-oil cures to conspiracy theories about the origin of SARS-CoV-2, the virus that causes the disease, the internet is awash with baseless, often harmful ideas. We denounce these: Some ideas and people can and should be dismissed.

At the same time, we are concerned by a chilling attitude among some scholars and academics, who are wrongly ascribing legitimate disagreements about Covid-19 to ignorance or to questionable political or other motivations.

advertisement

A case in point involves the response to John Ioannidis, a professor of medicine at Stanford University, who was thrust into the spotlight after writing a provocative article in STAT on Covid-19. He argued in mid-March that we didn’t have enough information on the prevalence of Covid-19 and the consequences of the infection on a population basis to justify the most extreme lockdown measures which, he hypothesized, could have dangerous consequences of their own.

We have followed the dialogue about his article from fellow academics on social media, and been concerned with personal attacks and general disparaging comments. While neither of us shares all of Ioannidis’ views on Covid-19, we both believe his voice — and those of other legitimate scientists — is important to consider, even when we ultimately disagree with some of his specific analyses or predictions.

advertisement

We are two academic physicians with different career interests who sometimes disagree on substantive issues. But we share the view that vigorous debate is fundamental to the existence of universities, where individuals with different ideas who have a commitment to reason compete to persuade others based on evidence, data, and reason. Now is the time to foster —not stifle — open dialogue among academic physicians and scientists about the current pandemic and the best tactical responses to it, each of which involve enormous trade-offs and unanticipated consequences.

Since Covid-19 first emerged at the end of 2019, thousands of superb scientists have been working to answer fundamental, vital, and unprecedented questions. How fast does the virus spread if left unabated? How lethal is it? How many people have already had it? If so, are they now immune? What drugs can fight it? What can societies do to slow it? What happens when we selectively evolve and relax our public health interventions? Can we develop a vaccine to stop it? Should governments mandate universal cloth masks?

For each of these questions, there are emerging answers and we tend to share the consensus views: Without social distancing, Covid-19 would be a cataclysmic problem and millions would die. The best current estimate of infection fatality rates may be between 0.4% and 1.5%, varying substantially among age groups and populations. Some fraction of the population has already been infected by SARS-CoV-2 and cleared the virus. For reasons that aren’t yet totally clear, rates of infection have been much higher in Lombardy, Italy, and New York City than in Alaska and San Francisco. To date no drug has shown to be beneficial in randomized trials — the gold standard of medicine. And scientists agree that it will likely take 18 months or longer to develop a vaccine, if one ever succeeds. As for cloth masks, we see arguments on both sides.

At the same time, academics must be able to express a broad range of interpretations and opinions. Some argue the fatality rate will be closer to 0.2% or 0.3% when we look back on this at a distance; others believe it will approach or eclipse 1%. Some believe that nations like Sweden, which instituted social distancing but with fewer lockdown restrictions, are pursuing the wisest course — at least for that country — while others favor the strictest lockdown measures possible. We think it is important to hear, consider, and debate these views without ad hominem attacks or animus.

Covid-19 has toppled a branching chain of dominoes that will affect health and survival in myriad ways. Health care is facing unprecedented disruption. Some consequences, like missed heart attack treatment, have more immediate effects while others, like poorer health through economic damage, are no less certain but their magnitude won’t immediately become evident. It will take years, and the work of many scientists, to make sense of the full effects of Covid-19 and our responses to it.

When the dust settles, few if any scientists — no matter where they work and whatever their academic titles — will have been 100% correct about the effects of Covid-19 and our responses to it. Acknowledging this fact does not require policy paralysis by local and national governments, which must take decisive action despite uncertainty. But admitting this truth requires willingness to listen to and consider ideas, even many that most initially consider totally wrong.

A plausible objection to the argument we are making that opposing ideas need to be heard is that, by giving false equivalence to incorrect ideas, lives may be lost. Scientists who are incorrect or misguided, or who misinterpret data, might wrongly persuade others, causing more to die when salutatory actions are rejected or delayed. While we are sympathetic to this view, there are many uncertainties as to the best course of action. More lives may be lost by suppressing or ignoring alternate perspectives, some of which may at least in part ultimately prove correct.

That’s why we believe that the bar to stifling or ignoring academics who are willing to debate their alternative positions in public and in good faith must be very high. Since different states and nations are already making distinct choices, there exist many natural experiments to identify what helped, what hurt, and what in the end didn’t matter.

We believe that the bar to stifling or ignoring academics who are willing to debate their alternative positions in public and in good faith must be very high.

Society faces a risk even more toxic and deadly than Covid-19: that the conduct of science becomes indistinguishable from politics. The tensions between the two policy poles of rapidly and systematically reopening society versus maximizing sheltering in place and social isolation must not be reduced to Republican and Democratic talking points, even as many media outlets promote such simplistic narratives.

These critical decisions should be influenced by scientific insights independent of political philosophies and party affiliations. They must be freely debated in the academic world without insult or malice to those with differing views. As always, it is essential to examine and disclose conflicts of interest and salient biases, but if none are apparent or clearly demonstrated, the temptation to speculate about malignant motivations must be resisted.

At this moment of massive uncertainty, with data and analyses shifting daily, honest disagreements among academic experts with different training, scientific backgrounds, and perspectives are both unavoidable and desirable. It’s the job of policymakers, academics, and interested members of the public to consider differing point of views and decide, at each moment, the best courses of action. A minority view, even if it is ultimately mistaken, may beneficially temper excessive enthusiasm or insert needed caveats. This process, which reflects the scientific method and the culture that supports it, must be repeated tomorrow and the next day and the next.

Scientific consensus is important, but it isn’t uncommon when some of the most important voices turn out to be those of independent thinkers, like John Ioannidis, whose views were initially doubted. That’s not an argument for prematurely accepting his contestable views, but it is a sound argument for keeping him, and others like him, at the table.

Vinay Prasad is a hematologist-oncologist and associate professor of medicine at the Oregon Health and Science University and author of “Malignant: How Bad Policy and Bad Evidence Harm People with Cancer” (Johns Hopkins University Press, April 2020). Jeffrey Flier is an endocrinologist, professor of medicine, and former dean of Harvard Medical School.

  • An important video from two doctors in Bakersfield, CA was deleted from YouTube after 24-48 hours. They were reporting, very calmly, their statistics (from CDC) that showed we probably should open up. Why deleted?

    • These doctors & MANY others are being censored, & deserve to scrutinize the leading mascots of the Big Pharma that are bought-out cheerleaders.

      There’s only so long a lockdown can be plausible effective without unwinding everything else even with us all complying.

      Besides, when the rights of a few override the rights of the majority, then democracy isn’t at play.

      The government isn’t formed to decide for the majority of citizens, it is there to facilitate the rights & the constitution for those citizens in which it embodies.

      Citizens aren’t kids, they’re adults that are capable & have to ultimately deal with their own lives & be responsible for it – not the state.

      The point of the lockdown wasn’t to STOP the infection, (that’s impossible without testing kits), it was to SLOW it down to avoid the hospitals being overwhelmed if we all got it in unison.

      Also Billionaires are loving this lockdown.. Jeff Bezos (Amazon), Bill Gates (Vaccines), Big Banks, Big Pharma, Big Corporations swallowing up small business, & more.

      The constitution must NEVER be deemed non-essential even in an pandemic. It is the only thing that protects citizens from an overreach of government! This is more dangerous than the virus. And we can isolate the vulnerable without forcing the entire society in a sinking Titanic! Different models are needed in unison for the various levels of society.

      My concern is the other aspects this is having in skyrocketing statistics – domestic violence, opioid increases, depression, suicide, child abuse, homelessness, addiction relapses, increased poverty & more! This is collective suicide!

      So I think the hospital unpreparedness is an issue among a sea of others, and this is collective suicide! Let alone the over-reach of government when you switch off the mainstream corporate media & look at things through independent media.

      Also there have been nurses & doctors discuss publicly how the deaths are wrongfully being classified as corona deaths, and in so many presumed to have corona virus.

      Don’t get me wrong, I’m not saying there is no virus or anything like that. I’m just saying we have a huge inaccuracies with the figures & even the website admits that the cases are presumed. Don’t rely on the corporate media, they have a set agenda by the billionaires that own them, and they is divide & rule. Unite America. The world is watching. Look past the smoke & mirrors & think critically…

  • Courageous article. The message should be sung from every Ivory Tower scaffold, now gutted by PC politics. Somehow, the authors reached a respectful, restrained language to call out the unseen elephant in our elite communal room. His name is Truth, and he’s invisible. From what I see, “the pursuit of truth” has been filed away in archives next to “what’s best for the patient.”

    Medicine’s last 20-30 years has been a zip line descent down “Slippery Slopes.” I first heard that hilly-range metaphor as a medical student. Psychiatry mentors were quick to caution us about navigating the doctor-patient relationship. As almost-doctors, we had our sights set on our elders. They hung out at such high altitudes. The mentors must have sensed our enthusiasm for privilege. They warned us. One misstep on the doctor- patient path will lead you to take another. Then another. Long before Harvey from Hollywood happened, we’d been schooled in how the seduction of sexual misconduct could send us and our degree spiraling down a Slippery Slope. But it wasn’t until much later that I realized the most dangerous seductions involved surrendering integrity, not sex. Judging from today, integrity has also been banished to the archives.

    “Research,” at least in psychiatry, has been propelled into publication by the social fantasies of professional groups that embrace them. These groups have been sufficiently convinced of their rightness and apparently sufficiently well-funded that they have changed laws, disrupted families, and re-purposed public education. This past week, Harvard announced its intention to ban home schooling. This recent resurgence of Mom as teacher was rekindled by necessity, the closures from COVID. Ironically, the epidemic may have spirited the most healthy experience for the American family since John John and the Waltons.

    Is it possible we have come to embrace this elitism too seriously? Where’s the humility and wisdom, the presumed fruits of great learning? How many dishonest, closed-minded attitudes have come to shut-down the inquiries and shrink the boundaries of medicine? How can psychiatry endorse experiments of psychedelics for psychotics yet erect barriers for mental health treatment with acupuncture, a treatment refined for over three thousand years? How is it that a worldwide pandemic of a virus like no other has summoned an army of armchair epidemiologists? Most have no training. But all have conviction about what should have been done that wasn’t or what was done that shouldn’t.
    I agree with the authors. Scientists, physicians, and entrepreneurs have become too ready to exploit or demean colleagues’ opinions that differ from their own. We know why. In a patient, we call this pathologic narcissism. In ourselves and our colleagues, we call it excellence.

    Peggy Finston MD

  • Maybe some discussions should be between the people with the ability to understand them instead of being released to be misinterpreted and sensationalized by reporters who have no clue about what it means.

  • I don’t see how the posts on social media are personal attacks. They are harshly critical of the paper that Ioannidis coauthored (note, the standard is that if your name appears as an author, you should be able to defend the work).

    The tweets rightly criticize the methodology and present evidence that rebuts some of Ioannidis’ statements.

    Furthermore to acquire subjects for the study, someone circulated an email that falsely promised that subjects would get an FDA approved antibody test and such tests were used in some places for giving people immunity passes so they can go back to work. This deception is a serious ethical breach. It is claimed that this solicitation was done by an author’s wife (an MD who should know better), but you can’t delegate responsibility.

  • One of the authors, Vinay Prasad, co-authored multiple papers with John Ioannidis, whom the authors cite as an example of “independent thinkers” and refer to throughout the article. For the sake of transparency, this information should be disclosed within the article.

    Other than that, you’ve raised some good points.

  • Where have we heard this same argument before? Oh wait, that’s right. Evolution and intelligent design. Really helpful to have both sides there.

  • Thank you for writing this. The degree of group-think on covid and the “science is settled” mentality is absolutely shocking. Skepticism and critical thought are hallmarks of science.

  • I would like to see STAT address the claims of two doctors in California as presented on YouTube: https://www.youtube.com/watch?v=xfLVxx_lBLU&feature=emb_logo

    They claim to have tested 5000 people and go on to estimate the infection rate corroborated as they say by contacting physicians all over the US and by using publicly available data from around the world. Their motives have been attacked by the local press and others but no one actually refuted on the merits. What do the people at STAT think.

    • Their conclusions are wildly reckless based on data they know was not randomly sampled.
      I actually kinda hope they have ulterior motives and are not doctors that are that out-of-the-loop.

      Projections right now still say a total of 1.1M Americans will die from COVID-19.
      An additional 1M will die if the medical-system is overwhelmed.

      Those deaths will materialize if the entire country is released without effective-treatment and without herd-immunity.
      If we believe no effective treatment will be discovered soon and if we didn’t already have a vaccination in human-trials in Germany then you could argue that we need to face-destiny and “naturally vaccinate” like Sweden and New York are.

      With a potential pending death count of 2.1M if we just let-it-rip it gives us a national budget of $20.2T to spend before we hit the cross-over point trying to mitigate it. Note that small-business loans that get repaid don’t count against that budget and neither does the Treasury’s pawn-brokering of the bank’s t-bills (if the banks don’t repay then the public gets their t-bills back). It is *not* a bailout, unlike last time.
      Hand-outs count against it, to people or businesses.

      It is imperative that we keep supply-chains functioning and minimize impact to the food-supply-chain. A lot of that budget should be spent on that. Note that the current disruptions to the pork supply was caused by infections due to gross negligence at the packing plant and they should be sued by any family of anyone that dies. If they had been smart then the disruption could have happened *first*, everyone would have lived and stayed healthy(ier), they wait until adequate PPE is available to reopen. They even would have made more money because people would know pork is expensive now but it’s coming back soon and they would have had the staff to do it.
      Now the have created a PR/HR nightmare. They need to replace workers because they died from their egregious ineptitude managing the situation. Are you applying?

    • Bob is right. They claim that fatalities are similar to flu, when we know that statement will not be true come next Valentine’s day. Compare 12 months of flu to COVID-19 and that statement will not age well.

      The black haired guy also says “silent shedders” have a milder “strain” of the virus, an absurd statement. There is not deadly and non-deadly strains going around. Deaths correlate to an individual’s immune system and timely access to quality health care, not a “less virulent strain.” There is only one strain, and it is mutating slower than the flu virus. That’s a positive for developing a vaccine, but no, there are not multiple “strains” of novel coronavirus going around.

      Their repeated nonsense about “why can people shop at Costco and not go to restaurants and bowling alleys” ignores the epidemiological purpose of quarantine to not overwhelm limited resources. To illustrate, if you have limited financial resources and your wife spends $200 on groceries, that doesn’t mean it’s only fair for you to spend $200 on golf.

      They both abandon their medical credentials when they start going off about “Constitutional rights.”

      But again, addressing their original thesis, check back on this next February and then let’s compare COVID-19 to flu fatalities. Then throw in other systemic damage being observed in COVID-19 survivors. Google “COVID-19 heart lungs liver kidneys brain” for more.

      This is not just like the flu.

    • It’s almost comic but more sad how plainly Bob and Ridi’s reply to your question illustrates the point that Mrs Prasad and Flier make in this article.

    • “Projections right now still say a total of 1.1M Americans will die from COVID-19.”

      That’s from the Imperial College London Report of March 16th – their model assumed that if the USA did nothing, 81% of the USA would get infected, and they guessed a 0.9% Infection Fatality Rate, which would cause 2.2 million deaths. If we followed the best “Mitigation” measures for three months, that would slow the infection rate so only half that 81% would get infected in the 12-18 months before a vaccine and drug treatments showed up and Saved The Day. (They recommended the “Suppression” approach instead – keep the social measures for 12-18 months, getting the number of infections way below 40.5% before the Cavalry vaccines and drug treatments show up).

      I find their “1.1 million deaths” numbers unlikely – the Spanish Flu 0f 1918-1919 infected only 25% – 28% of the USA, and the Swine flu of 2009-2010 only 24%. Why do the pessimists at ICL expect 81% infection for this virus if we let it spread like the flu? The H1N1 influenza virus of 1918 was quite virulent – its polymerase (PB1 polymerase gene) was about 50 times quicker at reproducing the virus than typical flu viruses.

      Their 0.9% Infection Fatality Rate is also quite high, given the serology surveys looking for COVID-19 antibodies done around the world so far – everywhere doctors are finding many more infections than “confirmed cases”, which will continue to drive the estimated IFR down. I would bet 0.1% is the final overall IFR for the USA, with some anomalies like New York City. Who knows why that population is so sickly – drug addiction? Second-hand smoke? Unusually high blood pressure? The answers will come, sooner or later.

Comments are closed.