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.
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.
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 article long overdue and kudos for writing and publishing it.
As a physician taking care of complex patients and following the discussions, it is obvious that this is a complicated situation confounded by the media, the absence of precise description of terms and normal limitation of population based studies, etc.
What is also important are the assumptions and biases that we all bring to the table. We need dialogue with others, especially others who politely disagree, to challenge us and to help us generate new ideas.
Clearly no one has the “right answer.” How do we generate more of the “right questions.”
In that mode, has anyone studied the possibility that some of the discrepancies are due to different genetic subtypes of the virus which are the dominant agent in different areas or differences in the genetics of the patients.
Modern medicine has discovered the power of multi-trait genetics in explaining variation in certain diseases, such as Diabetes.
What are the unasked questions around Covid 19 that have been lost in acrimony.
The extraordinarily wide range of clinical course among those infected alone should alert us to the prospect of great variability in the virus and the hosts which might translate in the variable population studies.
I embrace the Enlightenment motto: “Dare to know!” And I applaud those with the courage of their convictions to put their ideas in print. But truth be told, the decision of where to put those things in print and where to air those views on television is a political choice. That certain media establishment players see the virus and the response to the virus one way and that others see it differently is an unfortunate artifact of American political cultural life at this point in our history. That said, it is naive in the extreme to think that views the minimize the impact of the virus and suggest that social distancing may be incorrect won’t find a welcome and enthusiastic response from the administration that has been arguing since January that Americans are not at risk. The the 15 cases will go to zero. The warm weather will miraculously end the threat.
What a totally rational article. Nice job guys. Science is, or should be, a constant discussion of what is known. Models are nice tools, but shouldn’t be misused and confused with fact.
And then you can look at NYC and possibly other major cities and say that those who predicted the worst were CORRECT. You are correct that there has to be a balance and part of that balance is the responsibility of patients as well. THEY also must make prudent decisions about their own health care needs and emergencies.
And let us not forget that in MANY communities the Covid numbers are low BECAUSE the closings and physical distancing worked.
I agree that a balance is needed, but it is my opinion that the steps taken were correct and necessary and now at this point in time some relaxation is possible.
I will add that the media frenzy over everything Covid 19 related in some cases stoked fear and in many cases gave hope of so called “cures” or treatments that, after controlled testing, were found to be neither.
Dr. Ioannidis is more rational in his approach than most of the talking heads in the media and he was more right than wrong about the fatality rate.
Other researchers produced models that was way off and wrongly predicted millions of deaths in the US. The WHO estimated fatality of 3.4%, Dr. Ioannidis said it is probably less than 1% by looking at data from the diamond princess cruise and he was absolutely correct.
It looks like it is safer in the scientific community to side with overestimation of a problem. Apparently, the argument they have is that nobody dies from being overcautious, right?
WRONG. In fact people are dying from being overcautious.
Hospitals all around the country saw 50% decline in patients with MI, diabetic emergencies, and strokes last month.
Obviously these diseases did not evaporate or magically cured itself, but people with these deadly emergencies are avoiding hospitals because they are so irrationally scared of COVID-19 that they think it is more deadly than a MI or stroke!! Most probably these people died a painful death in their homes while they could have been rescued in a hospital.
Colonoscopies, mammograms, PAP smears, and other tumor screening tests are down 60-70%. People are not being screened for colon, cervical, or breast cancers. Obviously these cancers are not going to disappear but the COVID scare and hospitals cancelling these “elective” procedures have put all these people at risk. They are going to present later in the future with advanced or metastatic disease.
People are losing jobs and with it they are losing their health insurance, which means less preventive care visits, less access to medical care and more deaths. And this is not the only consequence of job loss; the resulting poverty will lead to increased crimes, homicides, and suicides.
Scientists need to stop having this telescopic simplistic view of the world as if COVID-19 is all what matters. If you are worried about COVID-19, you have also to worry about cardiac diseases, malignancies, preventive care, health insurance, jobs, and poverty. We need more of Dr. Ioannidis and other like-minded scientists to counter the irrational fear of COVID-19 .
Presumably Stat’s policy on story clarifications/edits is to indicate them at end of article. For those of us following along at home, can you confirm/identify the post-publish edits (referenced in the popular literature) to this article. Thanks!
It’s nice to see balanced & reasoned analysis rather than the fear mongering that is found on so many other news sources, and some comments on this and other StatNews articles. One thing that stands out to me is the clear dichotomy between people who look at all sources of information to come to a reason based conclusion and those individuals who run with the most hyperbolic, and typically catastrophic view of Covid-19 and use heavily loaded language that is intended solely to appeal to emotions, namely fear, to further their arguments. I often wonder just how hyperactive their amygdala’s must be.
I, as an RN and member of the general population as well, wonder if you scientists ever stop to think about 5G, how enables cellular invasion, disrupts Ca channels & normal apoptosis with it’s extreme increase in microwave radiation levels and how this will effect children entering school in the fall. What level of panic will arise should this scenario play out. So many people rely on main stream media to tell them what to do and they say 5G is safe. As scientists how can you not consider the effects 5G is predicted to have ?
My question above relates to the corona virus specifically to Covid19 and the possible 2nd outbreak beginning at the start of the school year when many say 5G towers now being installed near schools nationwide. Whether intentional or not, will 5G not give the virus readily convertible host cells in school children?
The trolls arrive, and this one talks to itself.
While in the larger picture I agree with the authors, I do believe that we are in a very particular moment that requires actions by individuals and groups for the greater public good, and this is very, very challenging. With the current state of news and social media, ideas get disseminated rapidly but people may not have the educational background to contextualize science news and also may not pay attention to the other debate of which any particular piece is only one side. Because out best “weapon “ against the pandemic right now is social distancing and this is critical to saving lives and preventing health care infrastructure collapse, we cannot afford to have big debates about the science in public when we need the public to cooperate with public health mandates. If we could debate ideas of merit among scientists that would be great—that is how peer review and science journal publishing is meant to work—but debates over Twitter or on general media platforms are damaging to the larger public health goals in this moment of global crisis. In other words, I agree broadly with the authors but I think there is a time and a place for it. Right now, in the public eye, is neither.
👆What he/she said.
So your solution is to sensor any views that do not agree with your own? I think you entirely missed the point of the article, either that or you are too much of a zealot to acknowledge that you may not be correct in your assessment of the current situation.
You’re right us dumb sheep can’t handle that level of disclosure. Best to protect us from ourselves and keep us in the dark. Wouldn’t want us to think or have an opinion.
Of course not, his solution is to bring lofty debate to heel when the time is profoundly important for doing so! If you were from a part of the world seriously hard hit by this, you’d understand!
Thank you for taking a stand! One of America’s strengths is that we welcome intellectual debate (unlike some countries that stifle and crush any debate and now we see how that worked out. Read Malcom Gladwell’s “The Ethnic Theory of Plane Crashes” in Outliers – speaking up against the prevailing authorities can be critical!)
If a reputable scientist comes out with an opinion where the science is bad, let those who “know better” explain why it’s bad. But six weeks ago many were insisting the mortality rate for C19 was 3.4%, and voices who spoke out against that number were vilified.
Some hard truths are going to have to be acknowledged. We cannot prevent every death, and that is a terrible truth. We cannot spend 18 months – or even 3 more months – sitting in our houses. We may not have a vaccine for years – if ever! We are going to have to send people back to work – what do we need to do in terms of protective measures to make that happen soon? And we have to think about our children, and their children (and their children). The education they are clearly losing out on – which builds on itself year after year. The crippling amount of debt they are going to inherit. They need advocates as well.
Nicely put, shame that a chorus of irrational and short sighted Karen’s (male and female) can not or will not look at this matter rationally nor consider the unintended consequences of choosing to impoverish generation(s) in the name of saving every life no matter what stage it is at.
Nobody of consequence was arguing that C19 kills 3.4% of the people it infects. Anyone who cared to could understand that that was simply the case fatality rate, deaths divided by known cases. And that that number could be a decent estimate of the infection fatality rate, or it might not be — and the only way it would be is if two errors (undercounting deaths because not everyone who would die from current infections has died yet, and undercounting # of infected due to limited testing) happened to cancel out.
3.4% is a strawman that the likes of Ioannidis used to argue that other experts were dramatically overestimating the infection fatality rate. But they weren’t.
Let me put it this way, if herd immunity is expected to be attained at 60% and infection fatality rate were 3.4%, the # of predicted deaths in USA would be 6.7m. Was anyone reputable estimating that many deaths? No. Real death estimates were on the order of 2m if nothing is done, because those doing the real estimating took the time to use a more accurate estimate of infection fatality rate.
Well, there you go. Someone who goes by “Gian Termite” clearly knows who is and who is not “of consequence” and has figured out the whole prevalence and mortality rate thing out. Anyone with a contrary opinion is obviously mentally defective. He could be a MPH, or he might be a plumber (in any case, equally bad with estimates). This is how social media distorts and even creates “reality.”
Gian Termite, Anthony Fauci argued that COVID-19 would kill 1% – 2% of patients who had it. That’s not quite as high as 3.4%, but it is much higher than the rate we are seeing. Many people regard Fauci as a “person of consequence”.
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