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[34]First Opinion

Scientists who express different views on Covid-19 should be heard, not
demonized

By Vinay Prasad and Jeffrey S. Flier

April 27, 2020
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Lighthouse Lab scientists Sometimes the most important voices turn out
to be those of independent thinkers whose views were initially doubted.
PAUL ELLIS/AFP via Getty Images
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When major decisions must be made amid high scientific uncertainty, as
is the case with [35]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 [36]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 [37]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.

[38]Related:

[39]A fiasco in the making? As the coronavirus pandemic takes hold, we are
making decisions without reliable data

We have followed the dialogue about his article from fellow academics
on social media, and [40]been concerned with [41]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 [42]both
[43]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 [44]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.

[45]Newsletters

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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 [47]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
“[48]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.
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About the Authors

Vinay Prasad

[49][email protected]
[50]@vprasadmdmph

Jeffrey S. Flier

[51][email protected]
[52]@jflier

Tags

[53]Coronavirus

[54]research

[55]Republish this article

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*
Jim says:
[57]April 27, 2020 at 6:28 pm
Ok, cities states and nations shut down, the curve is flattened and
then decreases, at what point can things begin to open again? If
the virus is as infectious as it seems to be, there will not ever
be a way to contain it, other than a vaccine, outside of restricted
contact and movement for an indefinite period. There is a
difference between what is medically ideal and what is possible
within human societal systems. What we are doing now as a society
is unsustainable economically, psychologically, and medically. We
are conditioned to believe that any amount of suffering and death
due to disease is unacceptable, an admirable philosophy. Yet,
absurd in the face of the reality of how millions live and die.
If eventual herd immunity is actually the only way this disease
will be controlled, and from all evidence that I see, this seems
likely in the long term. Our current pathway is morally
indefensible.
Starvation kills tens of millions a year and is entirely
preventable, far more preventable than covid-19. Shutting down the
economic system will likely cause this figure to dramatically rise,
likely far in excess of those that will die to this virus. We are
making decisions that will kill millions. Yes, we will save mostly
the old and infirm in developed nations from a quicker death than
they could normally expect but have no doubt, we are condemning
millions of others to a very early death. Even developed nations
will likely experience political and societal upheaval (think of
the food price pressure as one variable in the rise of ME turmoil,
refugee crisis in Europe, and the rise of the far right).
[58]Reply
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Manuel Lopez says:
[59]April 27, 2020 at 6:09 pm
How dare you question the all-knowing scientists who fit the media
and DNC narrative! Everyone should stay home indefinitely until the
world ends. And people wonder how Trump got elected? People want
these authoritarian elites kicked in the teeth.
[60]Reply
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Christopher Leffler says:
[61]April 27, 2020 at 6:06 pm
A new study shows that if no precautions are taken to prevent the
spread of coronavirus that 600,000 people could die in the U.S.,
based on the observed mortality among New York MTA (transit)
workers, and the Diamond Princess cruise ship.
[62]https://www.researchgate.net/publication/340952853_How_Many_Peo
ple_Would_Die_If_We_Took_No_Precautions_to_Prevent_Coronavirus_Infe
ction
[63]Reply
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Jim Burdick says:
[64]April 27, 2020 at 4:32 pm
Agree with much in this long article, but not what I gather is the
main conclusion. Of course some views are more political than
others, we cannot hide behind a denial of that. Those arguing that
we are in control and can carefully restore normalcy are under a
huge burden to make the argument convincingly given the politics
and the horrendous situation we are in.
So, when specious speculations about the death rate per incidence
of positive tests keeps coming up, I get impatient. What are people
afraid of? Dying. Not the statistics per positive test. When US
deaths per million in the population begin to decrease, that is the
time to ease off our restrictions. All the issues about deaths per
positive tests are useful and interesting, but being manipulated if
we interpret them to negate the incidence of deaths in the country
incorrectly.
Jim
[65]Reply
*
Igor says:
[66]April 27, 2020 at 4:14 pm
Agreed, all opinions should be accepted regardless of their nature
and analyzed for their validity. Conclusions should be logical and
based on evidence that is independently validated. That is the
laboratory. In real life, much is swayed by political agenda,
greed, faith, despair, which is to say, it suffers from the Human
condition. For the most part I believe that the decisions that took
place, have slowed the progress of the virus. The social
distancing, the stopping of mass movement through airlines and
across borders, the isolation of potentially contaminated for 14
days. I don’t believe the use of a mask offers much protection. If
you have ever sanded drywall, the evidence is clear that these
masks do not seal well over time, but I suppose if it makes people
feel safer, then why not. I also believe that we should have begun
reopening business under the guide of the social distancing rules
sooner. If I can shop for groceries with many other unknown people,
then why can’t the same be said for all business. Just apply the
safe rules!
I am seeing a lot more people having a point of view on this, but
even more important is that they are willing to speak out about it,
which is a good thing. Freedom of speech is a pillar of the
Democratic society, don’t let fear silence you. There are three
kinds of people.
1. Those that watch things happen
2. Those that make things happen
3. Those that sit around trying to wonder what the hell happened.
Be a number 2!
[67]Reply
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dipthroat says:
[68]April 27, 2020 at 3:30 pm
Some believe that nations like Sweden, which instituted social
distancing but with fewer lockdown restrictions, are pursuing the
wisest course.
First, the US is not Sweden. Americans don’t have the civility,
education and socialist attitude (that is, giving up some of your
personal freedom for the common good) that Swedish have. And
Swedish citizens have been voluntarily social distancing because of
that. Not to mention, that the Swedish government has largely
changed its stance on the matter.
Second, all this talking about the final fatality rate is rather
pointless. The final toll of these few months will out class any
other “flu” season in recent history. And that, despite the fact we
tried to stop it. That is, the human toll would be significantly
higher if we didn’t do anything.
Third, I haven’t heard of a single ICU medical worker describing
the situation as normal, or even tough but already seen it. And,
that is actually the most relevant aspect of why a lockdown was/is
necessary. With inaction, the healthcare system would have just
cracked after a few days, and then the bodies would have been
seriously piling up.
Fourth, there are many indications that the final count should be
much worse that the current official one. Just look at Florida. By
any reasonable consideration it should have ten times higher deaths
than officially reported, and accidentally the local government is
one of those that acted sloppily and slowly. Now, either they have
been unbelievably lucky, or the swamps are filled with bodies.
Finally, there is a cockiness circulating simply because it turned
out the virus has been affecting mainly elderly people. If the
virus would have been as deadly in young children, or even across
all ages, in the US, there would be people shooting each other on
the streets by now
[69]Reply
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Jon says:
[70]April 27, 2020 at 3:23 pm
I appreciate this article and the measured, fair tone the authors
take towards this important issue. This is a difficult time, and I
agree that it is too easy to abandon norms of discourse and too
difficult to see the long-term consequences of doing so. And I
certainly agree that we must avoid personal attacks.
However, there is good reason that the community’s response here
has been so forceful. That’s because some of the people associated
with the study have continued to make media appearances to promote
topline results for which there is no evidence on reasoning which
was refuted within a few days of the preprint’s publication. These
appearances – in the midst of an incredibly critical period during
which we must base policy on good data – are themselves violations
of standard norms. The first response of the academic community was
to do what is has always done – examine the results and methods
with a healthy dose of skepticism. But this did not prove
sufficient to prevent a substantial segment of the population
getting the incorrect impression that new evidence supports a
flu-like mortality rate for COVID-19.
The question of COVID-19 severity is an important one that is
critical to determining the best way to move forward. And the
authors of this piece are correct to note that there are serious
trade-offs (in terms of both lives and livelihoods) of any policy
decision and there still remains a tremendous amount of
uncertainty.
But resolving this question will require convincing the scientific
community, not failing to do so and nevertheless trying to persuade
the public.
[71]Reply
*
TDMS says:
[72]April 27, 2020 at 3:14 pm
The greatest need, as the authors would surely agree, is to acquire
good and reliable data on which to base decisions. Antibody tests
for the virus shows some promise in being able to ascertain
community spread and narrow the infection fatality rate for this
virus to help guide public policy.
Unfortunately, a few states are rushing to determine and publicize
community spread without releasing any details, underlying data and
methodologies. New York state is using an assay that claims a
specificity ranging from 93%-100%. [73]https://on.ny.gov/2SclqMl.
That represents a false positive range of 0-7%. So, when Gov Cuomo
states that 15% of the state has been infected, he does not give a
range. Is it 8% to 15% or some other range? What is the 95%
confidence interval? How was the test validated? How many and what
type of controls used? These details need to be made public so it
can be reviewed by third parties. The tests in other states are
even more questionable.
The antibody test by Premier, used in the Santa Clara and Los
Angeles counties, was determined by California researchers,
[74]https://covidtestingproject.org/, to have a false positive rate
as high as 8% (95% Confidence Interval). The test by BioMedonics
used in Florida and Massachusetts has a false positive rate as high
as 21% (95% CI)
[75]https://www.dropbox.com/s/cd1628cau09288a/SARS-CoV-2_Serology_M
anuscript.pdf?dl=0 (See Table 2)
Clearly any measurements of community prevalence for the SARS-CoV-2
virus using these tests are just nonsense and just serves to
mislead and give rise to many comments asserting that the mortality
rate is very low because the prevalence is so high.
According to the National Academy of Sciences “All SARS-CoV-2
serological study results should be viewed as suspect until
rigorous controls are performed and performance characteristics
described…most [tests] so far have not described well-standardized
controls. Samples from patients with seasonal (non-SARS-CoV-2)
coronavirus infections are especially important as negative
controls.” See
[76]https://download.nap.edu/cart/download.cgi?record_id=25775
[77]Reply
+
Alfred says:
[78]April 27, 2020 at 4:20 pm
Moreover, it is worth noting that Premier Biotech was in
receipt from Chinese Provincial health authorities of their
evaluation of 97.3% specificity (4/150 false positives) for
IgM/IgG by 3/25/20 which is in agreement with UCSF/et al at
covidtestingproject.org. This was prior to Stanford releasing
their preprint.
The study results by Jiansgu Provincial CDC can be found at:
[79]https://imgcdn.mckesson.com/CumulusWeb/Click_and_learn/COV
ID19_CDC_Evaluation_Report.pdf
+
TDMS says:
[80]April 27, 2020 at 5:17 pm
Alfred. Good to see that covidtestingproject.org evaluations
of antibody tests are supported, in this case by the maker
themselves. The point estimate by this group, for Premier
Biotech was 97.22% (out of 108 negative samples 3 were
misidentified as positive) which as you say closely correlates
with the 97.33% from the maker. Given the small number of
negative controls, 108 and 150 respectively, the 95%
confidence interval is wide.
Even the best performing test, according to
covidtestingproject.org, Sure Biotech with no false positives
out of 108 negative controls has a 95% CI ranging from
96.64%-100.00%. A test with a potential false positive rate of
3.5% is almost useless to assess virus prevalence in low to
moderately infected communities. But it’s a good start and
needs to be evaluated further with greater number of negative
controls. Perhaps this is the test all states should be using.
I find it horrific that New York, Massachusetts, Florida and
other states are releasing prevalence numbers with inadequate
information about the reliability of the tests.
*
DrivingBy says:
[81]April 27, 2020 at 2:30 pm
But think of the children!
The only rational, reasonable thing to do is whatever I feel like.
Hang tight while I dig into a half-gallon of Snickerdoodle ice
cream and a big bag of choc-y pretzels while wondering if the
snackdown + unemployment bonus should be 6 months, 9 months, or
until my bariatric scooter breaks.
So I’m feeling pretty gross, and if you don’t feel like that too,
you must be a “———!“.
[82]Reply
*
Rass says:
[83]April 27, 2020 at 2:15 pm
Open the country back up June 1st. Have people who are immune
compromised wear masks and everyone needs to be accountable and not
go out in public if they are sick. If they are out in public sick,
criminal charges should be applied.
[84]Reply
+
Bruce says:
[85]April 27, 2020 at 4:35 pm
Different states are using different strategies. We will be
able to observe the results, and we should get a pretty good
indication of which strategies were most successful.

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