The Tragedy of COVID19
There are no rules in love and war
My take on COVID19 boils down to a simple worldview: I think it is reasonable to implement policies in the heat of the moment when you are scared and uncertain, but they have to be time-limited, and you have to work hard to run randomized experiments to separate what works from what doesn’t (the NIAID and CDC did not do those studies). Drug and vaccines are neither all good or all bad — they often work in some situations, but not others — and you desperately need randomized studies to sort the difference. And no person is a saint — Fauci made many, catastrophic mistakes: none worse than pushing for prolonged school closure.
If you rely on observational data, you do so at your peril. A sizable fraction of observational studies are incorrect, and without randomized data, you cannot separate wishful thinking from a true signal. Many observational studies may merely be a fulfilling prophecy — analytic choices that ensure the answer the authors seek. My worldview is nothing new. It is evident in both my books Ending Medical Reversal with Sensible Medicine’s Adam Cifu, Malignant, and over 400 peer reviewed papers.
Yet, during the pandemic, COVID19 policy issues became extremely heated and politically polarized. I was shocked and dismayed. It started early. In April 2020, Carl Bergstrom, a University of Washington professor, tweeted a clip from a news story about John Ioannidis with this comment.
Sensible Med’s Editorial Board Member, Prof Cristea shot back:
But the tenor was set. If anyone said anything that could be used to argue for less restrictive policies there would be no limits to what would be acceptable ways to discredit them. Ad hominem was fair game, but only if they were minimizing COVID. If they were exaggerating it, that was fine. If you even pointed out the errors to a maximizers idea, you were “bullying them.” It was a bizarre double standard.
Here, a professor tweeted a quote from a Washington Post article about John Ioannidis and added a GIF of a child. My opinion? Professors are often eclectic, but their personal choices and preferred suit color are not relevant to their policy ideas.
In the years that followed, nearly every single person who expressed skepticism about prolonged lockdowns, school closure, masking 2 year olds, vaccinating children for COVID 19 (despite dubious clinical data & high seroprevalence), perpetual boosters, paxlovid’s efficacy in vaccinated people, and the COVID19 testing industry complex was at one time or another labeled a contrarian, a right wing operative, a grifter, a charlatan, a disgrace, a crook, an anti-vaxxer, anti-masker, or a MAGA republican, etc etc.
The truth didn’t matter. I am a far left democrat. I supported Bernie Sanders and Elizabeth Warren. Both of my books are about progressive regulatory solutions to improve the medical drug and device marketplace. I am an expert in clinical trial design. I know the limits of observational data — I have taught many classes pointing them out, and my podcast Plenary Session is often praised as a great place to learn these skills. And yet, I was labeled many of these things.
Recently, a liberal colleague pointed out that my COVID positions were closer to the right than the left. I put it simply, “We should be embarrassed that ‘our side’ was wrong. Our fellow progressives were so nakedly partisan and openly ignorant that they were unable to read the literature on school closure, or masking kids. It never had good data, and should never have happened outside of randomized trials. Liberals were so close-minded, we could not accept the downsides of vaccine mandates, nor can even begin to understand the tradeoffs of boosting 20 year men forever. How can a political group that identifies itself as scientific be so anti-science? Liberals pride themselves on inclusivity, and now they write articles saying the unvaccinated have more traffic accidents— so we should raise their insurance rates? It disgusting.” He had no defense to offer.
John Mandrola, a writer on this website, was a coauthor of an important paper on rates of myocarditis post vaccine in adolescent boys. Anyone who has followed Dr. Mandrola knows he a straight shooter. Obviously, he was right to think that vaccines might be both a tremendous good for older people, but two closely timed doses in 16 year old boys might be dangerous. His paper articulated that concern, and has since been totally vindicated. Yet, look at the response he got. Medscape— the same website that publishes his writing— ran these quotes:
"The authors don’t know what they are doing and they are following their own ideology," tweeted Boback Ziaeian, MD, PhD, assistant professor of medicine at the David Geffen School of Medicine at UCLA, Los Angeles, in the cardiology division. Ziaeian also tweeted, "I believe the CDC is doing honest work and not dredging slop like you are."
"Holy shit. Truly terrible methods in that paper," tweeted Michael Mina, MD, PhD, an epidemiologist and immunologist at the Harvard T.H. Chan School of Public Health, Boston, more bluntly.
"I'd argue that at least one of the authors (Stevenson) is grossly unqualified to analyze the data. Mandrola? Marginal. The other two *might* be qualified in public health/epi, but they clearly either had no clue about #VAERS limitations or didn't take them seriously enough."
Imagine that. The website that has worked with Dr. Mandrola for years publishes a quote that says, he, a cardiologist with 2 decades experience, is only “marginal”-ly qualified to analyze case reports of heart inflammation. They even printed “holy shit.”
Of course, Mandrola was 100% right, and, I believe my own record of COVID19 policy analysis is solid. You can read everything I wrote in this thread (click on it). Every post has a date. I think all were right when written, and right now.
The Tragedy of COVID19
Each day my inbox fills with notes from pediatricians, ID doctors, cardiologists, public health officials (some from inside these agencies) with ringing endorsements of how much they agree, and how grateful they are for the thoughtful analysis. But the undertone is clear: they are scared to speak out publicly. They are even scared to retweet the content.
John Mandrola at some point limited commenting about COVID19 policy (I don’t blame him), and I was one of the few indefatigable people, but only because of a stubborn personality and a strong professional position (with 2 books and 400 papers before the age of 39, I’m hard to slow). Of course, I too will stop commenting about COVID19, but only because of boredom.
What I view as the tragedy of COVID19 is that medicine had no way to have a dialog about any important issue without devolving to ad hominem. Even policing ad hominem was uni-directional. The same people who wrote articles about online bullying or how to use twitter as a scientist were happy to bully John Ioannidis. IFR was window dressing. They were just scared that he was opposed to lockdown and school closure.
The mainstream media had a handful of weathervanes whom it repeatedly quoted, alongside a motley crew of postdocs, nutritionists, fellows — whose most important credential was a large twitter following. But missing was the voices of the majority of doctors or researchers with expertise on these topics. Now the American public is so far away from the news coverage of COVID19. You can spend days at a ski resort and not think of COVID at all. Open twitter, and you think the world is Elon Musk and COVID19.
There are no rules in love and war. And the same for times of mass panic. COVID19 killed millions globally, but the disruption to societies and prolonged school closure will kill millions more for decades to come. We had no way to sort sensible responses from hysteria because we live at a time where people believe anything is justified if it supports their worldview. They don’t understand the importance of randomization to separate truth from fiction.
I doubt the future will be better, but rather will slip into something far worse: on issues of gender, race, disparity, and any medical issue that intersects with politics— more and more doctors will grow silent. We will be left with two fringes of irrational people shouting at each other. Universities will continue to slide into their new role as the patient enrollment arm of the pharmaceutical industry, and podcasts will take on the role of universities as places for debate and scholarship.
I hope I am not alone at mourning the loss.