Below is the video and the full transcript of Concerned Ontario Doctors’ Covid-19 Summit, April 11, 2021. It features detailed discussion of public health, Covid-19, and various lockdown policies deployed around the world.
•Opening/Closing Address:
Dr. Kulvinder Kaur Gill, MD, FRCPC
President and Co-Founder of Concerned Ontario Doctors, Frontline Physician
•Moderator:
Dr. Richard Schabas, MD, MSHC, FRCPC
Former Chief Medical Officer of Health for Province of Ontario, Retired Physician
•Panelists:
-Dr. Jay Bhattacharya, MD, PHD
Professor of Medicine at Stanford University, Physician, Infectious Disease Epidemiologist
-Dr. Sunetra Gupta, PHD
Professor of Theoretical Epidemiology at University of Oxford
-Dr. Martin Kulldorff, PHD
Professor of Medicine at Harvard University, Infectious Disease Epidemiologist, Biostatistician
Dr. Kulvinder Kaur Gill:
Welcome. And thank you for joining us today for Concerned Ontario Doctors COVID-19 Panel. My name is Dr. Kulvinder Kaur Gill. I’m the president and co-founder of Concerned Ontario Doctors and a frontline physician in the greater Toronto area. I am honored to be joined by world eminent scientists and physicians today to discuss the harms of the lockdowns, the dangers of censorship and a path forward. Joining us today are three esteemed panelists who are giants in their field and who are the authors of the Great Barrington Declaration, which has garnered nearly one million signatures from physicians, scientists, public health experts, and concerned citizens globally.
First, we have Dr. Jay Bhattacharya, who is a professor of medicine at Stanford University, and a research associate at the National Bureau of Economic Research. He directs Stanford’s Center for Demography and Economics of Health and Aging. Dr. Bhattacharya’s recent research focuses on the epidemiology of COVID, including the fatality of COVID infection and the effects of the lockdown policies. Before COVID, Dr. Bhattacharya studied the health and the wellbeing of the vulnerable populations with an emphasis on the role of government programs, biomedical innovation and health policy.
He has published many articles in top peer reviewed scientific journals in medicine, economics, health policy, epidemiology, stats, law, and public health amongst other fields. He holds both an MD and a PhD in economics, both earned at the Stanford University. Thank you so much for joining us today.
Dr. Jay Bhattacharya:
Thank you.
Dr. Kulvinder Kaur Gill:
We also have on the panel, Dr. Martin Kulldorff, who is an epidemiologist, a bio statistician and a professor of medicine at the Harvard Medical School. His research centers on developing and applying new disease surveillance methods for the early detection and monitoring of infectious disease outbreaks and for post-market drug and vaccine safety surveillance. The methods are used by most federal state and provincial public health agencies around the world and by many local public health departments and hospital epidemiologists. Thank you so much for joining us.
And we have last on the panel, Dr. Sunetra Gupta, who is a professor of theoretical epidemiology at the University of Oxford with an interest in infectious disease agents that are responsible for malaria, HIV, influenza, and bacterial meningitis. Dr. Gupta has consolidated a large body of work on the evolution of pathogen population structure, which establishes a novel pipeline for developing a universal influenza vaccine. In tandem with her studies of pathogen diversity, Dr. Gupta has made fundamental contributions to the evolution of diversity in host genes that protect against infectious disease.
Thank you so much for our esteemed panelists for joining us today. And moderating today is Dr. Richard Schabas, who is a retired Ontario physician with specialty training in public health and internal medicine. He was Ontario’s former chief medical officer of health for 10 years, spanning from 1987 to 1997. He actually trained our current chief public health officer here in Ontario, Dr. Williams, and many other medical officers of health. Dr. Schabas was also the former chief of staff at the York Central Hospital during SARS.
He was critical of the mass quarantine during the SARS outbreak and the alarmist prediction surrounding H5N1 bird flu. He has been outspoken against the lockdown since the beginning of the COVID pandemic highlighting the tremendous harms to society. Thank you all for joining us today. And the floor is yours, Dr. Schabas.
Dr. Richard Schabas:
Well, thank you. And thank you, Kulvinder, for organizing this. I’m delighted to be here today. And as I mentioned before, you’ve faced efforts at censorship by our medical licensing body in Ontario. And it’s wonderful to see that you’re not being intimidated by that. One of the great casualties of COVID has been the loss of collegial constructive discussion. And that’s why I think this panel is so important. So to our distinguished guests, first of all, welcome to Canada, at least virtually. As I said, I’m delighted to be included in this.
I will say that I have found the last year to be a very, from an intellectual and professional standpoint, isolating experience. I’ve had a handful of supportive colleagues, but I have felt very much cut off from the mainstream of discussion in professional and scientific world and from the media where I’ve been effectively canceled. And it’s been great whenever I have seen one of the three of you give an interview or read something you’ve written, because it tells me that I’m actually not crazy, that my idea is well. I may not be right about everything or anything.
It’s not crazy and that these are legitimate perspectives. These are legitimate questions. And so I’d like to thank the panelists for their ongoing insights, for their willingness to speak out and for their courage, because I’m sure whatever animosity I have faced, you have faced orders of magnitude higher. So anyway, we have lots to talk about. We have about an hour and a half, so let’s get right to it. I’m hoping that most of the people who see this video will be familiar with the Great Barrington Declaration, which I signed way back in October, and many of us have signed, and that’s great.
But wonder if we could begin just by asking the panelists to go over what they see as the fundamental principles of the Great Barrington Declaration and in particular, it’s six months later, and there have been important developments in COVID. I would particularly highlight the vaccines and the variants. So what are the principles and where does it sit at the end of March 2021? Maybe if we could start with you, Jay.
Dr. Jay Bhattacharya:
Sure. So there’s two key scientific ideas to my mind that underlie the Greater Barrington Declaration. The first is that there’s an enormous risk difference by age in mortality from COVID. The oldest population, people who are the oldest, face the highest risk by far. So just to give some sense from several prevalence studies around the world, the survival probability for someone over 70 is 95% from infection, which is, I mean, that’s a really high death rate from a disease. Whereas for people under 70, it’s much higher, 99.95%. And for children, the flu poses a greater threat than COVID.
There’s this enormous age stratification in the risk of severe outcomes from COVID. The second idea, the second scientific idea is that the lockdowns themselves by causing disruptions in the normal functioning society pose great harm directly to the population. Not just in terms of economics, which I think sort of unfortunately emphasize to some extent, it’s really mainly in terms of the health and psychological wellbeing of the population at large. The lockdowns are not a human way to live. They separate people. They disrupt our ability to interact with one another in ways that are harmful to human wellbeing.
So if you combine those ideas for the oldest populations, we have to do an enormous amount to protect them from COVID. So that’s the first idea of the Great Barrington Declaration, focused protection of the vulnerable, the older population. For the rest of the population, the lockdowns are more harmful than COVID. So the argument from the Great Barrington Declaration side is to lift the lockdowns and instead focus on and think about creative ways to protect the vulnerable. And we, in the Great Barrington Declaration laid out a whole bunch of ideas for how we might do that.
But of course, we invited the public health community to join with us in thinking of ways to better protect the vulnerable without the lockdowns. I suppose we’ll talk a lot about how the lockdowns have failed. So I’ll leave that aside for now, but I’ll just say that the vaccines provide a perfect way to, I mean, a great way to protect the vulnerable. By prioritizing older people for the vaccines, you effectively defang the epidemic, take away the possibility of the epidemic harming the people that it’s most likely to affect by effectively vaccinating them first.
Dr. Richard Schabas:
Thank you. Sunetra, would you like to add to that?
Dr. Sunetra Gupta:
So indeed. So Jay’s laid out the basic precepts and vaccination indeed actually allows us to get away from the argument. Actually, it might be useful at this stage to revisit the arguments that were raised at the time, and to see how well they’ve weathered or what has happened in the last six months with regard to the arguments that were raised against this idea. One was that there may be no immunity at all to SARS-CoV-2. I was positive it was premature to pursue that. Now I would argue that anything is possible. But in terms of likelihood of there being acquired immunity, first of all, there were already studies, very, very elegant and very well conducted studies around showing that you made the type, an array of responses, antibody, and T cell that you would expect of COVID, of coronavirus.
I mean, the truth is we weren’t completely in the dark about this virus. We had ample knowledge of what other coronaviruses did by way of eliciting a natural immunity. So six months down the line later, I think we can say now with confidence that that was not a very good way to attack the idea. I mean, why you’d want to attack it in the first place is another whole story. Then the second line of attack, which was a little bit more reasonable, was that natural immunity was unlikely to be lifelong as it is the measles. And that actually was sensible reasonable hypothesis in that that is true of many of the other coronaviruses.
But what was wrong there in the thinking was that because natural immunity was not lifelong, we would never get to a kind state of endemic equilibrium whereby herd immunity reduce the risk of infection to tolerable levels in the population. Now, once again, with reference to other coronaviruses, that is exactly what happens that you reach a state, an endemic state in which sufficient numbers of people are immune to keep infection levels at something we can manage. And that is bound to be true for SARS-CoV-2 because while we do not become immune forever, in the sense of we don’t develop lifelong infection blocking immunity, you can maintain herd immunity.
In fact, it’s maintained exactly the same level for any other pathogen with the same or not through a slightly different mechanism, whereby immunity is lost, but regained. So you just have this much more dynamical flow, but actually the levels of immunity that you achieve in that way are identical to a system where immunity is lifelong. So loss of immunity does not actually impact on the proposition that our destination is one of endemic equilibrium, and that’s a fundamental epidemiological fallacy that I’m surprised that many people made.
And the third point criticism was that you cannot deliver focused protection. As Dr. Bhattacharya just said that it’s unfortunate that this was just treated as dogma because what we wanted at the very least was just a conversation with other public health practitioners. But anyway, that debate was never had, which is sad. But the truth is the vaccine now provides us a way of shelving that debate. Although perhaps we should keep it somewhere and shouldn’t shelve it too far back because it might come up again if we are to have a robust strategy for how we deal with these situations.
But so delivering focused protection has got a whole lot easier. And as far as I’m concerned, we in the UK have just done that. We’ve got there. Mission accomplished on that one. So what is a mystery is why we are now not opening up.
Dr. Richard Schabas:
Martin.
Dr. Martin Kulldorff:
Yeah. So there has been a very naive belief from one politician, journalists and some scientists that somehow we can suppress this disease with lockdowns and contact tracing and so on and protect the old and vulnerable that way. And as soon as we had the outbreaks a year ago in Italy and Iran, it was very clear this pandemic would be a worldwide. And once it’s in the country, that is an impossible thing to do. And we saw that there were those who believe that when their cases went down in the summer, but that was because of successful lockdown measures.
And that’s why in October, we decided to write this declaration because we knew that things were going to come back this coming winter. We didn’t know exactly to the extent of it, but we knew it was going to come back. And at the time we were criticized for doing a straw man, because nobody wanted lockdowns, but it only took a few weeks when people were starting to argue for lockdowns again. And the problem is there are two bad ways to deal with the pandemic, and there’s one good way to do it. But one bad way is to let it rip and not do anything and just let everybody get infected, old and young and so on.
And if you do that, a lot of old will be affected. And since they are high risk of dying from this disease, a lot of people will have high mortality and everybody can get infected. So it’s not the difference in risk of getting infected, it’s the difference risk of dying or having a serious hospitalization. So, let it rip is a very bad strategy, but lockdown is also very best strategy because it just sort of slows things down. And there are some arguments of doing that in the very beginning to not overwhelm the hospital systems where everybody doesn’t get sick at the same time, but to do it for a long period of time is very misguided and actually increases the deaths from COVID.
Because the more you drag it out, the more difficult it is for all the people to protect themselves. So basically locked down is let it rip strategy that’s dragged out a little bit more over time. So if we look at basic principles of public health and all the pandemic preparedness plans that most countries had done before the pandemic, it is to protect the most vulnerable, the high-risk risk people. And in this case is the older people. So that’s what the Great Barrington Declaration put forward. We have to do a much, much better job protecting older people because of lockdowns do not protect them at all.
And we have seen that. We have enormous mortality from this pandemic that because lockdown is a very bad strategy. And there are standard ways to protect older people. For example, in nursing homes, you should have less staff rotation and more testing of the personnel, etc. So your standard ways that we outlined the declaration itself or in the FAQ that goes with it, that should have been implemented and that weren’t implemented and that has led to tragic results with far too many people dying from this disease then had to be the case.
And then of course, for the younger people, they are not at high risk of COVID. As Jay said, for children, the risk is less than from dying from influenza and we don’t close schools for influenza and so on. So we have done the misguided things or trying to protect people who don’t need protection. We’re not protecting the ones who do need protection. Children and young adults, they have suffered a lot of the collateral damage from this, from these lockdowns, with school closings and plummeting vaccination rates, cancer screenings not being done, worse cardiovascular disease outcomes, people not getting their diabetes treatments, more overdoses, opioid overdoses, and deteriorating mental health.
So this has been an absolutely catastrophic public health disaster and fiasco of how we have responded to this pandemic. And I hope it will never ever be done again. And we need to now end the lockdowns. And what’s happening now is we had the new surge in the winter. So we have a lot more immunity now. So the reason that things are going down is mostly now because we have immunity in large sections of the population, which has helped by more and more people getting vaccinated also. And eventually as we’d all a bit further, the seasonal pattern is going to kick in, so that will also help us to lower the, the mortality during the spring and the summer.
Dr. Richard Schabas:
Well, thank you. And just to give that a little bit of a Canadian perspective, in the province of Ontario, for example, in the outbreak last spring, about 75% of all the deaths in the province were in longterm care residents. In the outbreak in the winter, that was down to about 50%. So there wasn’t far from perfect, but the measures were somewhat effective. And we, of course, I think quite reasonably immunized long-term care residents as a priority. And when I looked at the numbers yesterday, we’re still getting an average of 24 deaths a day in the province of Ontario.
There were no deaths in long-term care. So yeah, and the reported case fatality rate in the province, which you could estimate from the general numbers, was running about 2% at the peak of the winter break, the middle of January, it’s now running at about 1%. So you take away the 50% of the deaths in long-term care, which we appear to have done, and that’s the result you get. On the other hand, Canada in general has had relatively low rates of infection and certainly low rate of death compared, for example, to the United States and compared to Western Europe.
I’m not quite sure why we can talk and speculate about that. I’m a little loathed to attributed to our lockdown measures because they really haven’t been very different than anywhere else. In fact, maybe even a little less severe than in many places, and we’ve had a huge variation within the country. So we’ve had much higher rates in the province of Quebec, particularly the Island of Montreal, which are at Western European levels, and lower rates in Ontario, about half the rate in Ontario, and half again or less in British Columbia without any real indication that anybody has done anything particularly different.
But the result of that is that we probably have fairly low levels of natural immunity in Canada. And we’re starting to see the kind of uptick in cases that is being seen in a lot of other places in the world now, which presumably is due to the spread of what the next thing I want you to talk about, which is the impact of the variants. What do you think the impact of the variants is and how does that change or does it change the Great Barrington perspective? Can I start again with you, Jay?
Dr. Jay Bhattacharya:
Sure. So the variants, actually might want to tap Dr. Gupta because she is the world’s expert in this. But just to give you my view, much of which I’ve learned from her, the variants are sort of what you would expect when the disease has reached a sort of endemic equilibrium, close to an endemic equilibrium, the variants, this disease mutates all the time. There’s tens of thousands of more variants and most of them do nothing to the infectivity of the disease or lethality of the disease. The variants that have emerged, the empirical evidence that I’ve read to date suggest that they may be slightly more infectious than the wild type variant, the wild-type virus.
But and very, very mildly, more lethal with a very small, but with no change in the fundamental thing, which is the age grading and more lethality. Both the variants and the wild-type both share that same thing, which is that it’s much more deadly in the old than in the young. The other key feature for policy for the variant is that infection with the wild-type variant virus, and also vaccination seems to provide protection against serious outcomes from the variants. That is while you might get reinfected with the variants, it’s possible, so just like you might get reinfected with the wild-type.
When you’re reinfected, the outcome is very likely to be milder than the initial infection and certainly much less likely to produce a death or hospitalization. So in that sense, the variants don’t change the policy calculus at all. The lockdowns, if you thought that the lockdowns were going to be effective against the less infectious wild-type virus, I don’t see why you would expect it to be more effective against a more infectious variant. So I think the use of the variant to raise fear in the population is just a mistake, both from the scientific perspective and the public health perspective.
The variants are not cause for renewing the lockdown or shut because what’s the end point again. The end point is not the elimination of a virus that’s even more infectious. And the lockdowns, if we continue to do them will continue to wreak enormous harm on society. The right strategy is still focused protection.
Dr. Richard Schabas:
Sunetra.
Dr. Sunetra Gupta:
Yes, indeed. I don’t think it materially alters anything, any of the recommendations that were made at all. I suppose it’s not as if we, I mean, we would alter recommendation. We’re not sticking necessarily to a set of recommendations, but the general principle that you protect the vulnerable and that’s really all you need to do remains under what Jay just described, which is exactly as I believe is the right interpretation of the situation. Which is that within any kind of standard evolutionary theory, any model would indicate that the likelihood is that these variants, and I mean, it’s interesting that the same mutations have cropped up in different parts of the world.
So here’s a pathogen population that is trying to optimize its ability to infect people, optimize its virulence, which doesn’t mean that it becomes more or less virulent, but just finds just the right level that allows it to compete successfully against other variants. So the prevailing, the main principle here is that these systems evolve towards a state in which the optimal variant dominates and the optimal variant is one which may be slightly more transmittable, but there is no reason to believe that it is hugely more transmittable.
The reason why people are coming up with these ideas goes back to something you said, which is the level of herd immunity. So when there is no herd immunity, the lower the level of previous exposure, the bigger the pool of susceptible individuals the pathogen population has to play with. And so the lower, so it faces less competition in a totally susceptible population. As people become immune, the pool available of resources available to the pathogen becomes smaller and smaller at which point the competition intensifies.
And this is probably what’s happened leading in many parts of the world to the emergence of variants, which are remarkably similar in lots of ways and likely to be at least a little bit more transmittable, but crucially having the same age distribution of risk. The other thing they might be, they are very likely to be, is it to have to possess is some level of immunization. So there have been very nice studies showing that the South African variant, for example, is not neutralized to the same extent as the wild-type by people who’ve previously been exposed to the wild type.
But that doesn’t mean that the vaccines won’t work against them, or indeed the natural immunity to the previous variant won’t protect you against severe disease. So what all of this does is it refocuses our attention or it underscores the fact that we need to separate out the process of infection and the observations relating to that, that infections are growing, with the process of severe disease and death, because that’s what we want to prevent.
Severe disease and death, because that’s what we want to prevent. So if we start reacting every time we see infections grow, if we start imposing restrictions to stop infection in attempt to stop disease and death, then we’re always going to end up in a muddle. What we need to do is be very clear that what we want to stop is disease and death. And it’s a very naive attitude to assume that the only way to do that is by curbing infection. And so we need to get that right in our heads. If we decouple those and the variant situation kind of highlights or, as I said, underscores the need to do that. Then I think we’ll be in a better position to prevent the deaths from this virus.
Dr. Richard Schabas:
Okay, Martin.
Dr. Martin Kulldorff:
The only one small thing I have to add is that the key thing, with this variance, if right now they have the same age distribution in that anybody can be infected, but the risk for mortality for death is still the same, much higher for the old versus the young. And the only type of variant that will sort of change that is if suddenly we get a variant that starting killing the young people instead of the old. Then we have to fundamentally change the strategy, but that’s not the case. All these variants still have a situation where they are much more dangerous for the old and not at all dangerous for the young and therefore the focus protection of all the high risk people is still the right strategy.
Dr. Richard Schabas:
Thank you. And just again, a couple of comments. I want to come back to something Jay said, it’s kind of a pet peeve of mine, but I react negatively to the general use of the word mutation to describe what’s going on. As Jay said, this virus mutates all the time. In fact, all living organisms, including all of us are sitting here, merrily mutating away like mad. This is not about mutation. It’s about evolution and the virus is evolving and more or less in the way that we would expect the virus to evolve. And I think Sunetra’s point about it’s a reflection of the fact that it’s feeling evolutionary pressure, which is coming from population immunity. So not to be unexpected. I should also comment that a couple of days ago the provincial health officer in British Columbia, Bonnie Henry, who, I’m not going to say she’s been more sensible than the others, but has been less unsensible perhaps than some of the others, made a comment that she was concerned about the increase in cases with the variants, because they were happening mainly in young people.
And I just found that a complete head-scratcher, maybe she would have been happier if we were seeing more cases in the elderly who are going to die rather than the young, who, as we know, are by and large going to brush this off. So, anyway, moving on to a related subject, I think it was Martin who suggested a few minutes ago that we’ve never controlled respiratory viruses in this manner before. They can show a few pictures of people in 1918 wearing masks, and they shut the schools in some places in the United States for a couple of weeks in 1957, but lockdown as a strategy to control a respiratory virus is something we’ve never done before. It was never part of our pandemic planning. And if we reflect back to about a year ago, we went in the matter of a couple of weeks from being fairly relaxed about COVID, I’d say in hindsight, probably too relaxed about COVID, certainly I was, to a state of absolute panic, which is when we started instituting lockdowns based on the fact that China locked down and then Italy locked down.
So it must be the thing to do. And there were some compelling internet memes that encouraged people to think that lockdown was going to be effective. And then in kind of a pandemic of its own and matter of a couple of weeks, just about everybody rushed and locked down, including Canada. And I think there is, as we know, the evidentiary basis for this was very, very thin on the ground, but we’ve had experience with it for a year. And without dwelling at the moment, we can come back to it on the harms of lockdown. There is still a general perception, I think, out there in the world, that number one, we are faced with this sort of microbiological apocalypse that the models predicted a year ago with tens of millions of dead.
Even though I think very clearly that was a gross exaggeration, but there’s still a widespread perception that lockdowns are doing the job of preventing it. They’re doing the job of controlling the infection. And in Canada, we’ve gone through a whole series of places that were supposed to be the model for us. Back in the spring, the models were supposed to be Germany that was controlling the disease with contact tracing and the Czech Republic, which was controlling the disease by wearing masks. And then we were supposed to follow the lead of Michigan with their lockdown. And then we were told no, no, France is the place that’s controlled things with lockdowns. So my question is for our audience, do lockdowns actually play … are they really effective at controlling the spread of the disease? And if so, how effective are they and what sort of the long-term, if any, advantage of lockdown down in terms of disease control? Who’d like to jump in on that?
Dr. Martin Kulldorff:
I can start. So a year ago, when we started with the lockdown, that was a huge experiment for which there was no precedent and no studies. So it was a huge experiment. So there was no evidence that they would work. Now a year later, we do have the evidence and the evidence is that they do not work. They can sort of push things forward a little bit, but with the pandemic, it can never be kept out. So, this belief that they would work, that the lockdowns and a masks and contact tracing would work, that has created this big disaster. And a lot of people have died because of it, because it didn’t protect the old. We didn’t put in the measures to protect the old. And even before vaccines, there were many measures that we could have put in that was never used at the same time as we’re getting this collateral damage on public health that we’re going to live with and die with for many years to come.
Dr. Richard Schabas:
Okay. Anyone else?
Dr. Jay Bhattacharya:
The other thing, and this I’ve learned from Dr. Kulldorff. So I’m stealing directly from him, but he’s here. So he can take credit. Lockdowns are focus protection of the rich. That’s the way to think about them. They’re a form of trickle down epidemiology. If they protected anybody, they protected the rich. And you can see this in the evidence from Toronto, that rich neighborhoods of Toronto have been relatively hit less than the poor neighbors of Toronto. If you think about what lockdowns actually do, it’s not universal. People still need to have food delivered, grown. People still need to have all kinds of services provided, but who can afford to stay at home and have all those services provided for them. It’s the relatively well off.
Whereas, the working class has been exposed to the virus. Exposed and so you see this in places where there is a lockdown, you see this gross inequality in outcomes where it’s the poor and working class that have borne the brunt of the disease and borne the epidemiological sort of the cost for achieving herd immunity in some sense. In LA County, in California, where I live in California, we’ve been locked down essentially for a full year with the schools closed, churches closed, businesses at half capacity or less through much of the epidemic. And in LA County, the death rates are three times higher for Hispanics than for whites. And for people living in places like Beverly Hills, high income neighborhoods versus people living in poor neighborhoods.
Again, the death rates three times higher from the disease in the poor neighborhoods, whereas in Florida, for instance, which has not been locked down for most of the epidemic, the results are much more equal. And in terms of the level, actually, Florida has achieved better results in terms of COVID mortality than California after you adjust for the older population there. The lockdowns have not worked. And in many ways it’s the most regressive economic and public health policy I have ever seen in my lifetime.
Dr. Martin Kulldorff:
Yeah. Thinking of the United States, I think the lockdowns is the worst assault on workers and the working class since segregation on the Vietnam war.
Dr. Jay Bhattacharya:
Sunetra do you want to weigh in on this?
Dr. Sunetra Gupta:
Yes. Well, I’m going to quote myself. Some time ago I found myself saying lockdowns are a luxury of the affluent. And I was essentially echoing all the things that have been already said by Martin and Jay, but also thinking very much of other countries where lockdowns are simply not an option. So I guess my bottom line is I don’t even care whether they work or not. I do, of course, but even if there was now very good proof that they worked and we should actually qualify that word worked. What does worked mean? Suppressing infection. Okay. So what if they suppress infection? I mean, again, actually go back and drill down to that a bit further. What are lockdowns for? Lockdowns could either keep the infection in, which is what they used to do in medieval times during the plague is okay, the villagers would agree we’re not going to let anyone out.
And that was a noble use of lockdown. And you could argue that, that’s what Wuhan, actually, that was their purpose, at least declared purpose at the time. And indeed even Bergamo. It was all about keeping it in, which one can understand as a strategy, even if it’s not realistic. Then of course there are countries who have used lockdown to keep it out. And you could argue there’ve been successful, New Zealand, in certain circumstances you can keep it out. It’s an entirely selfish strategy, but it can work. But we’re talking about lockdown suppressing infection, and you have to ask, even if it does work, first of all, to what end. And I guess the only answer to that, that might be reasonable is, until we get a vaccine, but that’s a big gamble. That’s a debate that needs to be had.
But then the real issue is even if they do work, can we afford them? And the answer I think is no, not in the UK, maybe there are some very rich, very affluent countries where the wealth is distributed evenly, who have money in the bank. Maybe Norway can say, well, we’ll stay in lockdown until we have a vaccine. But as such, I don’t think lockdowns are an option. They’re only an option for the affluent within most settings. And for most countries, they’re simply not an option at all. And the sad truth is that in focus protection is not an option for many countries on this planet. And we should be aware of that when we think about this problem.
Dr. Richard Schabas:
So those are all great points. Certainly one of the criticisms I’ve had from the lockdowns from the beginning. And I think Sunetra’s really touched on this is it’s never really been clear what the lockdowns were trying to accomplish. I think when Canada went into lockdown in the latter part of March almost exactly a year ago, nobody was quite sure why. There was an atmosphere of panic, but I think the prevailing perception was we were doing this so we could get our healthcare system in order so we did not face the problems that they had in Northern Italy. Now, there were all kinds of reasons why Bergamo and Northern Italy had the problems they had, and there were lessons to be learned and they were learned very quickly. And it was pretty obvious by, within a two or three weeks that our healthcare system was actually empty.
It wasn’t being overwhelmed by COVID, but the goals and objectives of lockdown, which had never [inaudible 00:42:36] had never been clearly stated here, or I don’t think anywhere else sort of morphed. There was this sense of mission creep and it then went, well, we’re going to do this because we’re going to prevent deaths. And of course, it didn’t work terribly well with that, but by the fall, it had morphed even further. And it continues to morph into now we’re going to prevent cases. We’re going to not zero COVID or very little COVID or stop the waves of some people have called it in Canada. So the objectives of lockdown keep changing. And there’s a great public health, Dr. Yogi Berra, who once said, “If you don’t know where you’re going, you won’t know when you get there.”
And we certainly don’t know when we’re getting there in terms of lockdowns. So underlying, the principle of lockdown is another hugely controversial area. And I think an area of significant scientific uncertainty with regard to COVID, and that is the issue of asymptomatic and presymptomatic transmission. And so much of the rationale for the lockdown measures is based on the presumption that these are important engines of transmission that we can’t simply avoid the symptomatic people. We can’t use what would be more typical means of controlling the disease because of the importance of asymptomatic and presymptomatic transmission, which I think undoubtedly happened. But that’s not really the point. The point is how important are they in the overall transmission of the virus? Would any of you like to weigh in on that?
Dr. Jay Bhattacharya:
Sure. There was a fantastic study published in the Journal of American Medical Association earlier this year, that was essentially a meta analysis of transmission within a household setting. Your kid gets the disease or your wife gets the disease. What’s the likelihood that the infection then spreads to other members of the household. So it’s a kind of a controlled setting. Generally with no social distancing, no mask, nothing like that. And it was a large meta analysis of, I think like 54, some studies. They compared presymptomatic and asymptomatic transmission on the one hand versus symptomatic transmission on the other hand. And what they found was that if you have a household member who is asymptomatic or presymptomatic, the disease is spread to other household members in seven out of 1000 cases, seven out of 1000, versus if you have a symptomatic patient, the disease is spread in 200 out of a thousand cases on that order. The likelihood of transmission, asymptomatic transmission relative to symptomatic transmission is orders of magnitude lower.
It, as you say, it can happen, but it is not the primary mech … It primarily is very unlikely to happen. Any given interaction between a asymptomatic individual and a immune naive individual is much, much, much less likely to result in a transmission then a interaction between a asymptomatic individual and another individual. So if that’s the case then, I mean, in household settings, it seems like it’s going to be much more likely even more so in outside settings, because in outside settings, people are social distancing. Even in places that don’t mandate it, you’ve seen social distancing. This spreads by droplets. It spreads by aerosol, but aerosolization events are more likely for someone that’s symptomatic. Infected droplets are more likely to someone that’s symptomatic. So I think both from a sort of physiological point of view, as well as the sort of the evidence on the ground, asymptomatic spread can happen, but should not be the primary driver for our thinking about how to control this disease.
Dr. Richard Schabas:
Anyone else?
Dr. Martin Kulldorff:
Well, for people who Are aiming for a zero COVID of course, whether it’s asymptomatic or symptomatic, transmission matters, but zero COVID is impossible. So the question is, what strategies do we use? And it doesn’t really matter whether there’s the matter of asymptomatic versus symptomatic spread in either case focus protection is the right approach where we protect those who are at high risk for mortality. And to try to prevent it from spreading among asymptomatic people who have no symptoms or anything is not useful for public health, is more likely to be as harmful.
Dr. Richard Schabas:
Sunetra.
Dr. Sunetra Gupta:
Yeah. So I would say overall, and one of the, I think, strengths of the solution of focus protection is that some of these questions, I mean, it’s robust to the answer that we might have obtained with regard to what we should actually do. But in terms of public health recommendations, obviously this shows the importance of staying at home when you’re sick, how much more important that is to altering the course of the disease or whatever it is that you’re again, trying to actually do.
If you want to stop it from spreading, or if you want to stop it from spreading to somebody in particular, vulnerable person, for example, it’s particularly important to, for a symptomatic person not to engage in activities that would promote that. So I think what it does is it just shifts your perspective from what would you focus on in terms of preventing the spread in situations where you need to prevent the spread? Now, overall, I would say we don’t really need to prevent the spread. We need to protect the vulnerable while spread is naturally occurring. So in some ways it’s not a very critical question in terms of how we protect the vulnerable, but I think it obviously has other epidemiological relevances and which we’ve already talked about.
Dr. Richard Schabas:
Yeah, it certainly is important for the issue of quarantine. We call that self isolation now. Isolation, of course, is what you do to cases, not what you do to contacts, but we call it self isolation, but it’s really quarantine. And it’s been very widely applied around the world for contacts, for travelers, for whatever. And of course, it’s based on the notion, presumably, that you are some risk to others when you are asymptomatic. It’s, I’m sure, been immensely inefficient. I haven’t seen any good data on the proportion of different kinds of contacts who ended up eventually developing the disease. But one of the knocks on quarantine of course, is that it’s immensely, immensely inefficient. And in fact, if presymptomatic and asymptomatic spreader are not a major feature, they’re not a major risk, then it’s also in fact, entirely unnecessary.
What you should do is observe people and if they become symptomatic, then you should isolate them. There’s a very good reason why successful respiratory viruses make us cough and sneeze. It’s not because they want to make us miserable. It’s because that’s how they spread efficiently, I think. Well, coming back to something I alluded to a few minutes ago, which is the models. One of the points that I made with SARS some 18 years ago, and at the time was that we spent all of our time worrying about what SARS might do, rather than actually looking at what it was doing. And with the first SARS, we missed the boat entirely because it, in fact, was not a highly infectious disease and it was only spread and people who were critically ill and primarily in hospitals, and the minute we started taking proper care of people in hospitals and proper infection control, SARS essentially disappeared.
And in spite of the fact that there were models at the time that were predicting 120 million deaths from SARS, we ended up with, I think about 800. But models in fact have played a huge role in our response to COVID. And for reasons that I still scratch my head, because a model is like the guy who predicts the football game or pick stocks. And when they start getting the answers right, you start paying attention to them, but they have to get a few right before you pay attention to them. And when they’re always wrong, after a while, you just tune out and go somewhere else, but they have taken on a role of their own. So I wonder if maybe you could reflect on why you think we have become so enamored with the models and why you think so many of the models have been so consistently wrong.
Dr. Sunetra Gupta:
Should I start?
Dr. Richard Schabas:
Please, please.
Dr. Sunetra Gupta:
Okay. Well, I think, and I’ve been trying to quietly say this and I actually kind of gave up after a bit, for the last 20 years or more, that models are fantastic conceptual tools, almost all of my thinking for this pandemic and everything else that I’ve done in my career has been by models, mathematical models. And they give wonderful insights. For example, actually the fact that the rapid loss of immunity doesn’t actually impact on the maintenance of herd immunity. It’s something that I would certainly have found hard to understand without the aid of a model. I’ve used a mathematical model to generate a flu vaccine. So I have huge trust and faith in models, not just in advancing conceptual understanding, but in the ability of these concepts to be translated directly into public health outcomes. So what is my problem with predictive models?
Predictive models require us to make assumptions about the parameters and the processes within the models, but particularly let’s dwell on the parameters, which are very difficult to nail. So the reason, I mean, there was no difference between Neil Ferguson’s model really. It was big, large computer simulation and a paper that we put on Med Archive around the same time last year about this time, which the difference was that our conceptual model just gave you an idea of what the various extreme, I mean, what the scenarios were that were compatible with the data that we had and pointed to what data needed to be collected in order to discriminate between the different possibilities. What the other form, predictive modeling, does by contrast, is you take a model, often a complicated one, and you try and use statistical methods to fit it to such data as are available at that time.
And that means you come up with your best guess and each time what you’re doing is making some sort of guess, which you use statistical methods to try and dignify, but at the end of the day, they’re not very accurate. They’re not very reliable by [inaudible 00:55:07] because they rely on inaccurate measurement really, an inaccurate guess even a basic one at what the parameter is. And often the outcome is so sensitive to that parameter, for example, how many people are going to die when they’re infected, that it just becomes a nonsensical exercise. And then you end up doing things to the model that should never be done. So you make an assumption about how much transmissibility will be reduced by closing schools. And then you run the model and you say, this how much infections will drop, because you’ve made an assumption that transmissibility will be altered by closing schools.
So, I mean, at that point, it just becomes not a very useful tool, should we say? And I think that’s … But as I started to see 20, 25 years ago, there was this problem, which is that there’s a seduction to numbers and equations, or they can frighten people. They intimidate people. So once you see some equations and graphs, it’s very easy to believe that this is the truth. And I think that it’s our responsibility as modelers to make sure that people are aware that that’s not the truth. That is a projection. And of course you can make an educated guess or have your favorite projection or say, this is what I think is going to happen, but it is unfortunate that those projections and predictions have in some ways taken the place of mathematical modeling.
Dr. Richard Schabas:
[crosstalk 00:57:10] I apologize … Sorry, go ahead, Martin.
Dr. Martin Kulldorff:
I agree with that wholeheartedly. And just as an example, if we take the Imperial college model that Neil Ferguson has worked on, they assume that the infection fatality ratio would be, I think, it was around 1%. So that’s the percent of people who are getting infected that will actually die. That was one of the input parameters. And at the time it was not known what that infection fatality was. So that was one plausible thing, but it could be something else. So they developed this very fancy, computational simulation models to then get out how many people would die. But I could have done this with that 1%, and then a few other assumptions that were made, I could have made the same conclusions from some hand calculations.
… You could have made the same conclusions from some hand calculation on the back of an envelope. But because it’s sort of a complex sophisticated system that becomes like a black box, then people have more confidence in it. As me, as somebody who worked a lot with models, I have less confidence in it in that case. Now if instead you have assumed the 2% effect, so the 1% affects your federal arrangement that the estimate for the US was I thinking about 2 million deaths. And if we, instead of putting 2%, they would have been twice that approximately, so 4 million deaths. But if we put in a chance of a percent it would be much less. So these system is very, very, as Dr. Gupta said, it’s very, very dependent on the input parameters that we don’t really know. And that makes these complex sophisticated computer models useless for public health purposes.
Dr. Jay Bhattacharya:
Can I address that for just very briefly just to give a sense of the, I mean I completely agree with both of my colleagues. I mean I think they can be useful in helping you think about things, trade-offs, but they should not be used as gospel truth because they rely on so many assumptions. But what I want to address is things that we end up missing because we’re beguiled by the complexity of the model we have, because the reality is much more complex than any model we can ever devised. And just let me give you a concrete manifestation of that in the context of lockdown. So in the United States the hospitals are staffed by people that are in the labor force, that you’d expect. When schools got closed in the United States a large number of women stopped working to care for their kids at home and oversee the instruction for online instruction, they withdrew from the labor force. At this point actually, the female labor force supply in the United States is at the lowest level it’s been since, in 40 years.
That had a knock on effect of making staffing at hospitals more difficult. And it actually made the likelihood of hospitals being overrun by COVID patients or other patients more likely, because it reduced the staffing levels of hospitals. I didn’t see that in any of the models, because no one had thought about the knock on effects of the lockdowns of closing schools on the labor force supply. It’s not in the Ferguson model, it’s not in any of these models that we see on the internet but it’s a fact that has happened in the real world. If you act on models without a broader wisdom about how these interventions will play out in the world, you’re going to get these sort of unintended consequences that make the goals you’re trying to achieve, whatever they are, more difficult as well as causing all kinds of other harm.
Dr. Richard Schabas:
Okay, thank you. And Sunetra, I apologize. I wasn’t dissing models and modelers, I was simply-
Dr. Sunetra Gupta:
Of course not, no.
Dr. Richard Schabas:
Reflecting on the role they’re playing in public policy, and I think we all agree that they should not be the drivers of public policy that they have so uncritically become. So let me pivot and turn to another issue, and I don’t know if anybody wants to talk about this, but I want to talk a little bit about masks. I was struck when you did your interview with Unheard when you announced the great [inaudible 01:01:43] declaration that the three of you were sitting side by side at a table, and none of you were wearing masks. And I wondered if that was a statement or whether it just never occurred to anybody that that was the politically correct thing to do.
But just as lockdowns kind of swept the globe in a matter of a couple of weeks, we went from being generally very skeptical about the public use of masks in casual social situations, based on I think many years of experience, and a not inconsiderable body of evidence. And then in the course of about a month, in April and into May of last year, the world pivoted 180 degrees and became very enthusiastic about mask use, and masks have become kind of the emblem of COVID control. And people I think sometimes wear them as much to show where their minds are at and whose side they’re on as opposed to just to prevent disease. But what are your feelings about masks? Do you think masks play a role in COVID control? What do you think that role is? What do you think about mandatory mask laws?
Dr. Martin Kulldorff:
Well one concern is that with the public health messages that had been sent out that masks are critical. And even the former CDC Director of the US claimed that masks were more important than vaccines, which is of course nonsense. But that means that a lot of older people think that as long as everybody wears masks they are protected being outside, going to the supermarket and so on. And the concern there is that because they think they are protected when they are not, they need to physically distance to protect themselves, they will take risks that they probably shouldn’t have taken. So that’s the concern that if you make people think that these masks are going to protect you but they don’t, that’s a problem with older people who need to be protected.
Dr. Richard Schabas:
Jay or Sunetra, do you want to weigh in on this delicate subject?
Dr. Jay Bhattacharya:
I mean I agree with Martin obviously on that, but what it points to is a failure in public health messaging around masks. I think with any intervention we should think about both the costs and the benefits, and try to think broadly about what the effects are likely to be. So my problem with the masks, I mean I don’t think that they’re useless. I mean I think like in hospital settings they’re quite useful. In crowded situations where it’s very difficult to social distance they might be useful. The empirical evidence in my reading is very, very weak on the subject, so I don’t have a strong opinion one way or the other in that sense because it’s just hard to evaluate. So I don’t, I’m puzzled by the latching onto it as if it were a strong thing. I mean like as Martin said, the idea that the CDC Director would say that they’re more effective than vaccines just still boggles my mind.
I think that what’s the other problem with masks, at least the messaging around them, is that it’s created this moralization of behavior that I think public health should seek to avoid. You know, if I wear a mask I’m a good person, if I don’t wear a mask I’m a bad person. I think that that has created social division where public health should seek to create unity in. In a sense it’s a cousin of how we’ve moralized, public health messaging has moralized COVID. The first question someone asks when someone gets COVID is, well who gave it to you? Where’d you get it from? Why weren’t you protecting yourself? We’ve stigmatized COVID as if it were, you’re now a pariah because you had it. Again, a failure of public health.
I think that the major problem in public health messaging it’s, every single pathology you could imagine in public health messaging has happened with COVID, and masks are just sort of the tip of the spear of this. Where we’ve created something that could be useful in some settings if we were to convey the information properly and treat the public like adults and say, here’s where the evidence is wrong, here’s where the evidence is weak. Instead we’ve turned this into this moral thing you can do to signal virtue about yourself. I think that was just an enormous mistake.
Dr. Richard Schabas:
Sunetra?
Dr. Sunetra Gupta:
Yes, I mean once again it’s all down to the framework of cost and benefit. I mean I have largely been indifferent to masks because you think there is very little cost mostly, so in which case it should be up to the individual. But the truth is, as my colleagues have just outlined, that that’s not correct, there are some costs. First of all, the idea of masking children, I think it is to me, makes me feel slightly sick. Because I just think that masking individuals, I mean it must have some quite serious mental health consequences. The idea of putting a mask on a child is really problematic for me. Masks of course create the illusion of protection, which can be difficult and dangerous actually, as has been mentioned.
And also masks have been used to buttress the idea that all of this prevention of infection is a communitarian activity, which is problematic because it’s not actually. The lockdowns and all these measures are in fact at some level, highly individualistic and people should at least be aware of that. I mean to believe that you’re performing or participating in something that’s communitarian, when in fact you are individualistically protecting your own affluent community, is to me a bit of a problem. So as such while masks may seem to have no cost, and where they don’t I think they could and should be used if it in fact gives the wearer a sense of security. Or maybe if you’re visiting a vulnerable person, why not take that extra precaution just in case. So I think it shouldn’t be taken for granted that there are no costs associated with this intervention.
Dr. Richard Schabas:
You know just reflect on that as a public health doctor, in public health we often make recommendations to the public that are in contrast to medical type interventions. They seem sort of small, they exercise more or eat more fruits and vegetables. It’s not like cutting off someone’s leg or putting them on a toxic drug. And we tend to be a little casual about them. And the strategy is if you can make a small change in the lives of lots of people you can actually have a significant, beneficial public health impact. But the flip side applies too. I mean masks are not without their harms. They are an imposition on the lives of people, they’re uncomfortable, they reduce our social interactions, I think spread fear among children.
And although you may say, well that’s a pretty small harm, when you multiply that across billions of people the cumulative harm is not so small. And particularly since it’s not clear what the end point is going to be. Again, it’s like with every aspect of lockdown, it’s not clear to me, once we start wearing masks, it’s not clear when we stop. Because if we wait until there’s no more COVID then people are going to be wearing masks, or at least some people are going to be wearing masks for a very long time, and I think we pay a price for that.
Turning to public health messaging, one of the things that has shocked me from very early on has been public health willingness to resort to fear as a legitimate tool to promote public health policy. And I know I’ve heard Martin and Jay both speak on this and how this is contrary, and I completely agree, contrary to the basic principles of public health, which are much more about giving people common and objective information to assist them in making rational decisions. But fear has become a big element. I think there are many, many people who are deeply fearful, often irrationally and unrealistically fearful of COVID. I want to know if you agree with those statements and if maybe you can talk about how we can move forward, because people who are fearful don’t make rational decisions. So who’d like to weigh in there?
Dr. Jay Bhattacharya:
I can take a stab at this. I mean I think it helps to try to understand why it’s a bad idea to induce fear as a public health strategy. I think there’s lots of reasons, but for one and you said [inaudible 01:11:29] completely needed. It’s very difficult to unring the bell once you’ve triggered fear as a response to assuage someone. To tell people really here’s what the data actually saying is not enough because they won’t believe you. People’s fear takes over, their willingness to listen, and it creates this division that lasts. When the fear ultimately dissipates, I think it creates distrust that’s very, very long lasting. It’ll be much more difficult to give people good public health messages about a whole host of other things that are even more threatening to their health then COVID. Advice about diabetes management, advice about cancer screening. Advice about a whole host of public health priorities are going to be much more difficult going forward, vaccinations, because of the use of fear as a tactic to control people’s behavior by public health. It undermines trust in public health.
I think, I mean I could go on at length about this but I think that the public health community is going to need to think very carefully about this, about how to undo the damage. And maybe it’ll take quite a long time to do that when we’re finally through COVID. I mean this is one of these things where I thought was a basic principle of public health that everyone agreed with, and yet we almost immediately resorted to this fear tactic. And even for COVID it hasn’t worked. The idea is we have to get people to understand and take it seriously, but what’s happened then is that we’ve conveyed this idea that COVID has this flat age profile and risk. And so to some extent people who are older have underestimated their risk, whereas people younger have overestimated the risk and have undertaken activities, actions that have actually harmed them out of that excessive fear of COVID.
It’s not possible to engineer the population to do exactly what you want them to do. It’s better to treat people like adults, as public health we have to treat people like adults, give people facts in a clear, meaningful way, and give them tools so that they can flourish. I mean that’s the purpose of public health, not to induce panic and fear, which is the way we sort of address this epidemic.
Dr. Richard Schabas:
Martin?
Dr. Martin Kulldorff:
I agree with that, so I don’t really have anything to add.
Dr. Richard Schabas:
Sunetra, do you want to weigh in on that?
Dr. Sunetra Gupta:
Well again, I’m not a public health person. So yeah, it just does seem to me that using fear as a tactic is, it’s a real insult to the general public that we should even consider such a means. I mean I’ve often been told, well you shouldn’t be talking about more optimistic projections because then people won’t take it seriously. And my answer has always been the general public are able to, they are equipped to understand this problem. It’s not quantum physics. The fact that infection spreads, and as it spreads people become immune, which impedes the progress of the pathogens through the population, these are not concepts that the general public wouldn’t understand, wouldn’t be able to take on board. I mean this discussion, what have we discussed here that someone won’t, a member of the general public would not comprehend? So why this disdain for the general public?
Dr. Martin Kulldorff:
If public health officials, it’s a two-way street. So if public health officials do not trust the public then automatically the public is never going to trust public health officials. So that trust has to be in both directions for it to work.
Dr. Richard Schabas:
Reflecting on my own career as a public health physician, when I retired I was often asked to reflect back on what the big battles had been. And without hesitation I would identify the fight against tobacco addiction as the dominant issue of my 30 years in public health. And I think we all understand that although we’ve made a lot of progress, particularly in North America, tobacco addiction as a public health problem still dwarfs anything that COVID-19 has come close to doing. And in Canada we have an estimated 40,000 deaths a year as a consequence of tobacco addiction. And those deaths, each one represents about 20 years of potential life loss. So as an impact on premature mortality, it’s six, eight times greater than what we’ve seen. Even in Britain tobacco addiction has caused a much bigger impact on premature mortality than COVID has in the last year. And of course, tobacco addiction deaths go on year, after year, after year.
But the point is that many years ago we learned that promoting fear was not a very useful tactic in controlling people’s tobacco use, that that was not a very effective strategy. And we moved away from that to things that were, as I say, much more balanced, much more rational. We didn’t try to scare people, we tried to give them the facts. And I think also when we use public policy, we did use public policy and have used public policy, but it’s not been coercive public policy. I mean people said, why don’t you just make tobacco illegal? Well you don’t do it because it’s a free and open society and because that won’t work. When you start using coercive measures, sooner or later people will push back as they pushed back with alcohol prohibition. So I completely agree that it’s contrary to the principles, and in fact the experience of public health.
Kind of a spinoff of that though, and I think it’s a spinoff of that, is we’re hearing now a lot about vaccine hesitancy when it comes to COVID. And there seems to be significant reluctance, particularly among some segments of society to get the vaccine. And just to give you a little background on vaccine hesitancy in Ontario, in Ontario for 35 years we’ve had something called the Immunization School Pupils Act, which is often characterized as a mandatory school immunization law. In fact, it’s not that, what it does is it gives parents options. They can either present a record of immunization or they can get an exemption. And there’s something, there are medical exemptions if you’re allergic to a component or if you previously had the disease, and then there’s what’s called a philosophical exemption, where all you have to do actually is you sign a piece of paper saying I’m philosophically opposed to immunization.
The point is that since the law was put in place 35 years ago, the percentage of children who have been exempted has been about the same, it’s been about 2%. It’s been very small and it’s varied a little bit between philosophical and medical exemption. But as of the last time I checked, which is admittedly is three or four years ago, it was still running at where it had always run, at about 2%. So the reality is in spite of all of the talk about people in general being hesitant about immunization, that really wasn’t reflected in the numbers. And parents with a little nudge we’re by and large very willing to get their children immunized. So I don’t see vaccine hesitancy as sort of a fundamental problem in our society, and yet we seem to be seeing a lot of it with COVID-19 vaccines. Would anyone like to talk about why that’s happening? And again, what we can do to overcome that?
Dr. Martin Kulldorff:
I think it has to do with the trust. Because of the mismanagement of the pandemic there’s much less trust in public health officials in the CDC, in the United States and so on. So then when these same people say we need to have a vaccine and it’s going to be mandated, then people don’t trust it. And if you try to coerce people into that with, for example vaccine passports, that backfires. It increases hesitancy and reduces willingness to get vaccinated. And the problem is it’s not just because of the COVID-19, it also spills over to other vaccines, incredibly important vaccines like missiles vaccines in children, for example polio vaccines. So in my view, I mean there’s a small group of people who don’t want, who don’t believe in vaccines often called anti-vaxxers, but that’s a very small group. And as you say, I don’t think they have been very influential.
But these people who are now pushing for vaccine passports for COVID, they are doing a lot more damage to vaccinations than these anti-vaccine people have ever been able to do. And one example is people want to mandate those who have had the disease to also get the vaccines, but people who have had the infection naturally do not need the vaccines. So when public health officials are saying those things, which are obviously nonsense, then obviously people are going to say, well I can’t trust you, why should I get the vaccine at all? So I think these people who think that they are promoting vaccines by arguing for a vaccine passport and mandatory vaccinations of COVID, they are doing huge public health damage, both to the willingness to get the COVID vaccines but also other vaccines. And they are the, at this point of time, they are the big anti-vaxxers because of what they are doing.
Dr. Richard Schabas:
Anyone else?
Dr. Jay Bhattacharya:
I mean that’s completely right. I mean the vaccine passport idea or the idea that you have to require the vaccine to participate in normal life, in a sense it’s like in the United States in the south we had this segregation between blacks and whites for generations called the Jim Crow Laws. So this is like a re-imposition of Jim Crow with the vaccine as the division in society. The vaccine hesitancy, the public research suggests that it actually is quite divided along socioeconomic lines, where it’s like minorities that are more hesitant, the poor are the more hesitant. People who have reason to distress public health are more hesitant. And if we then say, you can’t participate in normal life unless you’ve done this, we’ve essentially reimposed a sort of vaccine Jim Crow. I think it’s a deadly public health disaster.
Instead, tell people about how effective the vaccines are, especially for older people it’s a godsend as we said at the beginning of this. I mean it really does reduce the risk of being exposed to a deadly disease. For someone older we should be conveying this as a, just show people the data, convey it to them and inform them that they can understand, tell the people the truth and people will respond I think.
Dr. Richard Schabas:
Sunetra, do you have a weigh in on this?
Dr. Sunetra Gupta:
Yeah, just to say that I think that vaccines are distorting perception of risk. So if we were straight up and just said, look again, if we followed the focused protection sort of framework we would say, these are people who are really at risk, they really need the vaccine, and once we’ve given it to them we can relax some level. Then that would be a nice message. It would be truthful and it would make people more positive about the vaccine. But instead if we’re being told that, in particular in the UK, that nothing is going to change until we vaccinate everybody, this creates,
I think a perception of risk which will be somewhat at odds to what… Well either first it will either heighten the sense of fear, heightened the fear, or it will seem wrong to someone who goes and we… Now Oxford, I can’t remember which group at Oxford University, has produced this nice little app that you can use to calculate your own risk. And mostly you look at that risk and then you think, why are they telling me I have to be vaccinated? I think you can set up all sorts of conflicts and questions in the minds of the thinking public, and I consider most of the public to be thinking, or people are thinking. And so I think it’s really unfortunate that we haven’t just said, this is a fantastic tool for focused protection, this is going to liberate everybody, let’s use it to that capacity. And then yeah, sure, if you’re worried about getting long COVID and you want the vaccine go for it, that’s fine. But it’s the way it’s being presented or the plans for its use don’t align with the science. And I think it will cause more confusion and hesitancy.
Dr. Richard Schabas:
You know there are some interesting parallels with the influenza immunization, and actually that’s particularly relevant to the province of Ontario, which for the last 20 years has very enthusiastically embraced the policy of universal influenza immunization. It’s been really a major government policy. And it’s one that I actually initially supported, I wrote the editorial in the Canadian Medical Association Journal almost 20 years ago saying what a good idea. And then about five years ago I kind of changed my mind. And it’s interesting because even within Canada, the two other large provinces, so Quebec and British Columbia, don’t have universal programs, and in fact have been very resistant. Quebec has actually increased its recommended age from 65 to 75. And the issues are very similar.
I mean influenza vaccine has the additional problem that it’s not as good a vaccine, but the issues are very similar. And the real issue with COVID is what are you trying to accomplish? If you’re trying to limit death, well then you promote vaccine in the vulnerable. And if a vulnerable person doesn’t want to take the vaccine and they die, well it’s-
If a vulnerable person doesn’t want to take the vaccine and they die, well, it’s a free and open society, and that’s your decision.
And young people, well yeah they are not at zero risk, so if they wish to do it, or if they think it’s socially responsible to do it, but obviously the urgency or the importance of getting immunization in younger people is not as strong. I think that’s what the Cole Vendor got in trouble with the college for expressing sediments pretty much exactly along those lines. But again, if you don’t know where you’re going, you’re not going to be sure when you get there and if we keep changing the goalposts, and if I can mix my metaphors, keep changing the goalposts, then, in fact, we will never get there.
So that’s let me ask, the next question is, where do you think we are headed with all of this? And by way of background, I’m an incorrigible optimist. Last spring, when people were saying, “This is terrible.” I said, “No, wait. Once people realized that the outbreaks in Western Europe have peaked at about an order of magnitude less mortality than the models predicted, people will come to their senses.” Well, that didn’t happen. They didn’t come to their senses.
And then they said, “Oh, we’re going to contact trace.” I said, “Don’t worry. As soon as those strategies collapse…” And they lasted about 15 minutes in Canada before they collapse… “People will realize that that’s not an option.” And then [inaudible 01:28:29] And then I said, “Don’t worry. As soon as they realized that lockdown is not a short-term phenomenon, they’ll realize it’s unsupportable. That’s not going to change.” Didn’t happen. And then I said, “Don’t worry when the vaccines come along, it will all change. And this will all go away.” Well, clearly that’s not happening. The vaccines are here and the rhetoric is getting triller.
And I know I have some colleagues who think this is actually getting darker and darker in terms of the infringement on individual rights, on the stigmatization. And I keep trying to be an optimist, but ironically, I find it harder and harder to be optimistic. What do you think?
Dr. Martin Kulldorff:
I am an optimist. I don’t think there are a lot of people who have dug their heels in know they’re not going to change their views, but within the population, they are more and more people who are understanding what’s going on, who are learning about infectious disease technology, and who are seeing that it’s obvious, that lockdowns and contact tracing and not working. So I think that’s the gradual process, but that makes me optimistic, because I think during the [inaudible 01:29:41] people where a year ago, people didn’t know anything about these things, but as people learn more and more, there are more and more people who are realizing that the path we have taken has been a huge mistake. And I think that’s going to increase the number of people who come to that realization. So I’m optimistic for that reason.
I am pessimistic in some ways. For example, I’m pessimistic it’s going to take a long time, as Dr. Bhattacharya was saying, to regain the trust between public and public health. That’s a huge undertaking that we have to take to regain that trust and it’s going to take many, many years to regain that. We have all the collateral damage from public health, from the lockdowns that we have to deal with for many, many years. So in that sense, I’m not very optimistic.
And also in terms of the scientific community, where we have seen so much trying to limit scientific discourse, either by ignoring people or by slander and so on, and a lot of people who don’t dare to speak up. I don’t know if the scientific community is going to survive that. I hope it will be able to regain because if not, then the 300 years of enlightenment has ended now, and that would be very unfortunate I think.
In the short term, in just what I think is the priority to do next is to make sure that all children get back in school for in-person teaching. If there’s one thing I could change is that all children are back with in-person teaching by Monday. It’s so important for children. No school districts should… There’s no public health reasons to keep children away from schools, and there’s enormous damage, both short-term and long-term. And those school districts should prevent children from going to school and no parents should try to keep the children away from school.
And there is a change there, at least in the United States, where there are parents, as well as some teachers, are really rising up to demand that schools reopen. So it’s gradually happening, but it’s way too slow.
Dr. Richard Schabas:
Okay. Anybody else grounds for optimism? Pessimism? What do you think?
Dr. Jay Bhattacharya:
I think salvation, when it comes, will come from the people. I mean, if you look at Germany as a good example of this, right? So Angela Merkel had a renouncement that she was going to close the country entirely, grocery stores, a very sharp, sharp lockdown from April 1st to April 6th. And an enormous number of people protested because it’s an inhuman thing to do to prevent people from the [inaudible 01:32:44] would not be effective on stopping COVID. Because if you tell me a week from now, I’m not going to be able to shop for food for my family for a week, we’re going to crowd the grocery stores from now until then, right? Spreading the disease.
I think I agree with Martin, the people who have been arguing, who stake their professional reputations on lockdowns, the scientists and so forth will be the very last people to change their mind. And I don’t think that that’s really where the change will come.
In the United States, the lifting of lockdowns has happened because of political pressure on governors. And I think in Canada as well, that’s what it’s going to take. It’s not going to come from experts.
Dr. Richard Schabas:
Sunetra?
Dr. Sunetra Gupta:
So, I haven’t lost my optimism, but I have become disillusioned in certain regards.
I mean, I would say the biggest point of surprise and horror for me is how we’ve treated school children. I just didn’t think that was possible. I really did not imagine that the general public would permit such a thing to happen as to prevent school children from being in school. And also the blindness displayed towards the collateral damage I found very, very surprising.
I mean, there are many points… Then of course, the censure of my colleagues and the ways in which the mainstream media have behaved, all of these things have come as huge surprises to me. But I still remain optimistic that eventually there will be a sufficient kind of wash of opinion. People will return to their senses I hope. And at least the space for public debate will again be open.
Dr. Richard Schabas:
Well, and that leads nicely into my next question, which is why has there been such vitriol, so much rancor? I think back to debates to previous years, and I think back to SARS, which was a big deal in Toronto. We had in hindsight, we thought it was a major outbreak. It was not a major outbreak, but it seemed like at the time, and there was a great deal of concern and a great deal of worry. And there were divided opinions and my views were outliers. I think they eventually turned out to be correct, but they were outliers. But I was still able to meet and discuss and exchange ideas in a collegial fashion with my colleagues, even though we were polls apart on this, we can still laugh and joke and make side bets and do the usual things that that colleagues do. And that free and open exchange of ideas was important.
With COVID, from the very beginning it seemed to be different on the very beginning, back in March, when one of our local modelers, who I’d always regarded as a friend and a colleague, went to the media with the results of his models. And I sent him an email just saying, “Hey, heads up, don’t you remember we had this discussion 10 years ago with your model on H1N1 that was wrong by three orders of magnitude. Don’t you think you should be a little cautious with these numbers?” And instead of engaging me in discussion, he fired back an email accusing me of being in the pay of the capitalists. And I thought, “Whoa, we’re where did that come from?” And do it’s the ranker, it’s the political divide.
I don’t think I’m, I’m reading too much into it. In fact, I think some of you have commented on them. The three of you cover a broad political spectrum. I think Sunetra has been quoted as describing herself as left of labor, which is probably more or less where I’d put myself. And I know Jay has worked for the Hoover Institute, which I doubt is named after the vacuum cleaner company. So you’ve managed to overcome this, but in the world, both the scientific world and the political world, you’re either on the side of the Orthodox or you’re some kind of libertarian conspiracy theorist, anti-vaxxer, climate change denier, why has this happened? Where did we lose the collegiality? How can we get it back?
Dr. Martin Kulldorff:
Well, you didn’t mention my politics, but in my native Sweden, because I support the socialist government’s policies of keeping schools open. So there I’m a left-wing fanatic, and in the US, I support focus protection of the Florida government, et cetera. So here I’m a right-winger. So I guess I’m a schizophrenic in my politics, because I have two countries where the different sides in Sweden, it’s the left, who is in favor of trying to keep the society open and against the lockdowns and the right is sort of want to have more lockdowns, but in the US is sort of the flipped the other way around. So I guess that makes it sort of very schizophrenic for me having two countries like that.
Dr. Richard Schabas:
So how have you dealt with that as a group? I mean, is that an issue?
Dr. Jay Bhattacharya:
If Sunetra is left of center, count me as left of center, left to labor. I also am endorsing.
I, I think that, that, what I discovered is that there are values that are more fundamental than partisan politics that divide us. I mean, I find much more in common with my colleagues here, all the folks here. And I honestly I didn’t know about your politics Richard before you just mentioned [inaudible 01:39:01] I think there’s this commitment to small L liberalism of sort of a vision of society that sees the purpose of public health as promoting human flourishing, protection of life, but consistent with democratic values. I mean, I think all of those things are things we all share, that are much more fundamental than any, whatever partisan issues that divide us.
I think if we can make a comment on, I mean, I’ve been trying to think about what the answer to your question is, why we have this divide? And I don’t know if I have a full answer, but I will say I know that there’s two norms and two very, very different norms in scientific discussion versus public health discussion.
And scientific discussion, I view science as a dialectical process, right? You have an idea. I have an idea. They make different predictions. We do the experiment, the experiment favors you. I say, “Yeah, you’re right, Richard.” And we make a side bet, you won the side bet, I take you to dinner, right? And then we have another disagreement, we keep going, it’s a fun process of disagreement resolved by data that we look at together and argue over. And the one thing that can’t happen in a process is you can’t stop me from having an idea that disagrees with you.
That discussion, that open discussion is absolutely fundamental. That’s the part of the norm of scientific discussion, right? When Martin says”, That the Age of Enlightenment is ended,” That’s what I take him to mean, right? That discussion, that openness discussion ending is the end of science.
On the other hand, in public health, there actually does have to be some consistency in messaging, right? So you can’t really have a lot, a ton of, deep disagreements played out in front of the public because you’ll confuse the public, right? So there’s this norm of like, “Let’s agree on what we’re going to say.” And then when we communicate with the public, we communicate as close to a consensus as we can get so as to not sort of get conflicting messages. So there’s a little less of that norm of completely open discussion, there’s a norm of like consensus building before communication.
The problem here is that we have this situation that’s really novel, right? We have a virus, we don’t know what the infection, fatality rate is. We don’t know a whole lot of basic facts about it in March of last year or February of last year. And strangely, instead of letting the scientific process and debate get carried out before we arrive at a consensus, we decided we knew the consensus, we knew all the results and anyone that would argue against the consensus in doing normal science is dangerous. I think if the conflation of these two norms, especially with the premature application of the sort of public health norm for consensus, that has led to the problem that we’re seeing here.
I have a full answer to your question as to why maybe people thought that this is too important, or maybe it’s just fear took over even in the minds of public health and scientists, but in any case, I think that that’s what’s going on.
Dr. Richard Schabas:
Sunetra?
Dr. Sunetra Gupta:
So I see this as a collapse in the space in which people think. It’s a collapse in dimensions, everything suddenly collapsed down. It must have been fear and uncertainty that collapsed everything down to a single axis. So normally you think, “Oh, well so-and-so has these views. I really agree with those. But then that particular idea, I don’t believe in free markets as much as I think markets should be regulated.” But it’s never a sort of, “Hey, this person is evil because I think markets should be regulated, but he or she doesn’t.”
So I think that’s led to what I call a very big middle term, non distributed fallacy. So that people are looking to take all these different ideas. And usually you were able to think of an individual as having this idea, that idea, some of which aligned with you, a big sort of space in which their ideas existed and sometimes contradict each other, sometimes complemented each other and that’s all gone. So now it’s sort of like, “Well, you believe in focus protection, Trump believes in focus protection. So you must be you believe in Trump.” So that’s sort of a fundamental sort of syllogistic problem, I think, has flourished and become accepted. So I think that’s what the enlightenment militated against is let’s not think that’s not to commit those fallacies. And somehow we’ve gone back to thinking in those fallacies and that’s what’s led to this kind of tribalism.
Dr. Martin Kulldorff:
Now when that happened, what Sunetra describes, that means science becomes more religion than science because you belonging to a certain groups that had to sort of believe in a set of beliefs and you can’t have that attitude in science. So I think that’s why, if that continues, then we don’t have a bright future for science.
Dr. Richard Schabas:
Well, there’s so much more I would like to talk about, but I promised Kulvinder 10 minutes at the end. I think she wants to ask us a question and to sum up. So I’m going to take this opportunity to thank the three of you. It’s been wonderful, just been a delight for me, and it’s great to meet you. And again, thank you for all the great work you’ve done.
Kulvinder?
Dr. Kulvinder Kaur Gill:
Thank you, Dr.Schabas-
Dr. Sunetra Gupta:
Kulvinder, I have a hard stop in three minutes, but-
Dr. Kulvinder Kaur Gill:
Yes. Thank you all tremendously for sharing your insightful and informed opinions, and for sharing your wisdom and for your expertise. Ontario and Canada’s response over the past year has been tremendously myopic, very misguided and fear-based as we have discussed. And most frontline physicians here in Canada are hopeful that your discussion will bring the data and the science back to the forefront to allow for our policy decision-makers to start making ethical, evidence-based decisions.
Now going forward. What is one thing that all of you think should be done to ensure that we’re never in this situation, in this predicament again in the future?
Dr. Sunetra Gupta:
Can I quickly answer, and then I’m going to have to go, I’m afraid.
I think we need to take full stock of the collateral effects of the mitigation strategies that have been put in place. So at the very least, at a very fundamental level, we can do a cost benefit analysis, right at the outset. It seems to have been left for the end, like, “Okay, well, we’ll figure this out when we get to the end of this process.” And that is simply wrong and we’re going to be paying for that for decades. So that’s one thing that I would like, and in fact, many of us are actively engaged in promoting that particular activity, which is to have a very clear look and a clear tabulation of what these lockdown strategies have cost us.
Dr. Kulvinder Kaur Gill:
Thank you. Dr. Kulldorff?
Dr. Martin Kulldorff:
So in the immediate thing, the most important thing is to get our schools and school children and students back in school, with in-person teaching immediately. We can’t afford to have any more suffering and treating those children and students the way we have done for no good reason.
But in terms of the long-term, we have to go back to the basic principles of public health that was thrown out the window a year ago. It’s not one disease public health is about all the diseases, so all the collateral damage. We can’t just think short-term. We have to think long-term. Public health is about everybody in society. We can’t protect the laptop class or the Zoom class and throw the working class under the bus. Whether the issue of fear, we can’t use fear and shaming as a public health tool. It has to be trust between public health officials and the public and so on, where there are many of these other principles that we have to also [inaudible 01:48:04].
Also, for example, somebody who is sick, if somebody has symptoms, somebody has a case, or somebody has symptoms. Somebody is asymptomatic; it’s not a case of the disease. We, as public health officials, we can’t assume that everybody’s like we are, we have to listen very closely to the public.
And also one basic principle of public health is that we have to reach everybody. So I’ve been criticized for being on certain media, which is either left or right, because I’ve been on both, but we have to empower health, we have to reach everybody. You can sort only decide, “I’m only going to reach Democrats. I’m only going to reach Republicans,” you have to reach everybody in public health.
So there are many of these principles that are fundamental to a good public health strategy and the public health of the population that we have ignored during this last year. We have to get back into those basic principles of public health.
Dr. Kulvinder Kaur Gill:
Thank you. Dr. Bhattacharya?
Dr. Jay Bhattacharya:
I mean, I’ll really just endorse what both Dr. Gupta and Dr. Kulldorff just said.
I just, maybe I’ve had one thing to add is when these decisions got made in March, a very, very narrow set of experts raised the alarm and were incredibly influential. We have to set up processes where if we’re going to consider something like this again, a much broader set of experts need to be at the table, right? It just can’t be mathematical modelers or whoever it was. It has to be people who understand the breadth, the full breadth of public health at the table when these decisions get made.
And voices that urge for caution should not be sat aside and ignored, even demonized, but rather welcomed so that we can have an open discussion in the full eye of the public so that they can make up their own minds, as well as to the wisdom of these kinds of actions. What we’ve done now is, is essentially override that debate, force the public with the policies if there were no other choice and then withhold from the public, the fact that a very large number of experts disagree with what’s going on. It’s anti-democratic and it’s likely to lead to an enormous harm in the intermediate and long-term.
So I think what I would like to work toward that vision of expanding the debate at the highest levels to include more people and more viewpoints before we ever do anything like this again.
Dr. Kulvinder Kaur Gill:
Thank you. Oh, Dr. Schabas?
Dr. Richard Schabas:
Oh, of course. Like the other panelists. I could talk about this for several hours, but I think probably the biggest mistake, and we need to change at something that actually comes out of the intelligence committee. When you read about failures of intelligence, probably the most spectacular being the weapons of mass destruction fiasco, the lesson that they were supposed to learn from that, and maybe have learned, is that you need to encourage cognitive dissonance. You need to encourage critical thinking. You need to have people who are looking at things differently than your mainstream view, because it will help to prevent you from making catastrophic errors. It will help to keep you honest.
And we’ve done exactly the opposite instead of encouraging critical thinking, different ideas, we’ve stifled it. That’s what makes the actions of the Ontario College of Physicians and Surgeons towards you so shocking because it’s absolute the opposite of what we need to do. And it’s been that absence of critical thinking of incorporating critical thinking in our decision-making that has led to one mistake after another in handling COVID-19.
Dr. Kulvinder Kaur Gill:
Thank you for sharing your thoughts.
Dr. Kulvinder Kaur Gill:
Thank you all for being on a Concerned Ontario Doctor’s panel, and Dr. Schabas for moderating. This has been tremendous. And I really hope that this will be a pivotal point within Canada’s response to COVID-19. And I would ask all those that are watching to continue to follow Concerned Ontario Doctor’s advocacy closely. You can follow us on our website carenotcuts.ca, which has links to all of our social media. And thank you once again for your tremendous insights. And I truly hope that science and ethics and evidence-based decision-making is back to the forefront very soon.
Dr. Kulvinder Kaur Gill:
Thank you.
Dr. Richard Schabas:
Thank you Kulvinder. Thank you Jay. Thank you, Martin.
Dr. Jay Bhattacharya:
Pleasure to meet you both.
Dr. Martin Kulldorff:
Thank you.
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