Ten crucial lessons from Dr. Vinay Prasad.
Ten crucial lessons from Dr. Vinay Prasad.
Scientific knowledge is supposed to accumulate. We know more than our ancestors; our descendants will know far more than us. But during the Covid-19 pandemic, that building process was severely disrupted.
Federal agencies and their officials have claimed to speak on behalf of science when trying to persuade the public about policies for which there is little or no scientific support. This ham-handedness—and especially the telling of “noble lies”—has gravely undermined public trust. So has the hypocrisy of our elites. Look no further than the Super Bowl, at which celebrities and politicians had fun mask-free, while the following day children in Los Angeles were forced to don masks for school.
The upshot is that science and public health have become political. We now face the very real danger that instead of a shared method to understand the world, science will split into branches of our political parties, each a cudgel of Team Red and Team Blue.
We cannot let that happen.
Thanks to protective vaccines, a huge number of Americans with natural immunity, and a less lethal strain of the disease, now is the time to talk about how to undo the grave damage that has been done. To avoid similar pitfalls when we are faced with the next public health emergency—and to rectify the mistakes that are still unfolding—here are ten crucial lessons:
Identify the Most Vulnerable
Covid is far more dangerous to older people than younger people. The risk difference by age is the single largest epidemiologic risk gap I have ever seen in biomedicine.
The image below, put out by the CDC one year into the pandemic, shows that an 88-year-old has 8,700 times the risk of death of an 8-year-old. This astounding risk differential was known in the very early months of the pandemic. But it was consistently ignored by policy makers who pursued one-size-fits all restrictions with vigor. Scientists that advocated for a more nuanced approach—do more to protect older people, and put fewer limits on younger people—were demonized.
Protect the Most Vulnerable
We knew early on that older people were the most vulnerable to this disease. That’s why then New York governor Andrew Cuomo’s decision to force nursing homes to accept residents back when they were sick with Covid-19 is not just terrible in retrospect, but was clearly disastrous at the time. Yet somehow the U.S. hasn’t learned from this and similar disasters: We are still failing to adopt policies that focus on addressing stratified risk.
Others have done better. In England, among people older than 65, just 4 percent are unvaccinated and just 9 percent are unboosted. Compare that to the U.S., in which 12 percent of Americans in this age group are unvaccinated and 43 percent are unboosted. Rather than focusing on this population, which indisputably benefits from boosters, the White House has been obsessed with a one-size-fits-all booster policy, lumping together 12-year-olds with 82-year-olds. Putting aside the fact that there is a legitimate debate about whether boosters are necessary for the young, this heavy-handed strategy is distracting us from the morally urgent task of protecting the old.
Liberate the Least Vulnerable
Meanwhile, college kids are subject to a barrage of unnecessary restrictions, such as frequent testing, bans on eating in the dining hall, universal mask mandates, booster requirements, limitations on socializing and a host of other anti-scientific policies that have led to isolation, distress and depression. Students are asked to snitch on one another if they see violations, such as lowering a mask.
And for what? A healthy, vaccinated college kid is as protected as anyone can be from the coronavirus. The risk of a person ages 15 to 24 dying of Covid or even with Covid (CDC stats don’t separate this out) is 0.001 percent.
Some believe that these restrictions are meant to protect faculty, but faculty face far greater risk off-campus when they participate in dinner parties, vacations, and travel. They are not being forced by administrators to give up many of the things that make life worth living. Neither should students.
Fight for Normalcy
Children, who face the least risk from the virus, have been subjected to the most damage. They have been treated as vectors, not as human beings, and we’ve justified it by saying that they are “resilient.” Those who have fought for normalcy for kids from the beginning—especially parents—have been ignored and denigrated.
At last, the dam is breaking. Recently dozens of op-eds have lamented what has been the greatest crisis of the pandemic: our treatment of children. They have faced two years of disrupted education; continue to wear masks with no end in sight in many locations (both indoors and outdoors); and are constantly subject to testing, quarantining and pauses in school.
Proportionality is a cardinal principle of public health ethics, and we must restore it for our children. The Urgency of Normal is a group of doctors and scientists—I am one—who have created a toolkit for policy makers, showing the way to return the joys of childhood. Clear limits and checks must be placed on the state to prevent this from ever happening again.
Learn from Other Countries
We have been foolish not to learn more from the experience of other countries.Vaccine policy varies widely across Europe, which treads lightly with younger people. Some nations have decided against vaccinating healthy kids between the ages of 5 to 11, and reserve it only for kids with comorbidities. Others have been reluctant to give a second dose to adolescents, uncertain if the risk of myocarditis—an inflammation of the heart muscle—exceeds the additional gain from a second shot.
On closures and masking, we have also been out of step. The World Health Organization advises against masking children under 6, and only selectively under 12—policies followed by many European countries. Many Western European nations closed primary school just for a few weeks, not years, and Sweden famously never closed grade school. Norway has stopped testing kids for mild symptoms and only keeps them out of school if they feel sick. These are all eminently sane policies that take into account children’s rights and wellbeing.
Run Randomized Trials
In medicine, it is often hard to know the effect of our interventions or policies. This is for three reasons: Most policies don’t work; those that do generally offer modest benefits; and we are an incredibly hopeful and optimistic species. These facts mean that doctors, scientists, policy makers and patients easily fool ourselves into believing that what we hope will help actually does. (I wrote an entire book on flip flops in medicine, which largely occur because of wishful thinking and getting ahead of evidence.)
Let’s say we want to find out if a particular policy—say, mask mandates—actually helps. A randomized trial is a tool that allows us to separate the biases of the world—some states are blue, some people take more precautions, some places have higher vaccine rates—and lets us figure out the actual value of an intervention. By randomly assigning groups to either have the intervention or not, you balance out the variables and isolate the effect of the mandate.
Many experts have called for more randomized trials during the pandemic. But they were ignored. We should have studied whether social distancing works, and how much distance is ideal. We should know a lot more about who to test, why we’re testing, and how often to test. Even school closure and reopening could have been studied. Randomized trials could have turned political fights into scientific questions. Not running them was a huge failure.
Don’t Promote Shoddy Studies
During the pandemic the CDC has developed a track record of promoting flawed studies to support their preconceived policy goals. Most notorious was an Arizona State University study highly touted by the organization (and published in their journal MMWR) that sought to justify mask mandates in schools. Journalist David Zweig, writing in The Atlantic, thoroughly debunked the study, making the convincing case that it was so flawed it should not have been published.
But the CDC did not stop there. I published detailed critiques of several more studies promulgated by the agency to support the White House’s policy goals. One claimed that Covid causes diabetes in kids, but failed to adjust for the body weight of the children, a crucial metric. (A more recent analysis from the UK finds no such association.) Another claimed that people who more rigorously wear cloth masks have 56 percent lower odds of testing positive for Covid-19. The paper was so irredeemably flawed that it should never have been published, as I outline here.
Don’t Ignore Inconvenient Facts
Don’t ignore scientific facts just because they don’t fit a policy imperative. For example, for most people, a Covid-19 infection results in a substantial immune response—what’s called “natural immunity.” But our officials, because of their singular focus on vaccines, have essentially ignored this basic fact, pretending natural immunity doesn’t exist.
The distinguished vaccine expert Dr. Paul Offit recently co-wrote an op-ed with former FDA employees Luciana Borio and Philip Krause explaining that people who have been infected with Covid should only have to get one dose of vaccine, not the three now recommended by the CDC. If natural immunity means people don’t need multiple shots—and I believe this is the case—our experts should say so. By ignoring the reality of natural immunity in favor of their desired policy of triple vaccination, our officials are not making us safer. They are undermining the trust that is essential between the experts and the public.
Don’t Stifle Debate
The pandemic befell us during the rise of cancel culture, which has captured so many of our institutions. Calls to censor, silence, de-platform scientists and others who disagree with official policy have been vociferous and very nearly constant. When faced with an unprecedented public health threat—and in a time when our culture responds in an unprecedented manner to disagreement—perhaps it was inevitable that crucial debates would be stifled and that dissidents would be smeared. And that’s exactly what happened.
Scientists who came out early in favor of focused protection of the elderly were labeled “fringe” by the NIH director Francis Collins and were quickly demonized. The chilling effect of this public denunciation was real. I know many like-minded junior faculty who refrained from commenting on Covid, fearing personal and career retribution.
Facebook infamously censored the lab leak hypothesis, only to recant, when the journalists Nicholas Wade and Donald McNeil showed that this was a story that needed exploring. Empowering massive technology companies with the ability to censor anyone is dangerous for an open society. I investigated Facebook’s third-party censors and found that in one instance, they selected a “fact checker” who had already tweeted criticism of the article they were asked to check. This is akin to selecting a juror for a trial who already stated she believes the defendant is guilty.
There is a real solution to information you do not like or that you disagree with: A detailed, methodical rebuttal. Not theatrical calls to silence the speaker.
Don’t Destroy a Brilliant Legacy
We should rightly be celebrating the magnificent breakthrough of the mRNA vaccines, which were quickly developed, saved millions of lives, and hold the promise for further medical advances benefitting all humanity. We also now have (when doctors can get them) effective medications for vulnerable people who contract Covid-19.
Of course, a global pandemic will result in many wrong decisions, missed opportunities, and inevitable tragedy. But during this one, our officials have too often misled us, failed to make timely corrections of mistakes, doubled down on a foolish policy that simultaneously overburdened the young and neglected the elderly, and thus severely undermined public trust. I fear all this will be our Covid-19 legacy.
Dr. Vinay Prasad has consistently been able to cut through the noise, the confusion, and the politics that characterize our public conversation about Covid-19. If you missed him on Honestly, listen here:
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