The Munk Debates Podcast - Be it Resolved: We Are Making High-Stakes Decisions About the COVID-19 Pandemic Without Reliable Data

Episode Date: March 27, 2020

COVID-19: Are we making decisions without reliable data? On this episode of the Munk Debates Podcast, epidemiologists John Ioannidis and Sten Vermund debate the motion Be it resolved, we are making high-stakes decisions about the COVID-19 pandemic without reliable data. SOURCES: ABC NewsBecome a Munk Donor ($50 annually) to get 72-hour advanced access to the full length editions of Friday Focus and Munk Dialogues. Go to www.munkdebates.com to sign up. Hosted on Acast. See acast.com/privacy for more information.

I think it's time for this toxic binary zero-sum madness to stop. We're not an imperial power. We're a revolutionary power. We are no longer in a world where you can plot out moves statesman to statesman like a chessboard. You don't know anything about my background to where I came from. It doesn't matter to you because fundamentally I'm a mean white man. We can't do this to the next generation because America will cease to exist. Welcome to the Monk Debates podcast. Every episode we provide you with a civil and substantive debate on the big issues of the day. Free of spin, focused on the facts and animated by smart conversation to arm you, the listener,

with enough information to make up your own mind. Today's debate, be it resolved, we are making high-stakes decisions without reliable data on COVID-19. Our country wasn't built to be shut down. This is not a country that was built for this. America will again and soon be open for business a lot sooner than three or four months that somebody was suggesting. Hello, I'm your moderator, Rudyard Griffiths. Well, COVID-19 is spreading across the globe and forcing entire countries to implement lockdowns and strict social distancing measures. hundreds of millions of people are now confined to their homes, and the global economy looks like it's heading into a deep recession.

Some scientists believe that national governments are taking drastic actions with insufficient testing and incomplete demographic models, possibly overestimating the threat COVID-19 poses to public health. Others disagree. The only way to stop the pandemic is to enforce large-scale society-wide lockdowns and social controls. All the information collected so far shows that COVID-19 is an extremely dangerous virus that requires a commensurate response. Here's Dr. Anthony Fauci, U.S. Director of the National Institute of Allergy and Infectious Diseases. What I like to see is when people look at what we're doing and say you're overreacting. The dynamics and the history of outbreaks is you're never where you think you are.

If you think you're in line with the outbreak, you're already three weeks behind. On this installment of the Monk Debates podcast, we challenge the essence of these arguments by debating the motion. Be it resolved. We are making high-stakes decisions about COVID-19 without reliable data. Arguing for the motion is Stanford epidemiologist John Ioannidis. Arguing against the motion is the dean of Yale's School of Public Policy and Health, Sten-Vermond. John, Sten, welcome to the Monk Debate podcast. Thank you for the kind of invitation. Our pleasure.

It's great to have you both here and an opportunity to have a conversation about an important issue. We've decided today to frame that issue in the context of a motion. We both discussed this with you extensively before our conversation today, and that motion is be it resolved. We're making high-stakes decisions about the COVID-19 pandemic without reliable data. John, we're going to ask you to speak first. you're arguing in favor of the motion. We're going to put two minutes or so on our proverbial clock and pass the microphone over to you. We look forward to your opening remarks. COVID-19 is a serious threat. There's no doubt about that. We need to understand how serious it is

and what is the best way to deal with it. At the moment, we are throwing extremely severe measures trying to do something. However, we have very little evidence base on how to guide our next steps. We really don't know where we are, where we are heading, and whether our measures are effective, or we need to modify them and change them. There's a possibility that many of our aggressive measures could be doing more harm than good, and especially if there are to be maintained long term, the consequences in terms of lives lost, as well as major disruption to the economy, to the society, to our civilization at large, is really very, very real.

I think that at this juncture, we need to act swiftly. At the same time, we need to act equally swiftly to collect unbiased data, data that will tell us how many people are infected, what is the chance that someone is infected, eventually will have a serious outcome and die, how is the epidemic evolving in different settings and places around the world, and what difference are we making with the measures that we're taking? It can make a huge difference, and there's a lot that can go wrong if we don't. Don't get it right in terms of having the right information. Thank you, John.

You've set up your point of view succinctly, and I appreciate that. So, Stan Vermin, to turn it over to you, let's get your opening statement on our motion, how we're kind of framing this discussion. You're opposed to it, and that resolution is be it resolved. We're making high-stakes decisions about COVID-19 without reliable data. I think it's a matter of perspective. I think John and I would agree that we need more data and that. The data that we have available is suboptimal.

But that is to be expected when in November of last year, coronavirus, this particular novel coronavirus had not entered humans and we had no information. We learned almost nothing about it in December when there was some denial on the part of public health officials in China. And only in January did information start to emerge. At the time, we had Wuhan-China data that suggested that over 30% of samples, admittedly small samples, were infected with the virus. And we don't see population saturation through casual respiratory transmission very often. Flu often peaks at 10 to 20% of a population, as do other common respiratory viruses. Measles is more thorough.

that's the super transmitter. So we knew we were much, much less than measles, but at least as bad as flu and perhaps worse. And there really is only one comparison in the last hundred years where we had 30% to 40% penetration, and that's the 1918-19-19-19-19-19-12-19-12-12 to once a pandemic. Now, mortality rates were very, very high from that pandemic because it predated modern medical practice.

We didn't have antibiotics or bacterial superinfection. have ventilators to keep people alive. I mean, you really can't compare 2019, 2020 with 1918, 19, 1990. But in terms of transmission dynamics, that's the one that it reminds us on. And we do have now the China and Korea experiences, the lockdown of the greater Wuhan area and the greater Daegu area and the social distancing practiced in much of the rest of the countries in China in particular, to the less extent. in Korea, which used a somewhat different strategy of widespread testing. And then we have the negative

examples, and both of those epidemics are declining rapidly in China in Korea. But then we have Lombardi region in Italy and much of Spain, where the intervention is simply too late or too undisciplined. So I think we know enough to respond to this particular pandemic. We know we're unprepared and do not have the bed capacity, ventilator capacity, or personal protective equipment, PPE capacity that we need to respond so that we know. And we also know that broad-based social distancing, hygiene, travel restriction, testing and isolation, hospital-based control, all has been beneficial in China and Korea. What we don't know is whether this model that the number of people are promulgating to simply wall off the elderly and the vulnerable, do a very short,

term, shut down to try to minimize transmission, and then let everybody who's less vulnerable go back to work, whether that will work. We have no clue. It's not been tried and it's not succeeded. My metaphor is that we're in a California wildfire, that a vulnerable family has decided to stay with a fire hose to project their fire. Will they save themselves, as some do, or will they be immolated by the overwhelming burden of the wildfire? I think that it's easier, in fact, to to have the harsh medicine of a national social distancing strategy to protect the vulnerable, to blunt the impact on the health system, than it is to take a chance on an unproven strategy. Thank you, Sten.

So, John, as we discussed at the outset of the show, we're going to give both of you an opportunity to kind of react to what you've just heard from each other. So let me ask you to kind of respond to what you've heard from Sten in his opening comments. I agree with Stan that this. This has been an acute situation. At the same time, collecting reliable data should not take time and should not really put a halt to our decision-making and acting fast. Getting information on representative samples of the population is very easy. It has been done in some settings.

For example, it has been done in Iceland where they have a cohort covering pretty much the national population. Looking at samples that have been provided, they see that they have an infection rate of 1%. and until now that we're talking, only two people have died. This means about 3,500 people in Iceland being infected and two deaths, which corresponds to an infection fatality rate, which is lower than the common flu. Of course, some people may be infected later, but nevertheless, these estimates would be very, very different compared to the original claims of a case fatality rate of 3.4% that were circulated and that really good. caused horror. And obviously, this is justified if you hear a 3.4%. At the same time, we have other pieces of evidence that indeed the number of people who are infected is much larger compared to the number of cases we have documented. In many places, actually in most places, with few

exceptions around the world, we are just testing people who have substantial symptoms who come to health care and seek help or even to be hospitalized. These are just the tip of the iceberg. The Iceland experience and other other data from Vo in Italy, where the entire city population was tested, showed that the vast majority of people are either completely asymptomatic or mildly symptomatic in ways that you would not be able to differentiate from common cold or common flu. It makes a huge difference while we are proceeding with aggressive measures of social distancing and lockdowns that may have tremendous repercussions, especially in the long term, to know whether populations are infected at 1% level, 10% level, 20% level, or who knows.

The solution to the problem is very different. It could be that we need to continue with lockdowns, but it's very likely that very quickly we would need to abandon blind lockdown and focus on protecting the lives of those who are susceptible, which we know very clearly are the elderly and those who have severe underlying diseases, and at the same time allow people who are. at very low risk and or have been already infected and have mounted an immune response to return back to normal life and not destroy our planet and our civilization. Thank you, John. So,

Sten, same opportunity for you just to react here to what you've heard from John. Well, the risk of having a debate between two scientists is that they might end up agreeing. I agree completely with John, that the absence of industrial scale testing capacity is severely constraining our ability to have a more targeted response to this epidemic in our country. We were very late to the commercialization and availability of an FDA-approved test. We were several months after China was testing, and especially Korea, where the Koreans had a very aggressive test. strategy and they were able to do a much more targeted lockdown, if you will. And so they knew where a disease was emerging and where it wasn't emerging.

They did not have to shut down their society in places where it was not emerging. And the trouble here is that without available testing at any kind of scale, I'm an infectious disease epidemiologist. I've been doing this since the early 1980s and I've never been so constrained in my ability to provide policy guidance to my region or my country or my world, because I've generally had tools. I mean, honestly, I almost feel like I felt in pre-1985 with the HIV epidemic, where we did not have a test until 85, and it was four years of inferential interpretation that happily the epidemiology was crystal clear, and we were able to make early advisories about high-risk sexual behavior.

But look what happened catastrophically to the blood banking industry, where they continued to use contaminated blood because of lack of a test and lack of willingness to use the epidemiologic data on who the higher risk individuals were and restrict blood transmission. So I almost feel like I felt back then. Today, I cannot launch a major survey of the city of me. Haven or parts of the state of Connecticut where I live, which are not suffering much illness, to know whether the virus has entered or has not entered those areas. So we have the governor telling the entire state the lockdown, and it certainly is a reflection

of the absence of information. It's highly plausible that the strategy in Wyoming might be different from the strategy in New York City. the strategy in rural America might be different from urban America. But in the absence of widespread testing, since we do not have it available, I can't take a magic wand and make it available other than advocate that our federal resources go into this intensively. In the absence of that, the more conservative approach, when we know that viruses enter the community, knowing how what a wildfire spread it can be

and knowing how overwhelming it will be on our health system is to do this more radical approach. You're listening to the Monk Debates podcast. Be it resolved, we are making high-stakes decisions without reliable data on COVID-19. Speaking for the motion is John Ioannidis, epidemiologist at Stanford University. Arguing against the motion,

is Sten Berman, Dean of the Yale School of Public Health. Well, let's get into our conversation. I want to try to put myself in kind of service of the audience listening. And John, maybe to start with you and kind of zero in on this word, phrase, reliable data that's in our motion today, be it resolved. We're making high-stakes decisions about COVID-19 without reliable data. Is the average person right or not in looking at the, the reports on the infectiousness of this disease, the so-called R-not number, and looking at

the fatality rate across a variety of different countries, and seeing that both of those variables are significantly higher than the standard flu, which in the United States kills tens of thousands, up to 70, 80,000 people a year, and therefore, you know, our response, our reaction to COVID is reasonable based on this. high R not number, the infectiousness, and the much more substantial lethality of this virus vis-a-vis the flu. The data on lethality of the virus that are circulating are extremely exaggerated. They pretty much pertain to the cases that come to our attention. And by definition, these are cases that have more severe symptoms, far more severe symptoms,

compared to the average person being infected, which, based on the Iceland infection, and other similar pieces of data probably never realizes that they have a problem. They are either completely asymptomatic or have very mild symptoms that they don't pay attention to. Clearly, we know that the infection fatality rate is much lower compared to 3.4 or any other similar numbers that have been circulating. Are they exactly the same or lower than the seasonal flu? We don't know that with certainty. Could it be a bit higher?

It could well be. And the only way to find out is to really get the, random representative samples to be able to have a fair assessment of how many people eventually die among those who are infected. I wouldn't be surprised if that number is very close to seasonal flu. I cannot exclude the possibility that it is a bit higher or even a bit lower. In terms of how many people are going to be infected, we have to be very careful about extrapolations using the R0 the basic reproductive number based on the early courses of an epidemic.

The figures that have been released, and most of those have not been peer-reviewed, range tremendously from 1.3 to 6.5. 1.3 is exactly the same as seasonal influenza. 6.5 is amazing contagiousness. We need to have a more complete picture of the epidemic before we can understand how many people eventually will be infected. and I suspect, much like what happens in many other epidemics, it's not going to be the same infectious density across all locations.

It's possible that some cities may have a very large share of people being infected, and others, perhaps rural locations or even whole cities, will have very low rates, eventually of people being infected. In the case of Italy, which is the one plastic disaster that one is talking about, we know that Bergamo, which is the city that was most hit among any other city by far, at about the time that the virus was circulating, there was a Champions League match where one third of the population went and then continued celebrations, dancing and embracing and kissing each other until late after midnight.

We don't have this type of situation happening in every single city around the world, and it makes a huge difference to compare a setting where an entire city is embracing and kissing, which is obviously not the thing to do at the moment, versus say that we're freezing every single citizen in place for weeks and months, if not a year, according to some estimates. Thank you, John. So, Stan, maybe you could give your thoughts on both the lethality and the R-Not number. I mean, do you share John's view that this may end up?

having a fatality rate at or below that of the common flu? I do not. If one looks at more comprehensive data for Wuhan, one does see an indication of a saturation of the population at a higher rate than is typically seen with influenza. Now, that doesn't mean it's more infectious than influenza because there is no cross-reacting immunity that is protecting somebody from the coronavirus,

the way that some people will gain some benefit. So, Sten, just on the basis of the layperson listening, cross infection, can you just explain that? Immunity? Cross-reacting immunity is something that occurs if, for example, I was immunized with a strain of that particular flu season, but the flu that actually circulated wasn't quite the same strain, but I do gain some benefit because the immunity that I'm mounting against the flu virus, even though it's not the right strain, is partially protective. Or perhaps I had flu two years ago and I still have some recognition of flu antigens. The strain that's circulating is different

from that of two years ago, but I get a little bit of partial protection. We don't have any of that with coronavirus because it wasn't in human beings before November of 2019, and nobody has any immunity of any sort to coronavirus. So that probably explains why the best estimates of our modelers are that it is at least as infectious or more infectious than flu. Similarly, our death rate data, I agree completely with John that the WHOS of 3.4 is based on a false denominator. So what I mean by numerator, how many people died, denominator, how many people were tested. And when you don't have a representative sample of the population tested, then all you know is the sick people who were tested. So that's a very artificial denominator. So then you have to say,

of the sick people, 3.4% died, not of the infected people, 3.4% of people died. That would be a false statement. The better estimates are probably in the 0.7 to 1% range. That's about half of what the American mortality rate statistics are, about 1.3%. So probably somewhere in the half of that about 0.7%. That's still seven times greater than annual flu mortality, which is about 1,000. So I don't think there's any way that we can say that the mortality of coronavirus is going to be less than annual flu. I think we have enough data to say that it's going to be higher and higher by a factor of five to seven to tenfold. So I do think that we're in a bind, and I think we're up against something where we're going to be filling the hospitals and the ICU beds as we are in New York.

Thanks, Dan. John, is there any interesting apples to apples data when we start looking at hospitalized cases? So when the denominator isn't the known unknown of how many people are infected or not in the population, but what happens when somebody is hospitalized and the fatality rates that emerge from hospitalization due to COVID versus hospitalization due to the flu? It seems that COVID is, is having higher percentages in terms of ICU, ventilator intervention. Is that a reliable piece of data for public policymakers to focus on and make decisions regarding? The hospitalization data is clearly interesting and we should pay heat to them,

but I don't think that they tell the full picture and actually they can mislead us substantially. What we know is that SARS-Curts, Cove 2 does tend to affect specific types of individuals. So it has a very steep age gradient. Influenza does have an age gradient as well, but for COVID-19, it is even steeper. And it also affects people who have severe underlying diseases like chronic obstructive pulmonary disease or others. And this means that it's very difficult to get a one-to-one comparison. Influencer, for example, kills many, many children.

We don't see really deaths in children less than 10 years old, and we see extremely few severe cases in young individuals in the absence of underlying disease, while we do see quite a bit, quite a lot with influenza. So the comparison is very difficult to make, and I think that what it points to might be that a solution where we really try to use draconian measures to protect those individuals who are at high risk may actually work.

We just don't know because we don't know what is the exact proportion of the people infected, as we discussed before. We don't know because we don't know exactly what is the overall infection fatality rate. And here we do disagree a bit with Stan. I think it is lower. I agree it may be higher than influenza. My bet, if I had to throw a number would be 0.3%, like 3, 4%. compared to influenza or 0.2%, which is two-fold. But again, we don't have data to

inform us. I think that we need to get that data. And unless we do that, we're just speculating. We're using medieval public health. Just close the door and stay in your house. Yes, we have to do it because we don't know. But that's not 21st century medicine and public health. These tests have been available for decades, both PCR and serology. We should be able to get them. We will know if we get even small samples, but representative samples, whether we can't compare apples to oranges, or it's completely similar or dissimilar. It could be either way. Stan, do you see any other reliable data? You know, we just talked about hospitalization, flu versus COVID versus other illnesses. Are there other sets of data that you have higher

conviction around that have surfaced as a result of different countries now dealing with this pernicious infection? Excellent question. These data are pouring in at rates that people like John and myself are spending a lot of our time trying to digest. I thought I might give a microcosm comparison. These are not definitive and these are not going to satisfy any of us on this debate stage. But yesterday in the Yale New Haven Hospital where my School of Public Health is adjacent, we had 39 hospitalized COVID patients. Today, we had 68. So it was up about 70%.

And of these 68 patients, 38 are in the ICU, and 32 of the people in the ICU are on ventilators. Three days ago, there were seven people on ventilators. If you go to the much smaller Greenwich Hospital near New York City, they actually have 45 patients on ventilates. We never see this in flu season. We have not even seen this in the pandemic H1N1-2009 pandemic flu. So you literally, for these sorts of numbers, have to go back to the 20th century, early 20th century, to see something that is this severe. and filling up the beds with such radically ill and sometimes borderline lethal patients.

Now, we hope we won't lose these patients, but the father of one of my work colleagues at the School of Public Health died of coronavirus, I think it was yesterday. So we are seeing the lethality, even with the best medical care that can be provided on the planet. And every year we have people who die of influenza.

There's no question about that, but the surge of people patients requiring ventilatory assistance is unprecedented. Thank you, Stan. My condolences to your friend of the loss. I think there will be many in the days to come. So, John, any reaction to that, that we're seeing some characteristic in this disease that is especially burdensome for hospitals and for the health care system.

And therefore, the reliability of the data needs to be kind of juxtaposed against the reality of the disease progression and how the disease affects a health care system and seemingly its capacity to overwhelm that system in a way maybe that the flu wouldn't? So I think I would agree with Stan that in terms of the burden that this epidemic and caused to hospitals, we need to be very cautious and we need to prepare and be ready for the worse. Preparedness for dealing with it at the hospital level is clearly indicated. There's no doubt about that. But it is very different to take measures to boost your ability to take care of sick people in a short period of time, to increase your capacity for ICU beds, for ventilators,

for equipment, for resources to plan in very limited time, unfortunately, in many places with hospitals that don't have resources to plan for your best response for an epidemic wave that is coming. I have 100% agreement on that point. But this is not necessarily something that you can extrapolate to what you need to do for the entire population and the measures that you need to take for the entire population. The comparison against 1918, I think, is very flawed. people who died in 1918, about 40 million, perhaps even 50 million, on average, their age of death was 28 years old. People who die with SARS-CoV-2, the data from Italy show an average age of 80 years old.

And 99% of these people have other underlying pathologies, have one, two, three or more other reasons they could be dying. actually talking with people who are leading the Italian response, they really get perplexed on how many of these people really died from SARS-CoV-2 versus with SARS-Cove 2, meaning that in an infested environment where they got overwhelmed with lots of cases coming in and getting even to the point of having noosocomial infection, having 3,000 of their physicians and medical personnel being infected, many people who were in that hospital environment would be colonized with SARS-CoV-2. It's a very different situation compared to influenza in 1918,

the same number of deaths but vastly different age profile corresponding to, even in the worst scenario, one-tenth of the quality-adjusted life years for SARS-Cove 2 compared to influenza 1918. If you adjust further for the size of the population, you need to adjust for an extra five-fold. If you take more conservative estimates of fate, case fatality, as we are describing and debating, it could be even less. So clearly, we need to act swiftly and protect our hospitals and prepare for the worse. But this is one aspect of our response, and we need to do our best. And the The second component is what do we do at the population level? What do we do with a single person

who is at high risk based on what we know versus what we do for the large majority of people who are at no risk or very low risk? Stend, do you have any other comments on this comparison or the analog of 1918? The only comparison I was trying to make was the magnitude of the saturation of the population with the virus. I think that the ability for this, virus to surge in a population in just a matter of weeks and in fact 30, 40 percent of that population, that is very different and is more reminiscent of that, especially infectious flu of 1918, 1919. I said earlier that you can't compare the mortality data, and I never commented on the age specificity,

which is very different, as John correctly noted. So I don't want to overstate the comparison. But if we're looking at history, we don't have anything that spreads as fast as the coronavirus unless you go back to that era. And we don't have anything that is filling our ICU beds and demanding ventilator support, anything in recent memory. So that's what I'm comparing to with 1980, 1990. And I accept John's points that there are many, many differences between the two.

For one thing, they're completely different viruses. One is influenza and the other's coronavirus. And they have different predilely four age groups and the like. But I do think that John was correct when he said, we don't have much choice but to do this at the present time. I feel that as the data are surging, we can make modifications to public policy. I would like the small business owners of the manufacturers of America to get back to work. I'd like the tourism and hotel and travel industries to get back.

I go walk in my small town here in Connecticut, and it looks like small business apocalypse. The only places I see open are places that can do take out food and our groceries. I mean, it breaks my heart. On the other hand, if we had not instituted broad-based social distancing, if we had not shut things down, I think that my hospital would be much, much worse shape. I think we'd be seeing mortality rates surge, and I think that we would be in much worse condition. I am all for gathering more information, just to validate one of John's points, when you look at the total testing statistics in the city of New Haven, we've done a paltry 1800 tests, and the test frequency positivity rate is 8%. And John knows, and I know, and I hope all your listeners know, that that is not possible.

We're missing all of the asymptomatic and mildly symptomatic cases. We haven't even encouraged people to get testing if they think they have coronavirus. We've encouraged them to stay home and only come in to get testing if they're very ill. So we are working from no coherent epidemiologic playbook here. And I'm as enthusiastic as John is to ramp up. up our testing, empower our health workers, our public health workers to get the kinds of data that can help us truly track the epidemic rather than just track the sickest among us. So I want to ask a question to you both, and it's a kind of professional question, which is,

you know, America, the world knew that a pandemic was a real impossible threat. We've known this for years. SARS was a scarring lesson in that. So why, John, are we in the middle of a pandemic, yet we have no kind of mass survey type testing capacity? Or how do we end up in that situation, kind of driving with the front windshield blackened out in terms of the policy response?

I think this is unfortunate, and it goes back to long-term planning, and it has been a perpetual approach. problem. You know, emphasis on public health, unfortunately, both in this country, and in most places around the world, is very limited because you don't think about it's important until you see some acute situations like the one that we have at the moment. I think if things get controlled, this may be a positive lesson for the future that we need more preparedness for public health, that we need to invest more on public health. Maybe we can learn lessons also about

helping public health to solve other problems that they can be solved if we had the manpower and the commitment. We are still facing, for example, a chronic epidemic of smoking that is not going away in most places around the world. And public health is completely outnumbered against the propaganda of tobacco industries, even though we're talking about 10 million people dying from smoking every single year. You know, if we had a worldometer of people dying from smoking, which would include actually most people dying with coronavirus because it hits preferentially people where smoking has damaged their lungs or their heart or their health in total, we would really be stunned. And I think we need to get that opportunity to think how we can

learn about investing more in public health, in giving it the resources that are required to do its job and to really keep us healthy. You're listening to the Monk Debates podcast. Be it resolved, we are making high-stakes decisions without reliable data on COVID-19. If you're enjoying this podcast, review us on iTunes. We also welcome your ideas for debates and debaters to feature on this podcast. Email us at podcast at monkdebates.com. Thank you for helping us bring back the art of,

a public debate, one conversation at a time. Now, back to the episode. Well, Stend, you're the Dean of Yale's School of Public Health, so you have an important national role. I mean, how did America end up in this situation? Not just without the testing capacity, but seemingly a botched rollout, the lack of personal protective gear, the lack of masks.

It all just kind of, it's bewildering that in the face of what is a kind of, of known unknown threat that currently the public health response seems so, I'm not saying unprepared on the part of the professionals, but the resourcing of the response seems chronically unprepared. As John said, there has been an unremitting drumbeat of warning that has come from the public health community on pandemic preparedness. We have a burgeoning human population. when I was born in the 1950s, there were 2.4 billion people on Earth. Now there's 7.7 billion people.

We are crowding our rainforests. We are crowding our natural habitats. And we're seeing a steady stream of what we call zoonotic diseases. That simply means a disease that goes from a vertebrate animal to a man or a woman. So these zoonotic diseases are a steady diet, if you will, for the human rights. race and they are not adapted to humans. Some of them are highly lethal, but not particularly infectious. The Ebola virus would fall in that category. We know how to prevent Ebola virus and we know when it's most infectious and we can control it. And despite this, we have

outbreaks in Liberia, Sierra Leone, and Guinea, and we've had more recent outbreaks in Congo. But we're better prepared for Ebola. But these pandemic respiratory diseases are the especially potentially lethal. They are more likely to jump continents, which Ebola has trouble doing. They're more likely to be casually transmitted on an airplane, cruise ship, or at a soccer match, as John pointed out, or a dinner party, which was written up in the New York Times, occurring here in Connecticut, which seems to have fueled our epidemic. And the reality is that we elect our representatives every two years.

And what the voters are asking them is, what have you done for me in the last year and a half? And I would love for the American voter to start asking, what have you done to protect my children and my grandchildren? What have you done for the epidemic that is looming related to global climate change? What about the obesity and diabetes epidemic, which is the public health community up against cuts in school budgets? that wipe out gymnastics programs and recess, that the pressures of the sugar and processed food and soft drink industry. We have a lot of global threats in public health

that are emerging from a lack of attentiveness to prevention. We're utterly addicted to treatment. We'll redeploy Tesla and GM and Ford and anybody else to make more ventilators. but we won't make the kinds of investments into coronavirus vaccine that we could have made in 2003 and 2004 when we already had the warning sign of coronavirus. So I think that if this is a wake-up call, it's a wake-up call to pay attention to prevention. All of our grandmothers told us and our mothers told us that an ounce of prevention is worth a pound of cure.

And we call that decision analysis modeling. and John Yonidas is an expert. He can wax eloquent about this until the morning. So finally, before we go to closing statements, just like your advice to policymakers, respectively, there's probably more than a few listening to us right now. So, John, what would you say to a state governor, to a provincial premier, to a mayor of a city?

What advice do you have for them right now in this crisis? I think that number one, they should be calm and they should try to do their best in terms of preparing hospitals in their jurisdiction to face what might be an epidemic wave that we don't know how many hospitals might be overwhelmed. At the same time, they should do their best to minimize exposure to the virus and at the same time collect some unbiased information on what is the status of the infection rate and therefore also of the infection fatality rate because this will be a game changer in terms of what are the indicated measures that we will follow in a week from now or two weeks from now. I think that they should also take the opportunity to think what

that means for their long-term planning. As Stan said, you know, there's so much at stake with public health being undervalued that this is. an opportunity to make a strong case about being better prepared. So, John, just to be clear, would you recommend to mayors and governors and premiers and presidents that the current tight controls around social isolation, lockdown and some states and provinces continue until we have that data, or, you know, is this something that can be adjusted based on information as it comes in? Personally, I'm in shelter-in-place situation right now, so I'm joining you from my home,

and I'm perfectly happy to stay in that situation for the next week or two, but this is enough time to collect the type of information that we have been discussing about. Depending on what that information is, it may well be that the strategy needs to be readjusted more surgically, more accurately, to find ways to clearly protect our high-risk individuals, but at the same time be able to mobilize the rest of the community and not continue just blindly shutting everything down. We just need these data. We can get these data. They're easy to get. We do have that week or two to inform ourselves and make the best decisions. And John, do you know if the CDC is doing this or other university networks?

Do you know if this kind of survey data is being collected now? There are several players who are active in this field. I'm working with a number of them, and I'm sure that there's others who do that without even me knowing it. And I'm optimistic that we will have some better information about that denominator of how many people are infected, which can make a huge difference in so many ways. Well, great. And, Sten, what would your advice to policymakers be right now? I mean, there's an increasing debate going on between what's happening to the economy and the damage that's being caused as a result of shelter in place, of lockdowns, and some pressure on the part of the business community and others to loosen up those lockdowns, you know, reliable data or not? I believe that if we had better data to track the true epidemic curve, we could open up venues quicker and more effectively. I agree with that.

For example, if we see a sweep through a community with reasonably reliable data and we see that the community is no longer experiencing the magnitude of transmission, one could start opening up segments, especially if one could test people and everyone in a workplace was negative and everyone in their household was negative. You could have islands of documented uninfected persons who would be congregated and that could work. But I'm afraid we're a number of weeks away. We still don't have the testing capacity in New Haven, Connecticut, home of Yale University in a fairly sophisticated state health department. We simply don't have the test kits. So it may take a while, and it may be many weeks before we are capacitated with what we should have had available a month or two ago. I should say that there are side issues here.

The lack of universal health insurance coverage is unadvisable for any modern society. There should never be anybody trying to avoid going for health care because they're afraid of a bill. And that's how you get people circulating in the underbelly of society and being aitis of infection rather than getting the health care they need. That goes for undocumented individuals as well. I think we need adequate infrastructure and workforce capacitation of state health departments. They've been slashed to the bone. We have rising trends in sexually transmitted infections in the United States because health departments have been cut. In some venues, they're struggling with basic services in public health and epidemiologic tracking.

And I also think it's very revealing that the administration wants to cut the CDC and NIH budgets every year. Congress has stood up to the administration. But what kind of insight is it to slash. our public health infrastructure and our biomedical research infrastructure in this country, when we desperately need therapies, when we desperately need vaccines. So if there are some lessons to be learned, I agree with John, we need considerably more data than we have now. I am less optimistic than he is about our ability to lift the social distancing in the next few weeks. I think lifting social distancing by Easter is predictably not going to happen.

And if it does happen, I think it will unleash considerably more transmission than we're able to account. John, is that your feeling, too, that lifting social distancing by Easter is not advisable in the absence of reliable data? And it certainly doesn't look like you would have reliable data on a national scale by then, would you? Well, if that question is very difficult to answer, And what I worry is that we end up in the same condition several weeks or even months down the road without having the type of data that would inform us to take the next step. One might say, better be safe than sorry, but I want to be more optimistic that if not nationwide, at least I hope, we will have some representative data that cover substantial ground and maybe even more information internationally. that would allow us to pinpoint in more accuracy what type of a beast we are dealing with. I cannot promise about what will happen by Easter,

because then I become an expert trying to make predictions without data, and this is exactly what I don't want us to do. What I'm arguing is that we need to move swiftly to get these data so that we have less of blind experts and more of 21st century science. I fully agree with Stan. You know, we need more emphasis on preparedness, on getting funds for public health, for medicine, for research, for all of that. And now is the time to get this type of information that we need so desperately and to do our best.

I think we can do our best. We should do our best. You're listening to the Monk Debates podcast. Be it resolved, we are making high-stakes decisions without reliable. data on COVID-19. Speaking for the motion is John Ioannidis, epidemiologist at Stanford University. Arguing against the motion is Sten-Verman, Dean of the Yale School of Public Health. Well, let's give both of you just a quick opportunity to sum up. This has been a really rich, informative conversation and the civility and candor that you've both brought to it is

a credit to you as academics and thinkers and publicly. spirited individuals. So, Stan, let's have your kind of summing up first. Well, let me just say first that open debate is the nature of academia. I welcome from a student, from a colleague, to be questioned on what I believe, because if I'm forced to defend my point of view, I can refine my thinking and I can, I hope, come closer to the best testament of the truth. The whole philosophy of Bayesian analysis is that you make your best judgment when you have certain amount of data available, and then you can refine your probabilities based on new information, and I'm very much Bayesian in that period. I'm going to just close by a speculation. In 2004,

the global response to SARS was very aggressive and drove transmission to zero in places like Hong Kong and Toronto and Guangdong province where the epidemic seemed to emerge and many other smaller outbreaks. And we did not see the virus recur in humans in the next respiratory viral season, the next temperate environment winter. And I do hold a candle without evidence, I admit, that perhaps we could accomplish the same here. If we can limit spread in communities and essentially wipe out transmission by the summer or late summer, if we succeed in this, is it possible that this novel coronavirus will not recur in the next season? Now, this is a lot more transmissible than SARS was, so I might be completely wrong, but I hope that we might be might be completely wrong. But I hope that we might

be able to be aggressive in our response to this particular outbreak and see if it's conceivable that we could drive it down to such low levels that there wouldn't be a source of global transmission in the new respiratory flu season. So that's the wildest speculation you'll get on the debate, I would say. Stan, just on that point there, would there not be reservoirs of the disease and countries in the developing world where they really do not have the public health tools to chase the disease down to eradication? Well, in an environment where they're simply not going to have a public health response, and I just came back from Africa just in early March,

and I visited a couple of very undercapacitated nations, some of the poorest countries on the planet, And they have extremely low testing capacity. They have extremely modest intensive care capacity. And one can expect the virus to run its course with high mortality. Whether the global travel bans that we're seeing limits that is yet to be seen. But it's plausible that for a different reason, transmission will be low in those countries because they will have saturated their high-risk pool of individuals, and they will pay a terrible mortality rate consequence for that

because of the underdeveloped medical capacity. So it may be for a different reason that we don't see transmission in some of these venues. So all of this is highly speculative. I just thought it would be interesting for your audience. Yeah, absolutely. So, John, we're going to give, as a person that kind of stimulated this debate with some of your thoughtful commentary in the media. Let's give you the last word.

I think that we're facing a very serious challenge. We have a lot of uncertainty. There's just too much at stake, both from the epidemic and the consequences and the measures that we're taking and unpredictable factors and some chaotic consequences if we try to speculate what would happen long term, like this fall or next year or who knows. five years from now. We just need to get it right this time. And I think that during this debate, we agreed, you know, I agreed with Stan in many, many points, but we need to get evidence on what this virus does and how many people it kills and how widely it spreads as quickly as possible.

I really have doubts whether our society, economy, lives at stake can allow having months and months of lockdown. We know that there will be severe consequences based on previous experiences of economic meltdown that really cost many, many lives. And in this case, it's not just one country, it's the entire world, and it's a situation that is very peculiar.

So if we have evidence, we can act swiftly, we can modify our strategy, we can optimize it, and we can be better prepared also for next time, And whenever that next time is, you know, this fall or 55 years from now, who knows, we will know how to get it right. And we will have responded in a proper way. Well, John Sten, again, this is the big topic of the moment. Both of you have brought clarity, insight, and hard-won experience to a thoughtful interchange and exchange of ideas.

So on behalf of the Monk Debates podcast, thank you very much for coming on the show. A million thanks. Our pleasure. That wraps up today's debate. I want to thank our participants, John Ionidas and Stan Vermon. You both give us a lot to think about. The Monk Debates podcast

is a place for civil and substantive debate on the big issues of the day. To listen to more debates on everything from climate change to religion, to geopolitics, to the future of human progress, visit our website, monkdebates.com. You can also find show notes on today's debate.

Thank you for helping us bring back The Art of Public Debate, one conversation at a time. I'm your moderator, Rudyard Griffiths. The Monk Debates are produced by Antica Productions and supported by the Monk Foundation. Redyard Griffiths and Ricky Gurwitz are the producers. The president of Antica Productions is Stuart Cox. Be sure to download and subscribe wherever you get your podcast. And if you like us, feel free to give us a five-star rating.

Thanks again for listening.