September 28, 2020
Florida Governor Ron DeSantis held a virtual roundtable on September 24 with Stanford University Professor of Medicine Dr. Jayanta Bhattacharya, Harvard University Medical School Professor of Medicine Dr. Martin Kulldorff, and Stanford University Professor of Structural Biology Michael Levitt. The following is a lightly-edited transcript of the conversation. Time stamps refer to this video:
DeSantis led off by asking Dr. Levitt whether there’s been a consistent pattern in how the virus has behaved: “We heard a lot early on about potentially runaway exponential growth of the virus. Has that happened, and what would you say about some of these models that were used to really inform a lot of policy in Great Britain and the United States, models like Neil Ferguson’s model from Imperial College, London?”
Levitt: “I’m not an epidemiologist. I come to this as somebody who looks at numbers, understands models, actually understands a lot of the biology… I understand the virus pretty well, and I got into this by accident early on. And understanding what happened earlier in China, it seemed to me that this virus was a virus with its brakes on. It didn’t seem to want to go very quick; it seemed to want to stop; it burnt out pretty quickly in Wuhan and Hubei… but basically my approach has been to simply follow the numbers, a little bit like a financial analyst would look at a market. He wouldn’t necessarily be a farmer in pork bellies, but he would understand the way the market worked by the numbers. And the numbers have been surprisingly consistent… perhaps with the exception of Iran, all the numbers have looked to me to make a lot of consistent sense and… I felt that a number of things were done very early on that were, I guess, unfortunate, like calling this a ‘novel’ coronavirus. Coronaviruses are not novel; we know them a lot. Common colds are coronaviruses, so this may be a new coronavirus, in terms of that we haven’t had this particular one before, but human beings do know coronaviruses.
“The other was that the initial death rates were quoted by essentially averaging very hard-hit areas with much less hard-hit areas, so in the city of Wuhan, where almost all the deaths were, the death rate was about 4-5% per case. But in the rest of China, which is a much bigger area, it was less than 1%. So averaging those two things and saying it’s 3% isn’t really a good idea. As for the predictions… it turns out that people, for whatever reason, seem to like the idea of exponential growth, and certainly if i was investing money in a bank, I would love it to grow exponentially. The thing is that exponential growth for these virus models essentially means the infected person manages to meet uninfected people all the time… This is actually not easy to do. As a result, particularly for coronavirus, where there are many undetected cases, normally when you come to a new area, people are already infected, so it’s hard to infect them. So growing exponentially isn’t easy; I was surprised by the predictions made by the Imperial College group. Early on, it said that the case fatality ratio, the number of deaths per case, were 14%, whereas I never encountered any number like that in the data. And then, when I saw their models, I was just surprised at how large they were. I was also surprised by the fact that I did actually try quite hard to engage with them. I came to the conclusion that British scientists have their email permanently on vacation mode… but this communication didn’t seem to work. I eventually got through, and it wasn’t very satisfying. I basically said their numbers were a factor of 10 too high, and they said they were not, and I just gave up because, you know, they were the experts. But I still believed what I said.
“Overall, in terms of consistency, I think one of the remarkable things has been just how consistent the behavior of the virus has been. There’s two sides to an epidemic: there’s the virus, and there’s the people. And I think that people have been way less consistent than the virus. Now, that’s not surprising because viruses are actually very simple… we’re hearing stories about places that you would have thought would be total disasters having become fine. So I think that all the evidence so far is that this virus is behaving well… but past performance is not necessarily an indicator of what’s going to happen in the future… But certainly, in every situation we’ve seen so far, things have been pretty understandable.”
Herd immunity threshold
DeSantis: “What has been the infection threshold? I think you’ve identified, you’ll see the infections increase, and once that seropositivity hits, is it the 15% window? That once it hits there, you start to see it lose legs?”
Levitt: “It’s hard because seroprevalence changes with time… we don’t know what fraction’s infected… cases are very complicated because… a case in Germany is very different from a case in Italy. For every case in Italy, there would be 10 or 15 cases in Germany because of more sensitive measurement. On the other hand… the places that have been hard-hit, the number of deaths per million population is… most of them are around 700 deaths per million population… Some places, particularly in the northeast part of the United States and the northwest part of Italy, have been about 2 or 3 times higher than that… It’s also true in places that have done nothing, like Sweden, or cities that have done really nothing, like Manaus in Brazil… whether this is herd immunity or whether there were a certain number of people who were fragile and didn’t survive, or whether there’s some kind of natural saturation, I don’t know… Sweden was a relatively late epidemic in Europe. By the time Sweden was about halfway through, we knew that in Europe, most countries were stopping at about 600 per million, and that number actually was exactly what Sweden got to… I think this number will vary, and again the big puzzle is Japan, South Korea, China… these countries all have very small numbers, maybe 10 per million instead of a few hundred. We don’t understand that yet.”
DeSantis: “Jay Bhattacharya, you guys at Stanford were the first to look at the antibody testing… what you guys were able to show is that for every case that may be documented, there may be 10 or 15 times as many infections out there… Can you talk about what your research at Stanford showed… and what the implications are for a policy in terms of COVID-19?”
Bhattacharya: “I worked on several seroprevalence studies… The point of them is to estimate the number of people in the population that have been exposed or infected. Just checking for active cases provides an underestimate because many people who get infected don’t actually respond with a severe infection; many actually have no symptoms at all… Now there are 75 of these studies worldwide, and they tell a very, very similar story. There are many times more people infected than identified as cases… The mortality rate from the virus has an enormous age gradient. For the oldest people in the population, it’s severe; it’s somewhere on the order of 2-4 in a hundred mortality rate, whereas for the youngest people in the population, it’s less severe than the flu, in terms of mortality rate – 1 in 100,000 mortality rate, or even lower, for children… Evidence is emerging that the antibody studies… probably overestimate the mortality rate because there’s some fraction of the population that has immunity to the virus through other mechanisms, not just antibodies.
“There was a debate yesterday between… Dr. Fauci and some other folks in the government… actually, the scientific evidence that’s emerging is pretty clear, that there seem to be other mechanisms, such as T-cell-mediated immunity, that provide some protection to some fraction of the population. The antibody studies don’t pick that up… The CDC estimates that there’s 10 times as many… infections as there are cases, so if we apply that number now to the population, roughly 70 million people have been infected in the U.S. That probably is an underestimate, is my take on it… Of course, there’s great uncertainty around that number because it’s a population sample and not a count; in some sense, that’s really good news. 70 million people infected, and we have 200,000 deaths, which are really unfortunate, but the mortality rate from the disease itself is much lower than we saw in the early days of the epidemic, and I think communicating that clearly, that if you’re infected, it’s not an immediate death sentence… addressing that panic is really important, giving people the truth about what the numbers are actually telling us regarding how lethal the disease is… and then taking into account the sharp age gradient, where the older population faces more of a risk from this than younger populations do, is also very important, I think.”
DeSantis asked about the September 23 discussion between Dr. Fauci and Senator Rand Paul about the role population immunity plays: “I don’t think he was saying the virus is eradicated, but as more population immunity is built up, it has maybe led to that in all these places… People like Suneptra Gupta at Oxford, Gomes over in Scotland… they’ve looked at how the virus works in populations, and people posit the Asia results, partially because people from 2003 that had SARS-1, they still have an immune response to COVID-19… Can you just summarize what the state of play is on that?”
Bhattacharya: “One thing it’s very important to understand: antibodies rise after you’re infected… and then that declines over time… You’re not unprotected after you’ve had the antibodies decline… We’ve only seen 2 reinfections out of millions of cases worldwide, so it’s very clear that there’s some long-lasting immune protection… That’s not magic; that happens with many, many diseases… This other T-cell-mediated immunity will provide you a lot of protection, so you’ll only have a mild disease and not a severe disease… When things loosen up, you will see cases. The question is who gets those cases. If we protect the elderly, we limit the mortality, we limit severe disease, we’ve done a really good job. That, to me, is the crux of the… policy issue… A policy that sort of asks the young, who don’t face a ton of risk from this, and whose behavior doesn’t tend to expose the elderly because they don’t interact a lot with the elderly, I think is a mistake.”
Efficacy of lockdowns
DeSantis asked Dr. Kulldorff about lockdowns that were initially proposed to protect the hospitals. “What can we say about the efficacy of these lockdowns? I notice Peru had one of the most severe lockdowns, and I think they’re #1 in the world for per-capita mortality… Have [lockdowns] shown to be able to really reduce deaths in the disease, or are they just pushing infections out over a longer period of time?”
Kulldorff: “Back in March, it made sense to flatten the curve because we don’t want to overburden the hospitals, and I think that was a success in most parts of the world except in, I think, Spain and northern Italy. But if you do a lockdown beyond that, you’re sort of pushing the cases in the future… We have an enormous difference in risk by age, so everyone can get infected, but the risk for mortality is more than a thousand-fold difference in risk for the oldest people vs. the younger… Even in a country like Sweden where they never closed the schools, all day care and schools were open in Sweden from age 1 to 15 throughout the height of the pandemic there, and among the 1.8 million children in Sweden, there were exactly zero deaths from COVID-19…
“We have to do as well as we can, and a lot better than was done previous in many parts of the world, to protect the elderly, both in nursing homes but also the people who live at home or people who live in multi-generational families…. but children and young adults, they should be able to live life normally, more or less. They should wash their hands, and those kinds of things, but there’s no public health reason to close schools. I think these sorts of general lockdowns of closing schools, closing restaurants, or closing beaches or whatever, they actually have a detrimental effect on public health because we have less cancer screenings, we have worse outcomes from cardiovascular diseases, we have… mental health issues, there are more house evictions, and all of these are very serious public health problems that we are generating through the lockdown, and of course, it’s primarily the working class who is suffering from this. So in a sense, we are protecting very lower-risk college students and professionals who can work from home, while we are putting older working-class people at risk because they have to work. That increases the total number of deaths, so that’s not the smart public health policy to do here.”
Should lockdowns be off the table?
DeSantis asked whether general lockdowns should be off the table.
Kulldorff: “Yes, and the focus should be on protecting the elderly, and… the elderly have to be protected until we reach herd immunity. Herd immunity is not a strategy, so we will eventually reach herd immunity, either through a vaccine or through natural infections, or most likely through a combination of both. If we drag that on for too long, if that takes year after year, then it will be much harder to protect the elderly because they can’t self-isolate forever.”
Levitt: “Yes. A death is a terrible thing; it’s not as if a COVID death is especially terrible. If we could lock down with zero cost to anybody, then maybe it would be useful sometimes, but the fact is that it’s a treatment that can often kill the patient. Since… the vulnerable people are those who don’t have the luxury of working from home or having meetings by Zoom—if you’re working in a restaurant or a gardener or any kind of service, driving a truck, you have to be exposed—so I do think that we need to think carefully about how to protect the elderly. Protecting the elderly is something which is easier said than done because if a person is 90 years old, then even under the best of circumstances, there’s a fairly high chance of dying… I definitely think that… one needs to think about the whole picture. I’m sure that Jay, with his economics background, would understand that you need to basically balance everything together.”
Bhattacharya: “Another lockdown would be disastrous, Governor. At this point, we know that the benefits of the lockdown are small… all they do is push cases off into the future; it doesn’t actually prevent the disease from happening. And the costs are absolutely catastrophic, enormous. Schools are a good example of this. Schools are places where kids get, obviously, education, but they get nutrition through school lunches, school breakfasts; they get counseling if they have psychological problems, or abuse is picked up. People who don’t go to the hospital because they’re more scared of COVID than they are of cancer is a disaster. Parents who don’t take their kid in for immunization. Lockdown costs are absolutely catastrophic. We know that for a fact; there’s not uncertainty around that. Whereas we’ve learned from our experience over the last few months that the lockdown benefits are much smaller than expected. Places that have locked down—for instance, Argentina and Spain famously locked down very sharply, and yet they’re still seeing a sharp rise in cases. Lockdowns are not a way to eliminate the disease. Lockdowns have never in history eradicated a disease, and it will not do that in this case, either, and the costs are too high.”
Efficacy of non-pharmaceutical interventions
DeSantis asked how the panelists would characterize the efficacy of non-pharmaceutical interventions (NPIs): “Obviously, you have some draconian, Australia-style lockdown in some of these places, but then you also have business closures, some other types of mandates. What’s the evidence that they’ve really been important in bending the curve? And I just mention this because in the sunbelt, we saw prevalence increase within a week of each other, from Los Angeles to South Carolina, and different policies, different openings, they’ll say, oh, Texas did this, but then I can point you to Georgia, that did the opposite. And the epidemic curves are pretty similar.”
Bhattacharya: “It’s mixed at best. Things like hand washing, I’m fully in favor of, and there’s lots of good evidence, a long history. I want to distinguish a mandate to do certain activities, like a mask mandate, from people naturally engaging in protective behavior. When people feel like there’s some threat, some risk, they will automatically, naturally engage in protective behavior. In places like Sweden, we see social distancing, even without mandated social distancing because you communicate clearly to the public what the risks are, and people will take those actions on their own—versus a mandate that says we’re going to fine you or imprison you or something if you violate this, if you don’t engage in the particular behavior.
“From what I’ve seen in the empirical evidence, these mandates seem to be uncorrelated—like for instance mask mandates—uncorrelated with disease spread. You have places that have mask mandates go in place, and you see cases continue to rise. Mask mandates are sometimes put in place during the decline in cases, and people say, oh, look, the cases declined, but the cases were declining even before. The path of the disease seems… uncorrelated with the imposition of these kinds of NPI mandates… A better policy would be to communicate to the public what the risks actually are, at the moment, and let people make their choices. If you’re in a crowded area where you have no choice because you’re working there, masks make a lot of sense; you should put them on. If you’re outside riding your bike alone, what sense do they make? A mandate is this sort of blunderbuss policy that imposes costs… I’m using masks as an example; I think it’s true for lots of these NPI mandates.”
DeSantis asked Kulldorff about business closures.
Kulldorff: “I don’t think it makes any sense to close businesses for young people. If people in their 20s, 30s, and 40s want to go to the park or to a restaurant, like they have been doing in Sweden throughout, that’s a good thing, a healthy thing to do. The people who should be careful are people who are the elderly, and they should avoid crowds… I don’t see any problem with having businesses open.”
DeSantis then gave a “snapshot” of Florida: The number of COVID hospitalized patients has declined 73% since the July peak; the number of COVID-positive patients in the ICU has declined 70% since the July peak; emergency department visits for COVID-like illness is down to levels last seen in early June; admissions for COVID yesterday were one of the lowest since early June, but discharges exceeded admissions by 20% throughout Florida hospitals; hospital capacity is currently 24% of beds empty, 23% of ICU beds empty, and COVID-positive patients represent about 3.5% of all licensed beds. “I mention that because the initial rationale… was to prevent hospital overrun. There were models put out by Neil Ferguson, IHME, predicting tens of millions of hospitalizations throughout the United States; I think we’ve had about 600,000. Is there anybody that thinks COVID-19 represents a significant threat in terms of overwhelming hospitals in the United States?”
Bhattacharya: “It’s the opposite, Governor. I think a lot of hospitals around the country have faced financial difficulties because they’ve been empty. At this point, certainly not.”
Levitt: “I certainly would agree, but I think that we’re in the minority, worldwide. People are still locking down and engaging in behavior which is likely to be detrimental in the long run.”
Risk to the elderly
DeSantis then gave the CDC’s latest estimate of survival rates for COVID-19:
He added, “I would say in Florida the plurality of our deaths with COVID—and they are ‘with,’ because if you test positive it counts, it may not have been the cause—but of deaths with COVID, the plurality are age 85 and above… I think all of you have advocated mitigation policies focused on shifting infections away from the at-risk group, rather than suppressing society as a whole. Dr. Kulldorff, if you try to suppress society as a whole, is there an argument that could actually increase risk to the elderly population?”
Kulldorff: “Yes, there is, and it’s actually shown with mathematical models by Wes Pegden and his colleagues, because there’s a certain percent needed for herd immunity, and we don’t know what that percent is. But whatever it is, if there’s a lot of old people in that group, we’re going to have a lot of… death. So if we do nothing, that’s not good because then there will be quite a high proportion of the old people who get infected, but if we do the same thing for everybody, we will sort of push things out over time, but we’ll still have about the same proportion of each age group getting infected. So that doesn’t help the elderly, either. What helps the elderly is if the young take this very minimal risk and live normal life until there’s herd immunity, and when we have herd immunity, then the older people can also live more normal lives.” (38:20)
Testing and quarantining at colleges and universities
DeSantis asked, “How would that apply to the colleges and the universities? I know around the country, there’ve been some pretty significant interventions on the college students. I know they’ve done a lot of mandatory testing; I know they’re doing a lot of aggressive quarantining of college students; some colleges have even sent the students home, just on the basis of a positive test. How would you approach colleges and universities as it relates to COVID-19?”
Kulldorff: “I think they should operate almost normally, so the students should be on campus, and they should go to in-person classes. If they get sick, they should maybe stay in the dorm room until they are well, if they have a cough. They don’t need to be tested; I don’t think there needs to be any testing at universities… They should certainly not go home because then they are putting their parents, who are older, at risk, rather than their classmates, who are lower risk… The one thing I think we have to do with colleges is—there are some professors who are older, and people 60 and above are at high risk, so it makes sense for those classes taught by older teachers, old professors, 60-plus, that they should be done online. The students can go to the classroom and maybe there can be a TA there, but the professor should do it online. But for the rest, the colleges should operate more or less normally.”
Limiting social activities of college students
DeSantis: “Jay Bhattacharya, do you agree with that—in particular, I know some colleges and universities have put a lot of emphasis on policing social life amongst undergraduate students, trying to limit some of their gatherings… off-campus. Is that likely to be an effective approach?”
Bhattacharya: “No, I completely agree with Dr. Kulldorff. I saw, I think it was a CDC report, that said there were somewhere on the order of 50,000 cases in 37 universities open but only 2 hospitalizations and no deaths. The risk is low in this college population. Opening up so that they can act like normal college students makes complete sense. Why would you prevent that? And in fact, there’s harm on the other side of that, as well. In the early days of the epidemic, there was a very sad story at the Air Force Academy, where they sent many of the students home. The seniors they kept, and they required that they stay in their own dorm rooms, and 2 of the cadets committed suicide.
“There are severe mental health problems that come from the kind of quarantine, especially on young people. There’s data, again from the CDC, that say that 1 in 4 young adults, age 18-24, seriously considered suicide in June. These kinds of policies to essentially and effectively quarantine young people are unnatural and are going to result in psychological harm. I think colleges and universities have an obligation to respect that, especially given the fact that the kids themselves face so low risk from COVID. They face higher risk, I think, from the psychological harm that comes from the lockdown policies that many colleges have imposed.”
Kulldorff: “They also face a higher risk from traffic accidents.”
Testing and quarantine in K-12 schools
DeSantis: “Dr. Bhattacharya, how about applying what you just said to K-12 schools? Should there be a lot of testing?… There’ve been widespread quarantine of healthy students who may have been in the hall or on the bus with [a student who got sick].”
Bhattacharya: “We should use tests to save lives… Absolutely, a student that is symptomatic should stay home, just like they should stay home if they have flu-like symptoms or other symptoms… The main purpose of checking [asymptomatic kids] is essentially to close the school down, to create a panic and close the school down, I think. And the costs of that, as we discussed, are enormous, much more than some extra kids getting COVID, because… the risks of COVID to the kids themselves are lower. That said, there are, just as with universities, there are older teachers who face some risk. There, I think, we should work creatively to use our resources to protect them. Maybe pair them with younger teachers so the older teachers can help with curriculum support or classes online… The principle is let’s protect the older folks so they can do their work while, at the same time, letting younger people, who face very little risk from COVID itself and much more risk from the lockdown, do their work… Opening schools up is safer for kids than keeping them locked down and closed.”
Secondary transmission in schools
DeSantis said that Florida currently has over 1.2 million kids in in-person school now, but not much secondary transmission has been observed. “Iceland, they actually did a very creative study, where they looked at how the disease was transmitted between adults and kids, and they looked at some of the physical structures of the virus that was identified, and they were actually able to determine which way the infection was going. Can you summarize that?”
Bhattacharya: “The Iceland study… they sampled… like 12% of the Icelandic population… and what they did is they sequenced the genome of the virus to look for mutations… so if I infect you with the virus, you will, in principle, share most of the mutations of the virus that I have… you may have additional ones. So from that kind of evidence, you can figure out who infected who… and they found a very low rate of children infecting adults in their study. What’s striking to me is now that study has been replicated numerous times in numerous places. Children seem to pass the virus on to adults at lower rates than you would expect from your experience with other respiratory viruses. That’s really good news, right? Kids, in some sense, pose less risk to the teachers in the classroom than the teachers pose to each other in the staff room.”
Schools as vectors of spread in the community
DeSantis: “Dr. Kulldorff, you’d mentioned the 15-and-under in Sweden, the schools remained open during the height of their pandemic, and… recently… one of the other Nordic countries put out a joint statement with Sweden saying Sweden kept the schools open; we didn’t; Sweden was right… Is there any evidence that schools, K-12 particularly, 15 and under, have been vectors of spreading the disease throughout the community?”
Kulldorff: “There’s no such evidence, and the evidence is actually in the other direction… COVID is very different from influenza. If schools were a primary conduit of the epidemic, you would expect that teachers would be affected more than other professions, but they did the study in Sweden and found that the risk to teachers was the same as the average of other professions, so that means that there is no evidence that schools are particularly spreading this disease, and I agree with Dr. Bhattacharya that, if I was a teacher, I’d be much more concerned about being infected by one of the other teachers in the staff room than by the children.”
Social distancing and masks in schools
DeSantis: “Is it evidence-based for schools to mandate some of the social distancing for schoolchildren and wearing a facial mask during the school day in order to stop or limit the spread?”
Kulldorff: “I don’t think so. There are some things that make sense and don’t have a bad impact, for example if some of the lessons are done outdoors, being outdoors is good for many reasons, there’s never anything wrong with that. Making sure that the classrooms are clean is also a good idea for many reasons, and maybe it’s a good idea to avoid large school gatherings, with the whole school… in the same room. So those are very simple measures to take, in addition to ensuring that children with symptoms are sent home. But to do more than that, I think, there is no evidence that would lower the risk to anybody.”
PCR testing of asymptomatic people
DeSantis: “There’s a lot of discussion always about just general testing and PCR testing, whether you should test asymptomatic people, just symptomatic, contacts… Dr. Bhattacharya… the New York Times had an article about a month ago, looking at some of the test results in New York and in, I believe, Nevada and Massachusetts, and they found that the PCR tests are so sensitive that up to 90% of the positives were not identifying live, infectious virus… I know Oxford’s Center for Evidence Based Medicine said if you have such high sensitivity, there’s no guarantee you’re even identifying live virus.… One, what does that mean for some of the testing and the case numbers that we see, but then, two, it seems to me that if you test positive with no symptoms, with a very sensitive PCR test, and they can’t even tell you if you’re infectious, we’re quarantining, across the country, probably hundreds of thousands or millions of people who aren’t even contagious, and I think that obviously has a huge cost to society. Doesn’t seem to be getting a lot of discussion, though.”
Bhattacharya: “It’s a very important point, and actually Dr. Levitt’s a biologist… he can tell us all about the PCR technology, but the key thing about the PCR technology that I think is important for this discussion is that essentially you are doubling the genetic material, the virus, if it’s present. If you have a very tiny amount of the virus, or if it’s a viral fragment that’s not actually… what you’re amplifying is something that’s not going to cause any risk, either to you or to others.
“So you’re asymptomatic, you’re positive with a PCR, it’s not a false positive in a technical sense, but in a functional sense, it’s a false positive. Epidemiologically, it’s a false positive. I’m not going to infect you, even though I’m PCR-positive, because it took so many doublings to reach the point, that we can infer that there really wasn’t much genetic material for the virus present to begin with. You’re absolutely right to point out the cost of that when you attach it to a policy of contact tracing and isolation and quarantine. We effectively are quarantining people on the basis of PCR tests, a functional false-positive PCR test, where it will have no effect on disease spread because they’re not infectious and at the same time, will impose an enormous cost on them.
“There’s another follow-on cost to that, that it makes people less willing to cooperate with contact tracers because they know the cost. If I am contact traced and I’m asked to say who I’ve interacted with, I know if I say I interacted with my friends, they’re going to be facing the same thing, they might get quarantined. If it’s possible it’s a false positive, a functional false positive, then I’m imposing costs on them for nothing.”
Tracking disease with PCR testing
DeSantis: “Dr. Levitt, can you talk about PCR testing?”
Levitt: “Firstly, I agree with everything that’s been said before. It’s important to point out that PCR testing has never been used widely on this scale, and you can do a thought experiment about if, during a flu season 2 years ago, you had done PCR testing, you probably would have found that very large numbers of the population were flu-positive because, really, flu does get around a lot. We’re basically not experienced in what it means to track a disease by PCR; we’re also not experienced in what it means to track a disease by contact tracing.
“I think the problem with contact tracing for COVID and for all respiratory infections is that essentially you don’t get it by touching somebody; you get it by being near somebody, maybe being in the same room as somebody, and as a result, there are many, many different paths of contact tracing. Diseases like Ebola, you really have to get very close to somebody. I think it’s also true of the 2003 SARS… Contact tracing is expecting people to be wired together, whereas COVID is a bit like WiFi… I think there were a number of novel things here that seemed to make perfect sense and give people a feeling of empowerment, like contact trace, test everybody, but I think I felt from the very beginning that testing was… There are certain people who really believe that testing is the solution to everything, and I’m not one of them.”
Cycle threshold (CT) values for PCR testing
DeSantis: “With the CT value of 40, which is the standard, Oxford has looked at it, they found that you can really only be sure it’s live virus if you’re in like the 25-26 CT range. Should we be re-evaluating that and trying to do tests that are going to be more indicative… that you’re infected?… You can test positive for 3 months, according to CDC… How should we do that?… In the clinical trials, you have to have either 2 general symptoms or one respiratory symptom and then have a positive PCR test.”
Kulldorff: “Well, it depends on the context also, because if you’re testing college kids, for example, you don’t want to have a lot of false positives… or testing students… and doing a lot of damage to these kids, sending them home or closing schools. On the other hand, in a nursing home setting, when you’re testing staff or visitors, there it could make sense to have a more sensitive threshold because then it’s better to be safe than sorry.”
Defining cases by positive tests
DeSantis: “In past… diseases, did they ever define a case as one positive test without any clinical symptoms?”
Bhattacharya: “In medicine, there’s a principle: you don’t treat a number, you treat a patient, and I think we’ve made that mistake with COVID… You don’t want to… diagnose just simply on the basis of a positive test alone; you want to look at the clinical context of the patient and say how do I manage the patient…”
How the scientific community has responded to dissenting views
DeSantis: “What’s the [scientific and expert] community done right, or what have they gotten wrong and how open has it been to evidence-based critiques to some of the prevailing narrative?… Professor Gupta from Oxford, one of the top epidemiologists in the world at one of the top universities in the world, said that… they’re having a hard time getting [research] published because a lot of the journals don’t like the results… Have dissenting views been welcome? Have people been willing to re-evaluate their initial assumptions from back in March?”
Levitt: “I think that most of the scientific community didn’t pay attention until it hit home, and at that point, I think they became panicked like most of the general community, and I was disappointed that there wasn’t more… this is a hard problem, knowing how to treat a novel outbreak of any kind is very difficult, and you solve hard problems by having discussion… by working them out face to face… I think that looking at the numbers carefully… everything we’ve heard here, for example, in treating age groups differently, makes complete sense. The need to let young people interact with each other for social reasons and for herd immunity make perfectly good common sense, so I think there should have been more of that, and I was very disappointed… one of the real pluses of this meeting that you organized is that I feel that I can now consult with both Professor Kulldorff and Professor Bhattacharya… I do think there should have been much more openness and much more understanding that we can all contribute. I really felt that, in some ways, humility was facing a crisis, maybe self-induced by our reaction to COVID, but it required people to stand up and really try to make a difference, and I don’t think it happened very often. I think Stanford, for whatever reason, is quite well represented in this field, but I think a lot of places have not done their duty.”
Kulldorff: “As a public health scientist who has been working with infectious disease outbreaks for many, many years, I am absolutely stunned by the reaction of the scientific community, as well as the media, to this… Dr. Sunetra Gupta, I think, is the preeminent infectious disease analyst in the world, and until very recently, she has had a hard time having people listening to what she’s saying. You mentioned Dr. Heneghan also at Oxford, another infectious disease technologist who is favoring the age-targeted approach of protecting the elderly better, while I think the young live more normal lives. And among my colleagues, who are infectious disease technologists, there are many of us who, quite honestly, think this is the right scientific approach… Some are afraid to speak up… Most of the high-profile scientists have been not in the infectious disease outbreaks but in many other fields, and I think that, as a scientific community, it is something we’ll have to deal with for a long time, that there is going to be less trust, both in science and in scientists.”
Bhattacharya: “Very, very disappointed with the scientific community… also the press as well. There have been open calls by fellow folks here at Stanford to establish, in effect, a censorship board over open science, published in the New York Times. I’ve seen my colleague, Dr. John Ioannidis, one of the very top scientists, epidemiologists, infectious disease experts in the world, his videos that he’s done, suppressed. I’ve seen… respected scientists descend to attack in the ugliest ways. I’ve been trying to understand what is motivating it, and almost always, the complaint is that if you have dissent on this issue, you’re endangering the public… I don’t understand how having open scientific debate could possibly endanger the public. Science is not a mechanism of population control; it’s a mechanism for learning true things when you have a very complicated situation, and everyone in science gets things wrong… That’s why we have open scientific debate, to correct one another. That has fallen away in service of this idea that as a scientific community, we should convey a single message, so we get the entire public to do the set of things we want them to do. That itself is an error and has really poisoned the scientific debate… I think it’s going to take a long time to repair.”
Balancing COVID with other health problems
DeSantis: “When a pandemic hits, do all the other health problems in the country, in the world, all of a sudden stop? And if we’re doing things to address the pandemic that’s exacerbating those, obviously that’s something that’s very significant. In terms of looking at public health as a whole… is the way forward to have an open society with those protections in place for those who are the 65+?”
Bhattacharya: “Absolutely… there’s really no choice. We are not simply bags of germs infecting one another. We’re human beings that need many, many things to be healthy and happy. Public health, to me, has always been about that, about promoting all of that… To structure society simply as a way to limit the number of COVID cases is a mistake.”
Levitt: “Absolutely. Again, I think a holistic approach is the only one that’s fair. Otherwise, we’re ending up privileging one kind of problem to another… Actually, I’m amazed at finding two people who actually agree with me! It doesn’t hardly ever happen.”
DeSantis: “Has there been any place that’s had a true second wave, where once the disease has kind of saturated through the society, gone on a real legitimate curve, has it gone back up and spiked in any cases?”
Levitt: “I looked at this quite carefully recently and basically tried to divide each epidemic into two parts if I could. In other words, if the number of cases went up and they went down again and then went up again, if there was a minimum between the two mountains, that was a way of deciding there was a second part—whether it’s an outbreak or a wave doesn’t really matter. What was interesting was that the saturation we’re talking about, if it has been achieved in the first outbreak, then there could be many, many cases in the second outbreak in the same country, but generally almost no deaths. In Europe, I think, the only country that had deaths in its second wave was Moldova… [which] was not hit before. I did the same thing for the U.S.A., and again it was only places that had been partially hit in the first wave that got hit in the second wave… The number of deaths per case in the second wave was much, much lower—maybe a factor of 10 lower… The second wave that’s happened so far just seems to be filling in the places that haven’t reached the saturation point before. It seems very, very clear.”
DeSantis talked about Louisiana, where New Orleans was hit hard early, possibly because of Mardi Gras, but the rest of the state saw an increase along with the rest of the sunbelt, while New Orleans didn’t see an increase with the rest of the state. Then he mentioned a town in Idaho that got hit hard in March and April, possibly because of tourism and skiing, but when the rest of Idaho saw increases over the summer, that town wasn’t hit.
Open up society?
DeSantis: “Dr. Kulldorff… do you think, from a public health perspective, having an open, functioning society, with protections for the folks that are specifically vulnerable to this disease, do you think that’s the best approach?”
Kulldorff: “That’s the right approach, certainly.”
The group then took questions from reporters, which couldn’t be heard clearly.
Is “herd immunity” equivalent to doing nothing?
DeSantis: “Dr. Kulldorff, the question was about this idea of herd immunity being used politically, and I think it’s being used to say that you should just do nothing and just kind of let the disease do what it wants. I don’t think that’s what you’re advocating…”
Kulldorff: “Doing nothing would be terrible. That would lead to many unnecessary deaths among the elderly. So the key thing is that we have to do a better job… protecting [the elderly] through a variety of measures. At the same time, we should let younger people live their lives… in public health, we differentiate who are at the high risk and who are at the low risk, and we have to protect those at high risk. But doing nothing, that would be a terrible thing.”
How young people can help build herd immunity
DeSantis: “And I think you had mentioned Wes Pedgen… what they showed was, most of the transmission occurs in kind of that 20-35 age group, so as more of them get basically asymptomatic infections, the ability of the virus to reproduce really starts to decline, because that’s the most active area in society.”
Kulldorff: “Some people are much more social, with more contacts. So those are the ones who will spread the disease the most. So when we talk, for example, about herd immunity, we don’t know what level is required for the herd immunity, but it depends on who gets infected. If a lot of elderly people who live by themselves are infected, that won’t really help build herd immunity, but if the traveling salesman or the supermarket clerk or the taxi driver, if they get infected, then that really helps building immunity in the community. And it’s obvious that in many places of the U.S., we have immunity in the community already building up, and Florida is one example. Whether it has reached the level of herd immunity quite yet, that’s hard to tell, but it certainly is a lot of immunity in the community, so we’re well on our way to that point.”
Does herd immunity mean the disease is eradicated?
DeSantis: “There was the discussion between Senator Paul and Anthony Fauci… Herd immunity implies, I think, that the disease is done, but I think that the role that population immunity has played thus far in epidemics waning, it doesn’t mean that the disease is gone, but it’s been a big factor in driving the reproduction rate below 1 in a lot of these areas. Would you agree with that?”
Kulldorff: “Yes. And COVID’s never going to go away… it’s not going to be eradicated. So it will be endemic. Always new people are born, they don’t have the immunity to it, so in the future, I would expect children will get it when they are 1 or 2 or 3 years old, where this is not a serious thing, but I think the discussion in the Senate was about New York City, and certainly the reason why there are so few cases now is mostly because of immunity. Whether they have reached herd immunity yet, that’s uncertain. My guess is that they may have reached it in the working class areas, but when the rich people come back from the Hamptons and the Berkshires, then they’re going to hang out with each other, and then there’s probably going to be cases from that.”
Is herd immunity a strategy?
DeSantis: “When Dr. Scott Atlas was being hit, saying he’s advocating a herd immunity strategy, I think you’ve pointed out herd immunity is not a strategy. How would you respond to that?”
Kulldorff: “It’s a natural phenomenon that every epidemiologist agrees exists, which we will reach, sooner or later. So to call it a strategy would be like saying an airplane is using gravity as a strategy to land the plane. If you’re in an airplane, you’re going to eventually hit the ground, no matter what. So the strategy is, do you do a soft landing, so everyone survives, or are you going to do a crash landing, which is not so good?… It’s the same thing in public health: herd immunity is there; the goal is to minimize the mortality until we reach that stage, and the best way to do it is through a vaccine…”
DeSantis: “The goal of the vaccine is herd immunity, correct?”
Kulldorff: “Yes… herd immunity is a situation where those who are vulnerable—in the case of COVID, that’s the elderly—they can be protected because other people are immune…”
Should young people be mandated to follow social distancing rules and wear masks?
A reporter asked whether the recommendation that young people should live normally should include mandates for masks and social distancing.
Bhattacharya: “The evidence doesn’t suggest [masks] are particularly effective at slowing the spread of the disease. And what I have seen, also, is that these kinds of mandates cause a lot of social strife, people in conflict with one another, that, as a public health matter, one would want to avoid, if possible, as a policy matter. Advising people that there are places where some kind of mitigation would be useful: if you’re in a crowded place, yeah, it would make some sense, but just providing people the advice about what seems to work, what doesn’t work, the uncertainty around that, I think is the right policy. A mask mandate, as I said, I think the scientific evidence is that it doesn’t seem to work. Providing people the right data, the right information, communicating it clearly, not sowing panic, I think that’s the right public health policy here.”
What about masks in K-12 schools?
DeSantis: “A third grader—not probably a really significant vector, in terms of infecting other people, I think the research shows… not that it can’t happen, but certainly not a major portion—the mask requirement, to the extent schools do, in Florida it’s mixed on schools requiring it, but it’s for source control, we’re told. CDC has said no evidence it will prevent you from being infected and that they may be helpful for source control, and I know there’s a lot of randomized clinical trials that were done prior to this epidemic which would probably say even that is a little shaky, but nevertheless, it’s where we are—but for a third-grader, a mask mandate there, should that be a parent’s decision, should that be just something that schools don’t do, or do you think that’s a good thing for them to do?”
Bhattacharya: “I think for third graders, it doesn’t make a lot of sense to require masks. There’s a school of thought that if you use the mask incorrectly, you actually could make things worse, so you’re touching the mask because it’s uncomfortable, you end up touching your face, and for third graders, we don’t have any evidence at all that they work in slowing the spread of the disease. A trained surgeon wearing a mask in a surgical room, absolutely, they’re not going to touch their face, they’ve worked really hard to suppress that habit. It’s hard enough for adults… in a first grader… in that setting, the evidence that it slows the spread of the disease is non-existent, and I think it just causes problems; there’s not enough benefits to require.”
Reducing local restrictions
A reporter asked an inaudible question.
DeSantis: “We’re the most open large state in the country, by far. We opened at the height of the infections, when everyone was saying shut down the state. We didn’t do that. We actually opened Disney World—now, Disney could have opened earlier; that was when they chose—people were saying, oh, how could you do it? Well, what happened is Disney opened, and infections have gone down, hospitalizations have gone down… so really, the final thing is some of the local restrictions, mostly in southern Florida, but every business, from a statewide perspective, is able to function, and we want to continue to do that. We also have the ability—we’ve done a lot on long-term care and nursing homes—some of the things, though, that we’ve learned is, ok, we didn’t allow visitors because we didn’t want to allow the disease to get in, but when you look at health holistically, that’s really negative for some of these folks, who need to be with family. So we’ve opened that up for visitation, we’re going to look to continue to do that because their health and well-being apart from corona is very, very important. We also now have the ability with point-of-care testing… we’re going to get millions of those over the next couple of weeks, so we’ll now have the ability… you have a college student wants to go visit their grandparent… now we’ll be able to do that…” He said he favors providing people with information and trusting them to make the appropriate behavioral changes.
Fauci’s handling of the epidemic
A reporter asked the panelists’ opinions of Fauci’s handling of the epidemic.
Kulldorff: “One thing that’s important to realize is that infectious diseases are very complex. So there’s not one person who is an expert on infectious diseases because there’s the science–virology and immunology; there’s how we treat patients; and there’s the public health aspects. Dr. Fauci is a very eminent immunologist, so if you have questions about immunology or infectious diseases, he’s a very good person to ask those questions to. Don’t ask those questions to me because I’m not an expert in immunology. My expertise is in the public health aspects and how infectious disease outbreaks are detected and how they spread and so on. So different people have very different expertise within infectious diseases…”
Bhattacharya: “Dr. Fauci’s been involved in infectious disease control for a very long time. He is a preeminent scientist for a good reason; he is an expert. But in early February, March, we sort of put him on a pedestal to essentially give his knowledge about a whole range of things, some of which was in his control and knowledge set, and some of which was not. And I saw him a few months ago… where he very humbly said, look, I’m giving you my expertise, as an infectious disease expert, on how to manage this disease. I’m not looking at the broader policy context.
“We think about science like giving us all the answers, but that’s a mistake. What science does is it tells us if we do A, we might get B. It’s up to… non-scientists to make a decision: Do we want to get B if we know the cost of getting B are C, D, and E? Do we really want zero COVID? If you get zero COVID—I don’t know if it’s even technically feasible—we know that we’re going to have to destroy our society in order to get it. We’ll have to get rid of all of our freedoms; we’ll have to make sure that very few people interact with each other; essentially, it’s so high a cost that it’s not worth it. Science can tell us, here’s how you can maximize the probability of getting zero COVID, but it’s up to non-scientists to decide whether it’s worth it. You can’t put one person on a pedestal and ask them to make that decision for society. I love that I live in a democratic society where those kinds of decisions aren’t up to experts; it’s up to people deciding together through electoral processes what we value. I think that is important to remember: we shouldn’t elevate one person as the arbiter of all the right things to do on infectious disease…”
Evidence about masks
DeSantis asked Bhattacharya about Fauci’s statements on masks, referring to a March interview in which Fauci said masks may make you feel protected, but people touch their faces and possibly increase infections. “All scientists were pretty much saying that. Now many say basically mark of a good person, are you wearing it or not. It doesn’t seem like the underlying evidence has changed very much… what is the average person [supposed to think] when they were literally tweeting at you ‘Don’t wear a mask,’ and [I don’t think] the explanation that we want to save them for healthcare workers… really flies because healthcare workers aren’t wearing cloth masks… So something changed between March and probably about May or June; it doesn’t seem like there were any new RCT studies that had come out, though.”
Bhattacharya: “I agree; I haven’t seen a ton of evidence that suggests that… I would have expected to see a lot more study about the kinds of masks people actually wear, and I haven’t really seen that… It would be a really good idea because that’s something the public health community is saying we should do to keep ourselves safe or keep others safe… Checking to see if the kinds of masks people actually use, not the kinds that we prescribe them to use, do they actually work? I don’t think I’ve seen any studies that suggest that the typical mask that people use, that they use and re-use, often without washing them or whatnot, are those effective?
“I think people like masks because intuitively you think, ‘I am giving droplets out to you that might have the virus, and so it’s got to provide some protection.’ Intuitively, it might, but as a scientific matter, it’s still an open question whether they do or not. Often in science, we end up with results that are not intuitive; we’re surprised by the experimental results. I think this may be one area where… you can probably hear my reticence to weigh in because I don’t know of a ton of studies that definitely say one way or the other on this, and that’s actually a problem. I think there ought to be more if we’re going to create this into this talisman that we have to wear in order to be a good person.”
Denmark’s mask study
DeSantis: “So Denmark, they have completed, I think the only randomized controlled clinical trial that I’m aware of. It’s been done; they said it was gonna be published, I think by the end of August or beginning of September; still hasn’t been published. So I think that would be useful to get those results… But that was really the only one; most of the other ones were influenza, which I think would probably be a useful analysis, as well.”
Should a pandemic response be more about politics or policy?
A reporter referred to Bhattachary’s previous response and asked whether the response to a pandemic should be more about politics or policy.
DeSantis: “I guess what I would say is, these are fundamentally policy questions, which, you take into account scientific views about the virus, although I would note… when people say trust experts, there’s experts that disagree. And I think what often happens is there’ll be a narrative that’s set, certainly, in the press. They will find someone with a credential that buttresses their narrative, and then they will act like dissenting from that means you’re ignoring experts, when there’s experts on the other side just as credentialed, many times more so, who may disagree… Is this a policy response, or should you really be finding a health official, putting them in charge, and then having the elected official just simply defer on all these questions?”
Bhattacharya: “We don’t live in a dictatorship, and that’s a very, very good thing. I think the key thing is… it’s a policy question. If you think about what policy means, we consider a broad set of costs and benefits of a particular policy when we make decisions about it. We may differ on what those costs and benefits are, but we certainly, if we’re serious people, consider both costs and benefits. A lot of the discussions around lockdowns have focused mainly on the benefits, slowing down the disease spread, and have ignored the costs altogether. And emblematic of that is elevating public health officials; public health officials only care about COVID control, as if that should determine policy for all of society.
“In the United States, politics has to play a role; there’s no other choice, in some sense. It doesn’t have to play an ugly role; we can discuss openly what we value, and our elected officials can make decisions around that, and they bear the consequences for getting it right or wrong… I think that’s the only choice in a democracy. There’s no other choice. If we decide to cede that, what else are we deciding to cede? Elevating scientists to the role of sages who know best for everything about society, that’s a mistake, and that’s why I’m uncomfortable answering questions about Dr. Fauci: he’s said that he just cares about disease control—that’s what his expertise is, that’s what he’s been asked to do. We shouldn’t be asking him to do this broad policy decision-making; that should be left up to our elected officials, advised, of course, by the scientists on both sides, so you understand the uncertainty around what we’re telling you.”
DeSantis: “When you have an infectious disease expert on the task force, maybe you should also have an economist on the task force…”
How do we protect the elderly?
A reporter asked what protecting the elderly entails: should you mandate that any visitor get tested? DeSantis said Florida has been focusing on a symptoms-based approach and having visitors wear adequate PPE with appropriate distancing.
Bhattacharya: “I think testing can play a role, especially with these rapid antigen tests. The nice thing about them is they’re very, very, inexpensive, and they’re fast. That could play a very, very important role in protecting the elderly if we implement it right… Broadly speaking, you should use the resources you have so that you can protect the elderly… That’s the key idea… One very important thing is that many nursing homes share staff with other nursing homes; the same person working in Nursing Home A will work in Nursing Home B. So regulations around shared staff might be useful… I think this is a hard problem… What you pointed out, Governor, is true. I think to a large extent, I think Florida has been more successful than most of the rest of the country. Florida famously has a larger fraction of the population elderly, yet the proportion of mortality among the elderly population from COVID is lower than much of the rest of the country.”
DeSantis said the state has been underwriting bi-weekly testing of all the staff at nursing homes, and the positivity rate on that has been under 1% for over a month. He added that CMS has now sent guidelines for testing on a schedule that depends on the prevalence in the community.
Sanctions on university students
A reporter asked about sanctions that universities are threatening against students who go to parties above a certain number of people and mandatory self-isolation if students test positive. DeSantis: “If I were a student, I’d ask what the CT value of the test is, so I would know. What do you think about that approach?”
Kulldorff: “I think it’s terrible. I think that the young people should live close to normal lives, as long as they don’t invite the grandmother to those student parties, I think that’s fine.”
DeSantis: “What I would say is… I agree with the experts. Let’s protect the faculty members, let’s focus on the things that we can control–kind of policing them off campus, I just don’t think that’s likely to be effective. In terms of the testing, I think this is a huge problem. If you can get a positive test with no symptoms and the test cannot tell us whether you have live virus, I think it’s a big problem that you’re asked to isolate. It’s one thing if the test—maybe it’s a little less sensitive—says you have live virus; I’m totally fine with isolating under those circumstances. But no symptoms, CT value of 40, maybe picking up dead virus, and what? You just sit in your dorm for 2 weeks?… We’re looking at it, we’re talking to the FDA about it.
“I think if you don’t have symptoms, if that CT value is above 30, it’s very problematic… because I think you’re isolating healthy people; I think you’re isolating people who are not actually infectious. That New York Times article was astounding, that 90% of these cases… It got almost no play, which is odd… The New York Times is kind of the bible for the mainstream media, yet you didn’t see any play off of it, but that has such profound implications for how society is governing… If you’re at risk of infecting people, you need to stay home… But if someone tests positive and it’s dead virus from 2 months ago and they have 0% chance of infecting anybody, keep ‘em in a dorm room or whatever for 2 weeks? I think that’s a problem… I would recommend that they’re not doing that at 40 CT…”
Should negative tests be required for medical procedures?
A reporter asked whether going into a hospital, for a procedure, for example, should be contingent on having a negative PCR test.
Bhattacharya: “I think that depends on the infrastructure of the hospital. If you suspect someone has COVID, for instance, they’re symptomatic… you absolutely should take precautions… Let’s say I need an eye surgery. Do I need a negative PCR? I’m completely asymptomatic… No, I think the answer is no… because they’re very unlikely to be passing the infection on to people, and the people that are going to be treating them will all have PPE, all of them—effective PPE, much more effective than the general public… I can understand hospitals that might want to do it, but to require that that happen for every single person… The reason I say that is that there are costs to that. People will not get—we call it elective procedures, but they’re vitally important for health. So people will stop getting colonoscopies because they don’t want the COVID test. They’ll stop getting all kinds of procedures that are vital for their health… Is the benefit worth the cost? I don’t think so, in general.”
DeSantis: “I think it’s the way CARES is structured, that if you go in for some type of non-COVID procedure but you pop positive for COVID, that is a COVID patient for them, in terms of reimbursement… they report people hospitalized, being treated, and incidentally… In the height of the outbreak over the summer in Miami-Dade, at Jackson Memorial, 40% of their “COVID” patients were not in for COVID; they were in for something else, they got swabbed and tested positive. Many of them were asymptomatic. So I think it’s a good faith attempt, by and large, to prevent disease spread… but I do think there are costs… The delaying of a lot of the cancer screenings that we’ve seen through the country… It’s still not where it needs to be, and that’s not going to manifest itself in mortality this year, most likely; it may take 4 or 5 years to fully see this come to fruition, but it is going to be problematic… We’ve got a lot of empty space in the hospitals; if you need screenings, if you have heart problems, we can see you. You can get care. It’s safe…”
Negative health impacts as a result of lockdowns and panic
Desantis: “Obviously, we know COVID is causing death in folks. But I think we’re probably going to see some deaths that were a result of a combination of fear, combination of some of the changes in society, and those are, I think, deaths that aren’t being discussed right now; I think those are unfortunately things we’re going to continue to see. Do you agree that some of the effects of the panic and the fear and the mitigation are also gonna have negative health impacts?”
Levitt: “Without doubt. Even just economic downturns lead to extra deaths. So I think that all of these things will have an effect. Throughout all of this, we’ve been counting a life as a life, but certainly as a grandfather with a 17-year-old grandchild, I think his life is much more important than mine because I’ve lived my life, and he hasn’t yet…
“There are all these considerations that need to be taken care of; I think that what’s impressed me very much about hearing people who do public health, as both Professor Bhattacharya and Professor Kulldorff do, is they have a very nice, wide view. It’s not like we only care about COVID. They care about everything. And that’s what you need to do…
“There’s been a tear in the fabric of society… I think we’ve seen amazing polarization, and I think that maybe it’s a wake-up call, but it’s certainly worrying… I really feel that, as a society—it’s not the U.S.A., it’s Europe and other societies as well—I don’t think we’ve really shown our best side in this; I think the media has been irresponsible… acted very partisan, it’s been very, very difficult. I think we are going to see a lot of problems downstream. I’ve heard, for example, of very sad cases where children who have seizures, progressive insulin problems—if they don’t get treated, they become quite severely brain-damaged, and there’s probably thousands of such kids worldwide because of this… I also worry if, even during the epidemic, we didn’t see excess death that occurred coincidentally with COVID but was caused, perhaps, by people not getting treated for critical health issues like heart attacks and things like that.”
DeSantis: “Dr. Kulldorff, how would you weigh in on some of these other health effects?… You know a lot about Sweden, given your background there. There was the exchange yesterday with Dr. Fauci and Senator Paul about Sweden having lower per-capita mortality than the U.S., than Britain, than Spain, than Italy, Belgium, all these places that locked down, and Dr. Fauci’s response is, well, they have higher than the other Nordic countries, which I think for COVID is true, but I think if you look at the excess mortality so far this year, compare Sweden to the Nordics, I think it’s almost exactly the same. Do you think that’s because Sweden minimized some of the other types of fatalities by keeping their society functioning, is it a coding issue with COVID?”
Kulldorff: “It’s difficult to compare countries for a variety of reasons, coding and so on. And also within Sweden, there’s been differences, so Stockholm, for example, has a much higher rate than the rest of Sweden, even though the study was identical. So it depends a lot on who got it first. I mean, New York had very high rates, and that’s partly because they sent sick COVID patients back to nursing homes, infecting other patients. But it’s also because they were one of the first infected in the U.S. because they have a lot of international travel.
“So there are many of those things… around with who are mostly affected. Eventually, the excess deaths is what we’re going to look at, and the excess death in Sweden is much lower than the number of COVID deaths, so certainly there are reasons for that, also, but I think this collateral damage on other health is a really major problem because we don’t go to the doctor for the fun of it; we go there because we need help with treating a disease, with preventing death, and living a better life, health-wise. So when the number of visits to the doctors and to the hospitals goes down, there is obviously a negative effect of that.
“Now, some of those negative effects are immediate, like for example the increase in suicides; we see that immediately. But most of them are not immediate, and in public health we have to think not only about the present but also about the future. So for example, cancer screenings have gone down. Now, that doesn’t increase the number of cancer deaths this year, but somebody who will now maybe die 3 years from now because they didn’t get the screening instead of dying 10 or 20 years from now. So those things… we can’t measure those in terms of mortality right now, but they’re going to be with us for many years in the future, and I think that’s very unfortunate.”
College student bill of rights
DeSantis: “To go to your question about the universities, we’re looking at… whether there’s something we can do at the state level to provide some type of bill of rights for students, and I understand the universities are trying to do the right thing, but I personally think it’s incredibly draconian that a student would get potentially expelled for going to a party. That’s what college kids do, and they’re at low risk, and I just think that we’ve got to be reasonable about this and really focus the efforts on where the most significant risk is.
“I do think it’s very important that we do have the campuses functioning and kids back, and I think our great experts here—I don’t think either of their universities are actually open for in-person, so if you guys really want to have in-person, we’d definitely be able to find spots for you in Florida… We really believe the in-person instruction is very important, both from an academic and from a socialization perspective. So we are looking at that… and I will give our universities credit. They have not gone way overboard some of the ways these others throughout the country—I mean, some of these stories are just absolutely horrible… if i were a parent, to have a student treated the way some of those colleges in other parts of the country have treated them, I’d be none too happy on that.”
Easing restrictions in Florida
A reporter asked whether DeSantis was planning on easing the restrictions that were in place.
DeSantis: “We really don’t have very many restrictions… restaurants, we’re gonna do two things: we’re gonna preempt closure of restaurants from local, and this is evidence-based—we had an A/B test. Miami-Dade closed them at the height, when everyone was really panicking, at the beginning of July; Broward didn’t. Broward kept indoor dining. I challenge you to show me a difference in those epidemic curves. In fact, I think Broward probably went down… they’re both dense counties, they both had significant epidemics.
“So I don’t think that the closure of restaurants has proven to be effective. i get how you could potentially have spread there, but I also have to look at that, and I think that they’ve been able to use outdoors, but we can’t have these businesses dying, so they’re not gonna be able to be closed by locals any more, and they will be able to operate at the capacity that they’re comfortable with. So that’s gonna happen.
“And then with the bars…we obviously want them to just—I don’t necessarily blame them, but I think when you have situations where restaurants are saying hey, wait a minute, we’re doing all this and they’re not… many bars are operating, though, people forget. All they did was they started serving some food, but you still had bars throughout the whole state, except for the three southern Florida counties, but those are local restrictions, so that’ll be there…
“Limitations on capacity, like Disney, that’s self-imposed. I’m supportive of them going to greater capacity, and I think they should do it. The message is Florida is open; in fact, we were more open at the height than we were a month before the summer, with some of the theme parks… We’ve worked great with locals; we understand different problems, and we’ve given them a lot of latitude to do things that I personally wouldn’t have done, but I think that’s the way to do it—bottom up. At the same time, I think everyone in Florida has a right to work. Everyone in Florida has a right to operate a business. Now, there can be reasonable regulations on that, on a local level, but to say no, at this point, from a local perspective, I don’t think that’s viable. I don’t think it’s as much the State having restrictions as much as we may need to provide some level of assurances for people against some of the local restrictions that we’ve seen.”
Letting the evidence lead
DeSantis: “Let me just thank our guests for coming… I think these are really important issues. I think you guys have really tried to approach this from an evidence-based perspective. I’ve seen different writings and different things, and I think all of you, as new information comes up, I think you’ve always shown a willingness to re-evaluate what we’ve learned, and I think that’s very refreshing, to really let the evidence lead. In politics, you kind of reach a conclusion and then try to marshal whatever observations you can get to support the conclusion. In science, you really let the observations drive the conclusions, and I think that’s what you’re doing.”