A Conversation on Covid and Lockdowns: Drs. Prasad and Kulldorff

Vinay Prasad, MD MPH, is a practicing hematologist-oncologist and Associate Professor in the Department of Epidemiology and Biostatistics at the University of California San Francisco.  He studies cancer drugs, health policy, clinical trials and better decision making. He is author of over 250 academic articles, and the books Ending Medical Reversal (2015), and Malignant (2020).  He hosts the oncology podcast Plenary Session, and runs a YouTube Channel VinayPrasadMDMPH.  He tweets @VPrasadMDMPH.

Professor Prasad conducted this in-depth interview with Martin Kulldorff, Martin Kulldorff is a professor of medicine at Harvard Medical School and a biostatistician and epidemiologist at the Brigham and Women’s Hospital. His published work has been cited 25,000 times. He is  a primary author of the Great Barrington Declaration. He tweets @martinkulldorff. 

This wide-ranging discussion covers cell biology, virus mitigation, public health, lockdowns, and the choice between focused projection vs compulsory shutdowns and stay-at-home orders. 

Vinay Prasad:

All right, I think we’re rolling. I’m back in plenary session, joined via Zoom for a real treat. I’m speaking with Martin Kulldorff. Professor Kulldorff is a professor at the Harvard Medical School. He specializes in surveillance for infectious disease and other problems. Dr. Kulldorff, it’s a pleasure to speak with you this morning.

Martin Kulldorff:

It’s a great pleasure to be here with you. Thank you so much for inviting me.

Vinay Prasad:

Oh, well it’s my pleasure. I mean, there’s so many things to talk about with you. I mean, obviously there are issues of SARS-CoV-2 and Covid policy, which I’m going to be very interested to have you articulate your point of view on, and then the meta issues, I think, which is that when a society is faced with an unprecedented threat and responds in an unprecedented manner, I believe it is not only natural, but it is inevitable that there will be some professors who do not agree with the response as other professors. I mean, it could be any problem, it doesn’t have to be a virus, it can be anything on earth, that if you respond in an unprecedented way, people will disagree.

And then the question I have, the meta question is, well, how do we air those disagreements, how do we have those disagreements, how do we make substantive progress and seeing where we agree and disagree where there might be legitimate room for compromise, room to move in different directions, and what should that look like? And I worry about that, and I worry where we are. So it’s a pleasure to sit down with you. Let me first ask you if you might give listeners a little bit about your background. I have read somewhere that you were born in Sweden, which these days is a bias. So I wonder if you might tell about where did you grow up, where did you go to school, and how did you get to the Harvard Medical School?

Martin Kulldorff:

So I grew up in Sweden. I went to college there and then I came to the United States. I have a PhD from Cornell University. Then I worked at different places. I worked at Uppsala University for a while at the National Cancer Institute, and eventually ended up at Harvard. I’ve been there for maybe about almost two decades, and sort of by accident, I would guess. I was interested in the methods they have been developing, but it would be useful to collaborate more closely.

Vinay Prasad:

And you work closely with many of the Harvard epidemiologists who on the policy issues that you may not fully agree. For instance, you collaborated with Marc Lipsitch and other folks in that group.

Martin Kulldorff:

Actually, I’m a little bit different from most of the infectious disease technologists at academic settings, because most of my collaborations, they are actually with health departments, with state health departments. Some local health departments, like the New York City Health Department, as well as with the Centers for Disease Control. And they also interact with health departments in other parts of the world, because of those methods that have been developed, they are used by many different health departments. So they always have questions or issues or suggestions or ideas, so I have done a lot of interaction with people from different health departments.

Vinay Prasad:

I see. So I guess what you’re trying to articulate, if I may say, is that your space in this epidemiology surveillance of infectious disease is more of the pragmatic, practical side of things, your career has been sort of as a pragmatist, is that fair to say?

Martin Kulldorff:

Well, I work with practical problems. At the same time, I develop methods. So two sides of the same coin.

Vinay Prasad:

I see. But I guess the methods you’re developing are methods that will be implemented in the near term, these aren’t methods for the shelf, they’re not methods for publication, they’re methods that will actually be implemented by health departments ASAP.

Martin Kulldorff:

Yes. And sometimes they have some problem for which the methods don’t work. And then I develop… I adapt the methods to develop something new so that it will work for them. And that’s why it’s very valuable to interact with the health department, both for them, because they get the methods they need, but also for me as a scientist, because I see what the problems are and where the needs are.

Vinay Prasad:

Yes. And of course you see what happens when the rubber meets the road. So I’m wondering if you might talk about, prior to Covid, what were the most recent situations for which you developed methods, were they infectious agents, what were they?

Martin Kulldorff:

So for example, I worked closely with the New York City Health Department and their surveillance system for reportable diseases. So setting up a system where they monitor on a daily basis the cases of reportable diseases to see if there suddenly is an outbreak of, for example, salmonella. And I think it was in 2015 in the summer, there was a huge outbreak in the Bronx of Legionnaires’ disease. There were a dozen people, I think, who died, which seemed a lot then, but of course maybe today it doesn’t seem so many. But every life is extremely valuable, so that outbreak was detected through the system that we developed together with an automated system quickly detecting new infectious disease outbreaks. And so it worked there, and they use it for other infectious diseases and it’s used by other health departments around the world in a similar fashion.

Vinay Prasad:

I see. Reportable diseases salmonella, Legionnaires’ disease, and including some STDs are reportable, syphilis, for instance.

Martin Kulldorff:

Yes. Some of them are reportable, but then the methods also used for other diseases like cancer, for example, using cancer registry data, which is of course not infectious, so it’s not daily analysis. But they can still monitor cancers and do the surveillance for the cancers as well.

Vinay Prasad:

I see. Well, I guess a couple of years ago, I spent a great deal of time trying to get to the bottom of how SEER and the NCI actually project how many cases, incident cases, and deaths from cancer there are per year. And it was much more elaborate than I thought, I’ll be honest with you, yeah. It’s an extremely… It’s certainly not that we’re counting every case. We’re sampling a number of people and we’re drawing some extrapolations from that, and there are different methods in place to adjudicate death, for instance, death due to cancer versus death with cancer, from death from cancer, it was quite complicated. And we ended up writing a paper onto the Mayo Clinic proceedings.

Martin Kulldorff:

Yeah. Many things are much more complex than you think when you start.

Vinay Prasad:

Oh, Martin, no. Now if that were true, then certainly not everybody could make an Excel spreadsheet and then tell us what we should do for Covid policy. That’s what I see on Twitter. I see a lot of Excel spreadsheets. Okay, so let me fast forward to… Our time’s going to be gone before I know it, but I guess I want to talk.. Obviously we have to talk about Covid. So in March of 2020, the threat of SARS-CoV-2 was looming, it was actually… The history is a little bit different. The history is this: in January and February of 2020, some pundits went on CNN and they reassured us that SARS-CoV-2 is nothing to worry about.

Of course the flu is worse than Covid, just more cases every year of the flu than Covid. You should get a flu shot if you want to do something about Covid, don’t worry about Covid. The same experts of course did a real quick 180, quick 180 in March. What were your thoughts in March when you started to hear about the growing caseload and nations almost simultaneously within a two-week period in March all, based I think initially on what we heard from Wuhan, but then Lombardi, they all similarly reacted in the middle of March. What were your thoughts back then?

Martin Kulldorff:

Well, as soon as we saw the outbreaks in Italy, Northern Italy and in Iran, it was obvious to me that this was going to be a pandemic that was impossible to stop. It was going to be a worldwide pandemic, because it had reached Italy in Iran under the radar. There were already many people who were severely ill, so it was obvious that this would engulf the whole globe eventually. And I think that was probably maybe in February, so that was certainly before March. And then I was worried about 10 minutes, because then I looked at the data, the very early data from Wuhan, and I saw that there was… At that time, we didn’t know what the infection fatality ratio was. So we didn’t know how many people would die among those who were infected.

But from the Wuhan data, we could actually get a really good idea about the relative mortality by age. And already then it was clear that there was more than a thousandfold difference in mortality between the oldest and the youngest, because there was no reason to believe that the exposure between the ages would be very different, because nobody knew about the virus in Wuhan then. So everybody would go back to normal life.

Vinay Prasad:

I see. So what you’re saying is that just simply by virtue of the age with which deaths occurred, you would already be inferring that there’s a steep age gradient, because exposure [crosstalk 00:09:38].

Martin Kulldorff:

Yes, that was clear already back then. So I’m a father of three children, I’m a single father. And as the parent, the thing you worry the most about is not yourself, but the children. So I knew then that my children would be safe, and that this was not dangerous for them. It was clearly dangerous for older people, and we didn’t know exactly how dangerous it was for the people in the middle, but at that time it was very clear that it was not dangerous for children. So then I wasn’t so worried anymore, because I’m mostly worried about my kids than anybody else.

Vinay Prasad:

I see. And I guess… And the simple fact is, too, I mean, if you’ll permit me, what you’re saying is that if this virus were equally lethal in children, you would have expected to see reports from Wuhan of many, many child fatalities. You did not see that, you saw many, many fatalities in the eighties, the seventies, and some of the sixties. And from that you inferred, this virus has been spreading unchecked. The probability it’ll infect any person of any age is roughly equal, and the fact that the deaths are occurring disproportionally in older ages tells me there’s some steep age gradient here in terms of risk of death. And thankfully, unlike other respiratory viruses which may disproportionately kill children, this is not one of them. That all went through your mind very quickly.

Martin Kulldorff:

Exactly, so that was my conclusion. And then I was surprised that this was not utilized this fast. So people were talking about down the road, back in March, they were talking about closing schools instead of protecting nursing homes. And I was a little bit surprised and shocked, because to me that was obvious. And then I tried to share my thoughts on these things, and I failed to do so in the United States. Even though I have spent a couple of decades working on infectious disease outbreaks, I work I think at a reasonably respectable university, I was unable to publish these thoughts about the age gradient and what was the right approach. That’s not a hundred percent true, because that’s true in the US, and I failed the UK also a little bit. But in Sweden, I had no problems. In Sweden, I published three op-eds in the two major daily newspapers, so in Sweden it was not a problem to make my voice heard, but in the US it was impossible, and that surprised me greatly.

Vinay Prasad:

Well, I see. Well I’ll come to that, I have a little theory as to why that might be the case. But I guess what you’re telling me is, I think, it is difficult for people who observe you to say something like you would lack the credentials to comment. I personally don’t care for that line of argument, I think it’s always better to argue the merits of the argument, but in this case, I think you’re making a meritorious argument and you certainly have been in this space for a long time. And yet you’re facing extreme difficulties in publishing, that’s noteworthy. The next thing I wouldn’t want to ask you was, I’ve gone back and I’ve read a lot of the documents from the George W. Bush era about how society ought to deal with inevitable pandemic. A pandemic was… to some degree it’s expected that there would someday be a pandemic.

Martin Kulldorff:

Correct.

Vinay Prasad:

Right, there’s no surprise there. Everyone knew that was coming. Okay, when I go back and I read the documents, people… Peer-reviewed publications, and even some of these white papers that existed back then, there were certain restrictions they thought would be untenable. And among those restrictions, I think the lockdown of a free society, they believed would not be… You wouldn’t be able to do it. I mean, they believed that the US is different than Wuhan. In Wuhan, you can see a picture of somebody welding a door shut. You can have a center in Wuhan that says anyone who tests positive for SARS-CoV-2, you’ve got to live here for 14 days, quarantine yourself in this centralized location.

Those sorts of interventions we can’t even do. I mean, not that we lack political will, it’s just that the nature of this society is a society that will not accept those interventions. And yet in March, middle of March, we had discussed… And in fact, I mean to some degree they were different mandates, it varies very widely, shelter in place, nonessential business closure, but all under the heading of Tony Fauci’s “hunker down” slogan. What did you think when this was the response? Were you surprised that we were pursuing it, I guess is my question.

Martin Kulldorff:

Yeah, so I think the approach to the pandemic goes against the long established principles of public health in many respects. So I was actually stunned about these lockdowns, because it was clear to me, and I think it’s obvious by now that when you have a pandemic, lockdowns cannot work. It can temporarily flatten the curve, and that makes sense, you don’t want to overburden the hospitals in a short time, but it can never suppress the thing. And I think what happened after the spring, because it went down in the summer. So I think many of the lockdown proponents thought that it was the lockdowns that had done that, and that we were in the clear. But to me as an infectious disease [expert], it was obvious that this was going to come back. Not how much exactly, but it was clear that it’s going to come back.

So that’s why in October, I met with professor Sunetra Gupta from Oxford, one of the preeminent infectious disease [experts] in the world, professor Jay Bhattacharya from Stanford to write up the Great Barrington Declaration, which is the one-page proposal for using focused protection, which is very much in line with all those prior pandemic preparedness plans that had been prepared, and so there’s nothing novel or new in what we proposed in that one page,but it was important that we didn’t redo the same mistakes, when the second wave came back. And at the time, we were sort of derided that if the lockdowns were strong enough, nobody wanted to do lockdowns, then there was no need for it. But it only took a few weeks when people were starting to talk about lockdowns again. So it was obvious I think, to me and my colleagues, that there would be another wave coming. And unfortunately, when people thought that the lockdowns and that masks and that contact tracing would be able to suppress it and control this pandemic, I think that was a very naive belief. But in believing that, they thought that that would also protect the high-risk older people, which it didn’t do. And that’s what we have seen, we have seen enormous mortality among the old. So [crosstalk 00:16:56]

Vinay Prasad:

Let me ask you this question-

Martin Kulldorff:

Because they thought that it would work, there were not implemented basic well-established ways to protect the older high-risk people in a focused manner, at nursing homes, et cetera.

Vinay Prasad:

There’s I guess … I think, books will be written about some of the errors made around nursing homes, obviously. Including failing to invest in paid sick leave for people who work there, failing to have appropriate PPE provided, failing to prevent the same person from going to multiple nursing homes, failure to, if somebody is sick with SARS-CoV-2, sending them back into the nursing home like a cruise missile. This is just … defies any sense.

Martin Kulldorff:

Exactly.

Vinay Prasad:

Yeah, okay. So we’ll agree wholeheartedly there. And I think that this is one of the things that people miss, is that in … And I’m eventually going to get to this part, but I think to some degree, that you have been demonized and criticized and said all these things. And I’m going to ask you about some of them, but I think one thing people miss is that the person you may be demonizing because you disagree with them about some portions of the argument, may also be offering very legitimate, constructive suggestions for other portions.

For instance, all along, I think even your most ardent critics will concede to you that many of your suggestions around protecting nursing homes, are indisputably correct. I think that’s … Even if they criticize you on other aspects of your ideas. But let me come to this, on the lockdown. I wonder if you might concede, or if you believe it, or maybe it’s not the case. But a lockdown is not like taking a baby Aspirin. It’s not the same intervention every time you take it. It’s not the same for you as it is for me, what an Aspirin will do in my body. The lockdown depends on so many factors. One, when you talk about a Wuhan lockdown, they’re welding doors shut. Okay, that’s like taking 55 Aspirin.

I don’t know, that’s a strong dose of something. When you talk about a US lockdown, it’s something in between. And the lockdown also depends, I think, on the seeding conditions. In the US, if we start with a baseline of 50,000 people are infected and you lock down, and some tiny fraction of people are going to be cheating and going and meeting anyway. Versus in Australia, hypothetically, I don’t know the answer, but what if the seeding condition was 300 people were infected, 1,000 people were infected, or some difference in the seed. The seeding load may have something to do with whether or not the intervention is effective. Would you … is that even theoretically possible? How do you think about that?

Martin Kulldorff:

It is. So once it has come to a country, it’s sort of hopeless to suppress the disease. So you can only sort of drag it out for longer.

Vinay Prasad:

But you say that, but what about Australia, New Zealand? Perhaps, if there’s so few cases, maybe they can drive it to zero?

Martin Kulldorff:

Yes. So they started their lockdowns when they had few cases, but the key thing that they did, that made a difference …

Vinay Prasad:

Okay.

Martin Kulldorff:

That was very smart of them, and that was to place themselves in the Southern Hemisphere, when this outbreak started. Because we now know that there’s a big seasonal gradient. So, the herd immunity threshold is very different in the winter and the summer, it’s much lower in the summer. So, the Northern Hemisphere had a hopeless situation, because the first cases came in December, and then it sort of grew and grew. But this was during the winter season, when it spreads a lot. But for New Zealand and Australia, it was in the summer season. So it was much easier for them, they had fewer cases to start with. And then, they had the summer season with the much lower herd immunity threshold, so they were actually able to suppress it. And then, once they had done that, they closed the border. And required, I think, two weeks of quarantine for anybody coming in.

Vinay Prasad:

And they’re good about it, unlike other … They’re quite good about it, my understanding is, about that quarantine.

Martin Kulldorff:

Yeah. And since they are both islands, I guess Australia’s a continent, but they sort of have an island situation. So that it’s even harder to sort of sneak in, in some ways. But despite that, there were still more cases that did come in, so they had to do local lockdowns throughout. So I think that’s the difference, between the Northern Hemisphere and the Southern Hemisphere.

Vinay Prasad:

But I guess … I guess it’s a philosophical … I guess it’s an empirical question that someday maybe we’ll know the answer. But do you believe that under any circumstances, it’s possible the lockdown works, or do you believe under no circumstances it could work?

Martin Kulldorff:

Well, I guess it would depend on the disease.

Vinay Prasad:

Okay.

Martin Kulldorff:

But for a pandemic that spreads like COVID, it was hopeless in the Northern Hemisphere, for sure.

Vinay Prasad:

Okay. Okay, I don’t dispute that claim. But I guess, I don’t know. I guess I’ll be honest, my take on it is, I don’t know what the effect size is, of lockdown. I certainly don’t. I think we’ll get a lot of papers in the next decade that try to probe it. To me, I think it’s conceivably possible that, under some circumstances, it has some effect size. Obviously, the lockdown that we did in the US, in a lot of ways, it was a silly intervention. For instance, we were strictest about it in the whole nation in a short period of time, even though some places in the nation had no problem at all. And we were quite strict about it there. And then they eventually fatigued, and went back to doing certain behaviors. And the moment they fatigued, they eventually got the caseload there. And the degree to which we did it, obviously, was as much as we could do it, in this country, which is not welding doors shut. So I guess I have a lot of uncertainty. I guess I don’t know the answers.

Martin Kulldorff:

It’s not that lockdown doesn’t have an effect on the disease and the spread, because it does.

Vinay Prasad:

It does, okay.

Martin Kulldorff:

But for example, in the US, we locked down the laptop class. The people, the professionals, the lawyers, the bankers, the generalists, the scientists and so on, who can work from home. And who can then receive food delivered from the grocery store, so the Uber drivers will take it from the restaurants. But the working class, the workers, they still have to work, because we have to eat and we have to have electricity to our homes and so on and so on. So it’s impossible to lock down everybody 100%, unless maybe for a day or two. But you cannot do that. So you have to have society operating, otherwise we will starve to death. So what happened was, in the US, we did a lockdown that benefited the professional class.

And we can see that, for example, there’s data from Toronto but also other places, that the wealthy neighborhood in Toronto in the spring, and the same is true, now in the second wave, but in the wealthy … In the beginning, it was sort of increasing about the same. And then, when they did the lockdown, it sort of flattened out in the wealthy neighborhoods, but in the less affluent neighborhoods it has spiked. And then eventually of course, it came down because there was more immunity.

Vinay Prasad:

Yes.

Martin Kulldorff:

So it is possible to sort of protect a certain group of society, by having them locking down. [crosstalk 00:24:36] But it’s not possible to do it for the whole population, because we have to have food and so on, society has to operate. So what we did with the lockdown, we put the burden on the less affluent, on the working class. And especially, on the inner city working people.

Vinay Prasad:

Yeah. And I think the data that you’re citing is data I’ve seen Stef Baral present, I think he presented it in that BMJ forum. Which shows rather convincingly that lockdowns kept virus out of rich neighborhoods and unfortunately, didn’t keep it out of people who had to do essential work, or who need a paycheck to make it to the next paycheck. But I wonder if you might … And I think Stef has put it this way rather nicely, which is that, if one were to stand back and look at the things we did in the United States, one would see a set of interventions that is primarily concerned with protecting wealthy people. That we’re more concerned about mask mandates when you run outside, than we are with providing paid sick leave to people who work in a kitchen so if they have fevers, that they could potentially get paid and not have to go in. All these sorts of just discriminatory and classist kinds of interventions.

Martin Kulldorff:

Yeah, that’s the one thing actually that Sweden did right. Because, very early during the pandemic, they changed it. It used to be that you only got sick leave after the second or third day of being sick. That was sort of so that people won’t abuse the system.

Vinay Prasad:

Yes.

Martin Kulldorff:

But when the pandemic came, they did very quickly change it so that you got pay even from the very first day. I think that was a very smart move to do. Because that of course encouraged people, if you have a cold or a fever or whatever, or a cough, you should stay home.

Vinay Prasad:

Okay, now I-

Martin Kulldorff:

That’s the one thing that … that’s one way. And of course, that’s especially important in places where a lot of older people work, or where a lot of older people are, like nursing homes. But it’s sort of a thing that we should do generally, in a situation like this.

Vinay Prasad:

I agree with you. I just can’t see anyone dispute the claims that we would have done a lot better off had we provided resources to protect very vulnerable people, particularly people in nursing homes, which still account for a tremendous amount, a disproportionate amount of casualties in this country. I think, the people who disagree with you, the place they’ll disagree with you about is whether or not, and to what degree we could have had society functioning normally. I think that’s the point of disagreement, but the point of agreement that I think that is getting lost in the heat of the moment is that everybody, I think, should feel strongly that you can protect the vulnerable people. Let me ask you this, Martin, because I want to get to the Great Barrington Declaration and talk about the culture of science.

I guess, and forgive me for asking, it’s an impudent question, but I guess my question is, are you an extreme right-wing libertarian or not? I’m not even saying that that is a wrong thing to be. I think there are in fact good people who identify as libertarians. I personally don’t, I identify as a progressive political left, close to Elizabeth Warren. But I’m curious about your own, because you’ve been … it’s always something that people hang around your neck and I get the feeling that it’s not true. But I’m just curious, where do you fall on the political spectrum? Are you on the right, are you a libertarian?

Martin Kulldorff:

So the Swedish government, I think did the right thing in the spring, not only with the sick leave, but also for example, by keeping all schools open and daycare from age one to 15. So I very much supported keeping the schools open and never closing the schools. Now, Sweden has a socialist government, I also support the focus protection study that the scientists have done in Florida, and he’s (DeSantis) of course, a Republican. So I guess, the answer to your question is that in Sweden, I am a left wing fanatic, socialist. And in the United States, I am a right-winger. But in a way, I think … that’s just with Covid. In a way, I think the question is a little bit dangerous.

Vinay Prasad:

Yes, okay.

Martin Kulldorff:

Because, as a public health scientist, it’s important to communicate with everybody.

Vinay Prasad:

Yes, I agree.

Martin Kulldorff:

And I care for the life of everybody, whether they are socialists, or right-wing libertarians, or left-wing libertarians, or whatever. I care about the lives of everybody, and the health of everybody. And, if you want to communicate a message in a crisis like this, I think it’s not wise of public health scientists to mix their public health messages with their political views.

Vinay Prasad:

Yes, I agree.

Martin Kulldorff:

If I were to write tweets, and half of them are about the pandemic and half of them are my political beliefs, whether they are to the left or the right, I’m going to, basically, turn off half the population. And I don’t think that’s the right approach to public health. Of course, anybody should be welcome and encouraged to express what their political beliefs are. But I don’t think in my case, my political beliefs are very useful for others to know.

Vinay Prasad:

I see.

Martin Kulldorff:

But I do think I know something about public health, so that’s the message I want to get out. So for the time being, I’m sort of putting my political views aside. And if you go back to my history and that, you can find out what they are.

Vinay Prasad:

Okay. [crosstalk 00:30:32].

Martin Kulldorff:

If you’re an investigative journalist. But for the time being, I want to just put those aside and focus on the public health issues. And also, I have that as a principal, to talk to any media, versus left or right.

Vinay Prasad:

Yes. [crosstalk 00:30:50]

Martin Kulldorff:

I have written for the Wall Street Journal, who is on the right. I also had an interview with the Jacobin Magazine, which is one of the most left-wing socialist magazines in the US.

Vinay Prasad:

Yes.

Martin Kulldorff:

And same in Sweden, both the left and the right and so on. So I think … I don’t decline to communicate with the media because of their political views, because I think the public health message has to go out, no matter what.

Vinay Prasad:

I agree with you. And you’re preaching to the choir, because, I don’t know if you know, I’ve written about this a few times. Which is that I think that many people may be tempted to turn their Twitter feed into a mix of “masks work, hydroxychloroquine is unproven, vote for Joe Biden.” The more you do that, the more you specifically endorse specific candidates, you become a partisan figure, even unbeknownst to yourself. And you ultimately erode your credibility I think, with the large swath of people, who may otherwise see the wisdom of what you say, but identify you too much with that label. But let me put it … Let me ask you the question in a different way, because I guess I’m not so interested in your political beliefs, right? If I’m perfectly honest, I’m interested in one question, which is, if somebody said in March of 2020 to you, Martin, “We want to pass a federal bill and the federal bill will provide $200 billion of funding for one purpose and one … “

The federal bill will provide $200 billion of funding for one purpose and one purpose only, which is if somebody is impoverished and they come down with a fever and they feel sick, they can dial this hotline. With this $200 billion we’re going to use federal money, they dial this hotline, the hotline says, “Look, we got you covered. I know you don’t have a lot of money, I know you’re trying to make ends meet paycheck to paycheck. What we’re going to do for you, and you have a fever, we’re going to make sure you’re whole. We’re going to pay your paycheck. Two, we’re going to have you come out here. If you’re with a family, you got seven people in your household, we’re going to find a hotel for you in the area. We’re going to bring your meals to you. We’re going to make it easy for you. We’re going to give you a little bit of a check and we’re going to keep a close eye on your loved ones, and we promise we’re not going to involve immigration, if there are any immigration issues. We’re not going to make your life difficult. We’re going to make your life easy.”

If somebody said we’re going to take $200 billion in federal funds and pay for this service, a real public health service, would you be opposed to that service or would you be a supporter of that service in March, 2020?

Martin Kulldorff:

I think having paid leave for people who were sick was a very important thing that Sweden did, and I think it would have been important to do in the US. Whether the federal government should do it or the state should do it, that’s political rather than a public health issue. But I think also as part of the Great Barrington Declaration, one thing we have there is that to protect older people in multi-generational homes, which are often in less affluent families, it’s important to do that so that, during the height of a pandemic, that they can be isolated, and sometimes they maybe can move to a brother or a sister and isolate together, which might be the best way to do it. But if that’s not possible, we mention that making some of those empty hotel rooms available for that, for older people who had to, for a short period of time, separate from the children that they were living with in a multi-generational home. That would be a very good strategy.

Vinay Prasad:

In other words, I got you down on record as saying that you support the use of government funds to pay for services such as the ones described.

Martin Kulldorff:

I think, in a pandemic, the government has to spend money to make sure that people are-

Vinay Prasad:

Okay, there you go. There you go, Martin. There you go, Martin. You’ve answered my question. I think I’m satisfied with your answer, because I think that that is something your critics have unfairly foisted upon you. That you, for some degree, I think that they would allege, you do not believe the government should spend money on resources. But the fact is you do believe that the government ought to spend. I’m just trying to clarify in my own mind. I think my belief is, yes, absolutely, they ought to do it. I’m hearing from you that you believe that’s reasonable and part of a public health strategy.

Martin Kulldorff:

The government should keep the schools open and that’s [inaudible 00:35:10].

Vinay Prasad:

[crosstalk 00:35:10]. Yeah.

Martin Kulldorff:

But also protecting the oldest, not only about nursing homes. For example, in schools, the children are not at high risk because for them Covid is less dangerous than [inaudible 00:35:29]. Not that they can’t be infected, but in terms of mortality. Children do not die very much in France, but the risk is even smaller for Covid. In Sweden, they kept the schools open. The 1.8 million children ages 1 to 15, there were exactly zero deaths during the spring during the height of the pandemic.

Vinay Prasad:

According to the New England Journal of Medicine letter. Yeah.

Martin Kulldorff:

Sweden didn’t even use any masks in schools, no social distancing, and they didn’t do any testing. The teachers were less at risk than others. But for teachers above age 60, they are a little bit of increased risk. Not as high as the 70s, so it’s very reasonable, I think, to arrange that the older teachers can stay home and not work, provide in-person teaching.

Vinay Prasad:

Yes.

Martin Kulldorff:

But that’s no reason to close the schools, but you should use the resources that you have in the schools to make sure that those older teachers do not have to work in person.

Vinay Prasad:

Yes. The one thing I wanted to pin down was that, this issue of resources, I think it’s an important issue. The next thing I want to talk about is the schools. I think you’re right. The letter you’re quoting, isn’t this [Elude Vixen 00:36:40]? Who is it? What’s his name?

Martin Kulldorff:

There’s actually two things because the Public Health Agency of Sweden published a report in, I think it was early July, where the data was very clear that there was no childhood deaths, only a few hospitalizations, and that the teachers were no higher risk than the average other profession. What [inaudible 00:37:04] did was to formalize that, publish it in New England Journal of Medicine, doing certain adjustments for age and stuff like that. It was more of a solid scientific analysis. The early data from the Public Health Authority in Sweden were more raw numbers, but they were still very clear because zero deaths is zero deaths whatever adjustments you do.

Vinay Prasad:

That’s something that people point out about the vaccines. That if you get the vaccine, there’s been nearly no hospitalizations or deaths from SARS-CoV-2. Just to point out on this letter, this is a letter of 1.75 million kids in Sweden between March and June of 2020. They attended school, there was no distancing, there were no masks, and I think what it shows clearly is there’s 15 cases of people with severe multi-inflammatory syndrome in kids requiring hospitalization out of 1.95 million, which is roughly 1 in 130,000, which is low. There were zero deaths.

Vinay Prasad:

In terms of teachers, I think there’s a new paper out on Ember, and it looks at a pooled analysis of teachers who worked in person in many settings. It takes the risk of Covid spread in schools and contrasts it with out of schools. What they find is that, for teachers and students, you’re 20 times more likely to get Covid outside of school than in school if you were to attend in-person school, 20 times difference, and that the risk to the teacher of dying of SARS-CoV-2 from acquiring it in a school for the average age teacher, which you allude to, is roughly the risk of driving five miles in a car, and for an elderly teacher, it’s about 16 miles in a car, which is not a zero risk but is a risk that we always accept.

Vinay Prasad:

I agree with you wholeheartedly that the closure of public schools, I guess I would say, when they closed in March, I was okay with it because there was a lot of uncertainty. When they failed to reopen by the fall, I think that was when we had reached a crisis proportion. When they failed to open in October, November, December, January, February, when they continue to fail to open today, I think there’s no excuse for that. That is a calamity, and they will go down as the greatest error in policy perhaps for a generation.

Martin Kulldorff:

I agree with that. It is tragic.

Vinay Prasad:

It’s tragic. I think one of the things that’s difficult to articulate is that when one makes public health policy one must naturally value life, and life is precious and every life is worth… I heard you say that in the beginning of this podcast. Mental health is precious, too. Feelings of anxiety and depression ought not exist. The well-being and upward mobility of the children who will someday inherit this planet, that’s precious too. We must balance all these different things, and they’re not all the same coin. They’re different coins sometimes. But public health expertise and policy naturally values different coins.

I will say, Martin, I believe there’s a huge disconnect between social media and what actual people think. I walk around the hospital, and my office is on the ID, infectious disease floor of physicians, and I will say that many of them are deeply concerned with prolonged school closures. Many of them are concerned that lockdowns perpetuate inequality. Many of them are not the kind of people who want to go on Twitter and tweet their opinion because that puts them in the crosshairs and they don’t want to put themselves out there, so they are quiet. When they see me coming, they laugh at me because they see I’ve been lambasted on Twitter. But I don’t get it as hard as you do, Martin. Not as hard as you do. I wonder if you might just for a minute talk about the fact that when you approach a public health question, it seems to me you’re weighing all of these different things to some degree. Is that fair?

Martin Kulldorff:

Yes. That’s what I’ve mentioned, that we are throwing out the window many of the basic principles of public health. One is that, if you’re a physician, you have to treat your patient and maybe they have stomach cancer and you treat them for stomach cancer. You’re focused on stomach cancer and that’s the way you should be. But in public health, we have to look at all health outcomes. We can’t just focus on one disease and Covid. We have to look at all physical health and also mental health. That’s the basic principle of public health, that we can’t do something that might help for one disease and then it makes it 10 times worse for another. We have never had that proper discussion.

I’ve been helping a little bit setting up a webpage called Collateral Global that collects the various studies about the enormous collateral damage that we have seen to public health, both physical health and mental health.

Another principle of public health is that you can’t just look at the short term. If you go back into last year, you see all these studies which [inaudible 00:42:14] get better than the other. But it was just up to a certain point. You have to look at it over many, many years. That’s like judging a marathon run by who’s leading after one-and-a-half mile.

Vinay Prasad:

Yes, exactly.

Martin Kulldorff:

I could probably beat a lot of good runners by being ahead at one-and-a-half miles, but by the end of it I’m going to be far, far behind. So you have to look at the long term, both in terms of Covid. There’s no point in just pushing things into the future because that can just make things worse because it’s harder for the older people to protect themselves for a longer time, but also with other diseases.

For example, we know that cancers have dropped in 2020. We have less cancer diagnosed and less cancer treatment being started. That’s not because people don’t have cancer. It’s just because we don’t detect it. If we don’t treat them earlier, we will have worse outcomes. Somebody who might have lived 10 years might now die 3 or 4 years from now. Those are tragic consequences. The other principle is public health is about everybody.

Vinay Prasad:

The [inaudible 00:43:33].

Martin Kulldorff:

What we have done with the lockdowns, we have shifted the burden of this pandemic from the affluent to those that are less affluent.

Vinay Prasad:

Right.

Martin Kulldorff:

Both within the country of the United States, but also in the world. Because of the lockdowns, there have been thousands of children who have starved to death in the developing world. Things have gone backward with tuberculosis and other disease preventions. That’s another basic principle of public health. Another principle, of course, is that we cannot close down scientific discussions. We have to have an open discussion and open discourse.

Vinay Prasad:

Not anymore, Martin. Not anymore.

Martin Kulldorff:

About the science. That’s one thing that you have been a great advocate for, and you have taken a lot of heat for it for defending scientific discourse, so maybe we also need a group of people who can defend the defenders of scientific discourse.

Vinay Prasad:

We have 10 minutes left. That’s what I want to talk to you about. I want to come to your recent tweet that’s been censored. I guess, what do I want to say? I guess it baffles me that even people who disagree with you do not see that having a culture where you cannot let Martin even talk, when you have to label Martin’s tweets, when you have to say that Martin… Literally, people have said that you are somehow pro-death. I guess I don’t get the feeling from talking with you or from reading your work that you actually wish ill upon people. I’m going to be on the record to say, I’ll put myself out there, Martin Kulldorff does not want bad things to happen to people. You do not. That’s not one of your goals.

Martin may have a different way he believes public health should be. I’m sympathetic to a lot of what you say. But you and I may not agree 100%. That’s okay. We can still be friends, of course. We don’t have to agree on everything. But Martin does have a valuable perspective.

I guess what fascinates me is, similarly, people on the other side. There are some noted advocates of Covid-Zero and prolonged lockdown. As much as I disagree with them, I feel that their view may be couched in some naiveté, that they may believe that we are more powerful than we really are, that they don’t understand that policy is not just this thing you model on a computer. It’s this thing you implement in the real world and people cheat and people have other needs, and you can’t blame them for that, and I don’t believe shame is useful. I never once think to myself that they are bad people motivated by wanting bad things to happen. I think there are ways we disagree.

To me, what is an existential crisis will be if we reach a point where science and politics become indistinguishable and we quiet down and flag and dethrottle, which means showing it in fewer posts, views and opinions we dislike. I’ll just talk very briefly about your recent tweet.

Your recent tweet was something to the effect of… I don’t even know if I fully agree with you, but I think I may see a lot of wisdom in what you say. But the vaccine I think is terrific, particular for older people. If I were in charge of vaccine distribution, I’d give it to older people first and then let’s work our way down a little bit. Right now, we’re talking about giving it to people in this country, United States adolescents between 12 and 15. Whether or not you want to do that in the future, that’s an open question, I think, but I would certainly vaccinate everyone over the age of 70 globally before I get to 12-year olds in the US.

I believe it is an unjust world if you will vaccinate a 12-year old in this country before you’ll vaccinate a 74-year old in India. I think you must look yourself in the mirror and ask what kind of world are you participating in that is a world of hegemony and cruelty, because that 12-year old does not have the risk of death of that 74-year old in India.

Your tweet, I think, was something on the order of we ought to vaccinate elderly people, but whether or not every child requires vaccination is an open question, or something like that. Is that fair to say what your tweet was?

Martin Kulldorff:

Yeah, approximately. Yeah. I think that vaccines are very important for older people. That’s part of focused protection. I agree with you that I feel a little bit uneasy when I see young politicians or young students bragging on Twitter that they got the vaccine while I know people who are 86 years old and a lady who hasn’t gotten it yet, than the others. And of course, in the developing world, there are many people, all the people who haven’t got it because they don’t have the same… They haven’t received that many doses. And for example, this vaccine passport, I think that’s a terrible public health thing that isn’t good for two reasons. One is through coercion. You’re actually making people not trust the vaccine and not just the Covid vaccine, but also other vaccines.

For decades, we are trying to build up trust in vaccines. And I think they’ve been successful because the group who doesn’t are very small, but the people who are now pushing the vaccine passports, they are much more dangerous to vaccinations than any anti-vax groups have ever been.

One example is, because if we impose vaccine passports in the US or Europe, then the people from South America or Africa or Asia, those who want to travel, who are wealthy and young, they’re going to snag those vaccines before the poor or the lady in the [inaudible 00:49:20] who is 75 who really needs it.

Vinay Prasad:

Yes. So, I want to, I only got five minutes with you, I want to make this point that I’m very sympathetic to you on the vaccine passports. I worry a lot of the ways it can worsen inequities and inequalities. I hadn’t thought so much about whether or not banding about it might affect vaccine hesitancy. I’ll think more about that.

But the point I want to make to you is this, that I think reasonable people may disagree. There might be somebody who thinks that yeah, you ought to vaccinate kids. I’ve seen op-eds about that topic. Martin points out that we have to first prioritize the elderly. I think that’s another reasonable point of view. I mean, I don’t even want to say who’s right or who’s wrong. I have my own feelings, but the point I want to make is what should the social media environment look like?

And what happened is your tweet, a lot of people, first I’ll say they dumped on your tweet. So a lot of people who dislike you for, I think, your general stance, or for having signed this Declaration, and they’ve been beating up on you all this time, they dislike your tweet and many of them pointed out, this is stupid and then they tweeted and they screenshot and they say, Martin is a shitty person and all the things they like to say about you.

Okay, yawn, I’m tired of that. I’m tired of this kind of childish behavior, but okay, fine they say what they say, but then Twitter, the platform puts a stamp on your tweet and the tweet says, exclamation Mark. The same thing that Donald Trump got that this is misleading and you’re not allowed to like it. It’s going to be dethrottled.

You’re not the only person this has happened to. Marty Makary had a Wall Street Journal op-ed about how Marty thinks April 30th will be the day that we have herd immunity in the US. That’s Marty’s view. It’s an op-ed in the Wall Street Journal. You can agree or disagree, but Facebook has labeled that misinformation, they de-throttled it. De-throttling it means, people say, oh, it’s not censorship and you can still read it. But de-throttling is a type of heavy handedness. It literally suppresses this content from being in the eyes of people, even when their social network says that we like this content, we appreciate it, which is contrary to the normal way the platform works. Okay. So I don’t want to quibble about it, but I think it is a type of censoring. I will say that.

But what I will say is that we need to have an honest conversation, which is that even if you think Martin is incorrect about it, ought we use the brute force of the platform to suppress that idea? When we acknowledge there is uncertainty around that situation. And also when we recognize that we need to have a forum for dialogue and the threshold to, I believe to censor a Harvard professor who has worked in this space his whole career, it’s got to be really high. There has to be a process. It has to be transparent. There has to be an appeals process. And unless you put all those things in place, I’m deeply troubled. And the last thing I’ll say before, I let you have the final word, last thing I’d say is I investigated how Facebook censors. And I looked through their censoring.

They’re picking people who are on Twitter, disproportionately. They’re like overwhelmingly on Twitter. And these are people who are known to disagree with you. I know I have a sense of how you might view something. I have a sense of how other people might view some things and there are fundamental disagreements. And so if I pick people who disagree with you to be your peer reviewer, they’re going to stomp it out. And if I pick, maybe you did, you might stomp out their thing, but maybe you believe in freedom of speech. Okay. Last thought, what are your thoughts on this climate of how we label things and stuff.

Martin Kulldorff:

I agree with you, except for the few words that you used that started with F- I wouldn’t have used those.

Vinay Prasad:

It’s my show I can use it.

Martin Kulldorff:

And the article you wrote about Facebook, how they do the censoring, I think was fantastic. Excellent. So, what I would say is if one of your listeners, if they are an epidemiologist and they disagree with me about the Covid strategy or vaccine passport or something like that, I will be delighted to have a discussion. We can have a moderator discussion in public, and we can just talk about it. And I think that’s what’s needed both to study science and make progress in science and projects, but also to ensure that the public actually trusts science. Because if you start to censor science, then the public is going to distrust science, and that’s going to spill over.

It’s not just about this pandemic; it’s going to spill over to medicine in general, to other types of vaccines, which would be very sad, but also to other areas of science, including environmental issues and more social issues, economics and so on. It’s going to spill over to the rest of the science. And if we don’t maintain the scientific discourse, if it starts with censoring or, or slandering, instead of these discussions, then I think 300 years of enlightenment has come to an end. That would be very unfortunate I think.

Vinay Prasad:

I want to close. I agree with you wholeheartedly. I wonder if you would say this, if you took SARS-CoV- and you pulled it out and you dropped it in 1998, or even 2008, you wouldn’t have had the same pandemic, I’ll tell you why. This technology, the speed of the internet could not sustain what we’re doing right now. We couldn’t sustain it in 2008. We couldn’t have a video dialogue like this and record. We couldn’t have so many people of the white collar class work from home. Couldn’t be done. You couldn’t get food delivered to your house at a whim. You couldn’t get all this takeout delivered at a whim with Uber Eats and Amazon Prime. You couldn’t. So all these things were different. And, and I think had the same pandemic occurred back then we would have had focused protection, Martin.

Martin Kulldorff:

We would have had what you suggest. The technology allowed people who could tolerate the isolation. They didn’t get laid off. Can you imagine, 1998, you did the same thing. All these people will be laid off. They wouldn’t be working. They would be laid off if you decided not to work. And instead of being laid off, they would say, I’m going to come in there with a mask on. We’re going to sit apart. We’re going to open some windows. We’ll do our best to mitigate this. We’re going to have older people protected. Basically they would have been Great Barrington Declaration signatories. This is a hypothesis, I don’t know this to be true, but I offer it for dialogue.

I offer this hypothesis because I’m curious if you think there’s some truth in this, that the technology actually chained us to this response. It didn’t liberate us. It led to this response because the technology allowed people with means to protect themselves disproportionately from the virus, even while they instituted things that didn’t protect the least fortunate.

I think that are very interesting thoughts. I hadn’t thought about that, but I think you might’ve found the truth there to a lot of explanation of what is going on. It might not be the only thing that’s affecting it, but that might be a big part of the picture.

Vinay Prasad:

I’ll tell you another thing that’s affecting it. The same flu that hit in 57, 58, the people were different than the people today. This is another hypothesis I have. I think about my parents’ generation. I think about my grandparents’ generation. Those were different people. The way they viewed the world was different. The way they viewed the world, the way they viewed health and what it means to live a good life and the way they viewed risk and probability of risk and risk of death was fundamentally different. And those people, people who had tasted war and depression, they were very cognizant that the youth is something that’s very important. They were very cognizant that to some degree, life must go on to some degree. And I think that those same people, if you drop them in 2020, they would have been very critical of a number of the measures we had.

So, I think our society is different. This is the society where I walk by the park and I see adults, not even just in a joke. I say, adults, they stand on the top of the slide to make sure their kid doesn’t fall off the slide when they go up to the top, that’s a different culture. That’s a culture that didn’t exist when I was a kid. It’s a culture of safetyism. The safetyism does not mean that you care about safety, it cares about safety, you can see, you can count, you discount safety. You cannot see, you cannot count that in the future. It’s a certain type of cognitive belief or potentially bias. That’s also a factor here. If it were the people from 1957, you dropped them here, they would behave differently.

Martin Kulldorff:

And another one thing that is different is how we deal with infectious diseases. Because now we have vaccines for so many things so we sort of are not used to having to deal with infectious diseases, but 50 years ago we did, because at that time we did only a few things we had vaccines for. So for example, when I was a child, my parents told me to go and play with this friend of mine who had mumps, because they wanted to make sure I got mumps before I got into puberty, because that’s when it’s more dangerous.

Vinay Prasad:

Yes.

Martin Kulldorff:

So, the whole way that people were thinking of infectious diseases, I think was different 50 years ago from the way it is now.

Vinay Prasad:

That’s interesting. I think in my own life was the advent of a chicken pox vaccine varicella. And prior to that I remember the 1980s, a lot of parents would push the kids to get it over with, get it early and deal with chicken pox.

Martin Kulldorff:

Especially mumps, and rubella, because those are the ones that have severe consequences if you get it later in life, mumps for boys and rubella for girls.

Vinay Prasad:

Yes. It’s been interesting. I would say the last thing I’d say about the state of the academy is it’s also the digital, it’s the digital world, Martin. If people had to look you in the eye and say some of the things they say on Twitter, they would never say it because you’re not a bad person, you’re a good person and you’ve been working in this space a long time. And I think that’s very problematic. I’m going to go back and delete my little outbursts before I post this video so there’ll be no record of it. So I’m going to remove those two words that I was saying, but I guess I would put it to you this way. It really troubles me that people do not see what is going on in the sense that they are, they’re fueling the tribalism that they see as a problem, that their extremism, that their inability to talk to you, to see where you disagree.

But that itself fuels the pole that they are fighting is to some degree fueled by their own behavior. And I really worry, Martin, I sometimes think, but God forbid there’s some future catastrophe. There’s a piece of astronomic debris hurtling to earth. Just like the movies and we have to all decide, well, what are we going to do? Are we going to try to divert the debris? Are we going to blow up the debris? I was like, you don’t even need to get into that. The society will tear itself apart. The Academy will abdicate their role to even have dialogue about what to do. It will become the Republican position will be to blow it up and the Dems will say to divert it, it’ll become political. How the hell did that astronomic debris became political? And that’s why I worry that we are the weakest we’ve ever been for any challenge that faces science and policy, your thoughts.

Martin Kulldorff:

I think that tribalism is a problem. And maybe I have a slight advantage there as an immigrant, because if you’re an immigrant into a country, you’re maybe not so closely emotionally attached to one group versus the other. And I think that might actually be a reason why the three of us who wrote the Great Barrington Declaration we’re all immigrants, me and Jay, the US and Sunetra in the UK.

Vinay Prasad:

That’s interesting.

Martin Kulldorff:

I think that was an accident actually, I think there’s some explanation for that.

Vinay Prasad:

I guess I would say that my bias, I’m the child of immigrants. But my bigger bias is that I don’t belong to any tribes. I’ve never seen myself in that way. Not political tribes, not personal tribes, not identity tribes, no tribes. I have lots of interests. My biggest interest is how evidence is used to reach causal conclusions and how policy is made. I’m very interested in the gap between what sounds good in theory and what works in practice. I don’t have very strong views on what are, I don’t know, are there any like things we could never do or not do? So I try to approach every question by pursuing the data.

And I will admit that in March I didn’t see that schools were so bad until I started reading a lot of papers in June and July from the economics literature, which I think they do a good job of capturing the value of schools in a society. And then I realized that school closure is going to hurt the vulnerable people. And it’s going to have repercussions on society for years to come. And that’s changed my view by September, by October, I was doing a lot of podcasts on it. And that’s when I realized that school closure is a huge error.

Martin Kulldorff:

Yeah. And it is important to keep that open mind. I think it’s also important to actually read what those have different views, what they are saying. So when I read those who have similar views to me, it can get a little bit boring actually, because I already know what they’re saying, but I do extra effort to make sure I read those who have opposing views because the ones that I really need to understand.

Vinay Prasad:

I agree with you Martin, my work on cancer drug policy, which is where I pick most of my battles. I always read the opposing views and I learned so much and it makes me, it gives a half of our research agenda just thinking about what they said and how to maneuver around it. But Martin Kulldorff, it’s a pleasure to speak with you. I hope that someday that there will be some in-person academic seminars and many of the people who felt very strongly about you, I hope that they get a chance to talk to you and I hope that they maybe keep an open mind and realize that there were a lot of policies that you all would have really agreed upon if they were willing to hear you out. So thanks for doing this.

Martin Kulldorff:

Thank you so much it’s been a great pleasure talking to you.

Vinay Prasad:

Great pleasure.

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