We should debate the best COVID treatments. But let’s eschew revisionist history
Fahad Razak, Arthur Slutsky and David Naylor are physicians and professors in the Department of Medicine at the University of Toronto. Drs. Razak and Slutsky are also on the medical staff of Unity Health Toronto.
Original author: Fahad Razak, Arthur Slutsky, and David Naylor
Published: January 28, 2022
Norman Doidge, our medical and academic colleague, is renowned for his writings in the realm of neuroscience and psychiatry. Dr. Doidge’s recent essay on the COVID-19 pandemic, however, seems to have generated more heat than light. It has been criticized by some as a defence of vaccine skepticism and lauded by others who agree with his contention that dissent has been stifled because of a prevailing “master narrative.”
Those arguments will continue. Here, our purpose is to outline some concerns about the claims set out in the essay and its use of sources.
Claim 1: Vaccines have been treated as a silver bullet and treatment modalities neglected until recently.
Federal officials began seeking advice on treatment options and sourcing essential drugs soon after the onset of the pandemic. In May, 2020, the Government of Canada invested $175.6-million in Vancouver’s AbCellera Inc. to accelerate the production of monoclonal antibodies. By then Canadian physicians were already active with colleagues worldwide in planning or launching various trials of drug treatments.
That summer, Canada’s Chief Public Health Officer, Dr. Theresa Tam, went off script from the_ “master narrative.” On Aug. 4, 2020, in a widely reported news conference, she cautioned explicitly that vaccines were not a silver bullet. The next day, the federal government announced the launch of both a Vaccine Task Force and_ a Therapeutics Task Force.
Initially, clinicians had little to offer patients beyond supportive measures, but today there are therapeutics that range from pre-exposure prophylaxis (preventing illness among those who are exposed) to treatments for those who are critically ill. The Ontario Science Table has recommended 10 therapeutics to treat COVID-19, while the_ _CORONA project has compiled 2,399 papers on 590 treatments administered to 437,936 patients with COVID-19. Treatment modalities have not been neglected during the pandemic.
Claim 2: With the “master narrative” focused on vaccines, physicians were slow to use repurposed drugs to treat COVID-19 infection.
In fact, the first widely used and effective treatment was dexamethasone, a 60-year-old steroid drug still valued for its anti-inflammatory properties. Among the recommended drugs in current Canadian use, most are repurposed. This includes rheumatoid arthritis drugs (baricitinib, tocilizumab), hepatitis C treatment (remdesivir), a blood thinner (heparin), an asthma treatment (inhaled budesonide), and yes, the psychiatric drug on which the essay focused (fluvoxamine). Many more repurposed drugs have been studied worldwide but are widely viewed as unproven or ineffective. These include hydroxychloroquine, ivermectin, lopinavir/ritonavir, vitamin D, antibiotics such as azithromycin, and the immune modulator interferon.
Claim 3: Vaccine effectiveness against symptomatic infection has declined and we haven’t achieved herd immunity. Our faith in vaccines was accordingly misplaced.
Despite enrolments in the tens of thousands, early vaccine trials lacked statistical power to look at severe outcomes of infection such as hospitalization or death. As Dr. Doidge acknowledges, the decision to focus instead on protection from symptomatic infection was a strategic choice to accelerate trial completion during a rapidly escalating crisis.
Since then, evidence has rapidly accrued from multiple countries showing that vaccines were and remain remarkably effective at protecting recipients from serious illness, including from Omicron. For example, the latest real-world data from Ontario show that, for those with two doses of vaccines, the risks of being hospitalized or entering an intensive care unit are reduced by more than 80 per cent and 90 per cent, respectively. There is even stronger protection with three doses.
Instead, the essay emphasizes the reduced effectiveness of vaccines at preventing symptomatic disease caused by Omicron, and also obfuscates the big difference in denominators (e.g., only 12 per cent of people the age of five or older are unvaccinated in Canada) when highlighting similar ICU occupancy among those with and without vaccination.
The commentary on infection-acquired immunity versus vaccine-induced immunity is confused. In brief, we are still determining the separate and combined effects of these factors in the face of different variants. Blanket claims for the superiority of “natural” over vaccine-induced immunity are false, and ignore the markedly increased death toll that would accompany the development of “natural” immunity.
The inability of vaccines to provide herd immunity is raised often in the article as a critical shortcoming. Most scientists assessed this goal as impossible by early 2021 given animal reservoirs of virus and successive waves of more infectious variants. However, high population-wide levels of immunity from vaccination remain vital to blunt the toll of recurrent tsunamis of variants and will eventually usher in less disruptive and diminishing waves of COVID-19. Enthusiasm for vaccine campaigns was therefore not part of a “master narrative” created by a censorious military mindset. It reflected both the powerful impact of vaccination in preventing severe disease, disability and death, and the ethical imperatives of our profession.
Claim 4: Emerging variants are caused by mRNA vaccines
A leading virologist at Columbia is cited as arguing that mRNA vaccines cause variants, whereas a full reading of his media interview demonstrates he thought it was a “good decision to get vaccines out in less than a year.” The same expert later wrote an op-ed concluding that “Today’s vaccines can still end this pandemic.”
Early misinformation indeed claimed that the Delta variant that swept through Canada in early 2021 was produced by vaccination, when in fact it was first detected in India in October, 2020, well before the first vaccines became available. Current theories of Omicron’s emergence include development in an animal reservoir, in an immunocompromised individual who was infected for a long period of time and not able to clear the virus, or in an isolated population. There are continuing concerns that variants also are more likely to emerge in unvaccinated populations and more generally in environments that allow rapid viral propagation.
Dr. Doidge’s thinking here accordingly borders on tautology. Precisely because vaccines work and have been deployed widely, the most prominent variants will always be those selected out for their ability to escape vaccine control. That is why there are concerted efforts under way to engineer vaccines with a broader reach in the coronavirus family, different delivery mechanisms, and multiple targets as opposed to current vaccines focusing only on the spikes that dot the surface of each virus.
Claim 5: Medical Boards and Regulatory Bodies Are Suppressing Free Speech
The legal responsibility of medical boards and oversight bodies is ensuring safe and ethical practice. The Ontario regulator is currently investigating 40 doctors (out of a total of some 30,000 in the province) accused of providing COVID misinformation to patients or false medical reasons for vaccine exemption. In a free society, patients can refuse vaccines and physicians can refuse to give them. But freedom of speech is a weak shield for physicians who allegedly mislead patients about the safety and efficacy of vaccines during a pandemic.
The essay also cites an Amnesty International report in a series of paragraphs arguing that dissent against the “master narrative” by brave scientists and physicians is being stifled. The true focus of the report is quite different, highlighting authoritarian regimes ranging from Russia to Tanzania that are muzzling scientists and public-health officials trying to reveal the true extent of government mismanagement of the pandemic.
Claim 6: Scientists, Public-Health Officials and Physicians are Hewing to a “Master Narrative”
There has indeed been almost uniform medical support for vaccination given their remarkable effectiveness. But otherwise, much of the pandemic response has been hotly debated with stark international differences in policy and action. Consider vaccines again: In Canada, amid controversy, the first and second doses were spaced wider than the interval tested in the clinical trials; the U.S. never adopted this strategy. In Britain, the approval of vaccination of children lagged many comparable countries. And in the United States, the AstraZeneca vaccine was never approved despite more than a billion doses being given elsewhere.
This variability reflects the uncertainty that scientists and public-health officials have faced throughout the pandemic. Likewise, the medical reversals highlighted in the essay not only reflect the continuing revision of ideas about disease, diagnosis and treatment as more evidence comes to light. They also undercut any claims about “master narratives.”
In the final paragraphs of his essay, Dr. Doidge’s own narrative takes an odd turn. He attempts to draw a line between nature and medicine, as if the clinical and public-health responses to COVID-19 are somehow a manifestation of hubris. A reminder: In the past two years 5.6 million people worldwide have been registered as dying from COVID-19. Even if that toll is 100 per cent underestimated, it is a massive improvement compared with the last great global viral pandemic more than 100 years ago. Taking a mid-range estimate of the death toll from Spanish influenza, the fatality rate in that more “natural” state was 10-15 fold higher than today. So yes, let us debate the best treatments, vaccine strategies, and public-health measures – and strive to improve them all. But let us also eschew revisionist history and take a clear-eyed view of how far we have come, and how much further we need to go.