My first article on famed Stanford epidemiologist Dr. John Ioannidis discussed his flawed fatality calculations that required over 100% of New York City’s population to be infected with the virus, as well as his claim (later promoted by QAnon accounts) that death certificates couldn’t be trusted, as many COVID-19 victims were dying with the virus not from the virus. Looking back on my pleonastic article and the myriad of false claims I discussed, one has stuck in my mind more than the others. In that article, I noted Dr. Ioannidis’s appearance on the Plenary Session Podcast where he said (at 1:37:25) that “a lot of lives” were lost early in the pandemic in part because of doctors “not knowing how to use mechanical ventilation, just going crazy, and intubating people who did not have to be intubated”. Dr. Ioannidis did not provide any evidence for this claim, nor did the podcast host, who agreed with him.
The notion that COVID-19 patients were dying of premature intubations and not from the virus was never anything more than an internet rumor. There was never any evidence that doctors were “just going crazy” intubating patients, leading to their demise. In fact, a meta-analysis of 12 studies found “The synthesized evidence of almost 9000 patients suggests that timing of intubation may have no effect on mortality and morbidity of critically ill patients with COVID-19”. Though this meta-analysis was published after Dr. Ioannidis made his accusation, all 12 studies it reviewed were published beforehand. A subsequent study unsurprisingly found that intubated patients died at a higher rate, but “there was not a significant association between mortality and timing of intubation (within 48 hours of triage vs later in hospital course), when restricting only to intubated patients”. Another subsequent study even found improved survival rates in COVID-19 patients who were intubated early.
Perhaps because it was said as an aside during a podcast, I don’t think this false claim got the scrutiny it deserved. But let’s be clear: a paragon of evidence-based medicine publicly accused frontline doctors of killing a large number of their patients. He not only did so without any evidence, but in direct contradiction to the evidence available at the time. As I’ve discussed before, there are real-world consequences when people believe false information. Dr. Alison Pittard, an intensivist from the UK, said patients were refusing ventilators because,
They think if they do not go on a ventilator, they have got a better chance of surviving, because once they go on a ventilator they are going to die irrespective. And of course that is not correct because if you are faced with a patient who needs to go on a ventilator … if they don’t go on a ventilator then the chances are that they will die. So, that is almost saying there is a 100% chance of dying. Whereas if they go on a ventilator then they will have a 40% chance of dying.
Vaccinating young people may expose the elderly?
With this in mind, I was particularly dismayed to read a bizarre article by Dr. Ioannidis titled “COVID-19 in Children and University Students“. After presenting an argument for vaccinating young people based on “indirect benefits to other age groups and society at large,” he wrote the following,
However, the opposite arguments also exist, e.g. vaccinating the youngest age strata may shift infection to higher ages with high fatality especially as many elderly people in many countries are still not vaccinated and some vaccinated elderly have insufficient immune responses. Vaccinated people may still transmit the virus; given that vaccinations make infections milder/asymptomatic and people markedly increase exposures after vaccination (a risk compensatory behavior), vulnerable people may be exposed more frequently to vaccinated infected youth who are unaware of their infection.
That’s right, Dr. Ioannidis gives credence to the notion that vaccinating young people will spread the disease to vulnerable elderly people. He’s suggests this may occur in an imaginary country where young people are vaccinated, elderly people are unvaccinated, and these vulnerable adults are incapable of realizing they are still vulnerable. He referenced no real-world data to support this extraordinary claim, but rather his own “model” from a prior paper. Naturally, when discussing models that show benefits of the vaccine, he warns that “modeling projections of benefits are occasionally helpful, but also precarious”. To Dr. Ioannidis, models are useful when they suggest vaccine harms, but “precarious” when they show vaccine benefits.
It’s true that vaccinated people can still spread the disease. But the idea that vaccinating young people will cause more disease in vulnerable old people is nothing more than a new twist on an old anti-vaccine trope that vaccinated people “shed” the disease. Just because this claim is now being presented by someone with stellar academic credentials in a medical journal doesn’t mean we shouldn’t recognize it for what it is. Of course, unvaccinated young people can still spread the virus before they show symptoms. Unvaccinated people with COVID-19 have a higher viral load than vaccinated people with breakthrough infections. As such, unvaccinated people with COVID-19 are theoretically more likely to spread the virus.
Dr. Ioannidis is also giving credence the idea, promoted by signers of the Great Barrington Declaration, that it’s preferable to let young people get the virus than to get vaccinated. Via his strange reasoning, the fact that “vaccinations make infections milder/asymptomatic” is a strike against the vaccine. It’s not enough for children to merely contract the virus, they also need to know it. In order to protect elderly people, children need to feel sick. This is not the first time Dr. Ioannidis lamented measures that would prevent infections in children. At the start of the pandemic, he warned that “school closures may also diminish the chances of developing herd immunity in an age group that is spared serious disease”.
Well, schools are open now, and sadly many children in this age group haven’t been “spared serious disease“. Most young people do fine with the virus, thankfully, but when tens of millions of them get sick, rare harms add up. Dr. Ioannidis’s own paper showed that hundreds of children and thousands of young adults have died from COVID-19 in the US, though of course he suggests these numbers are inflated. Why does he think this? In an article from July 2021, he stated that:
Death certificates have always been inaccurate, but COVID-19 maximizes the challenge of prioritizing multiple comorbidities… In many other countries, death certificates are even more unreliable. Some financial incentives may promote coding for COVID-19.
That’s right, Dr. Ioannidis continues to promote the QAnon meme that the death toll is inflated because death certificates can’t be trusted. In fact, death certificates have generally been very reliable this pandemic and the CDC estimates deaths have been underreported this pandemic. In addition to repeating previously debunked claims, this time Dr. Ioannidis adds a nasty twist by suggesting that people who fill out death certificates have a financial incentive to put down COVID-19. His reference for this extraordinary claim was an article from India, which merely noted that the families of frontline workers who die of the virus on duty can receive financial compensation. This paper contains no evidence that anyone is falsifying death certificates for money. Again, Dr. Ioannidis is doing nothing more than amplifying mere internet rumors. In so doing, he joins Donald Trump who said, “Our doctors get more money if somebody dies from COVID. You know that, right? I mean, our doctors are very smart people. So what they do is they say, ‘I’m sorry, but, you know, everybody dies of COVID.'” Again, just because Dr. Ioannidis does this in a medical journal using formal diction doesn’t mean we should treat his words any differently than those of former President Trump.
While death is the worst outcome from COVID-19, it is not the only bad outcome. Tens of thousands more children and young people have been hospitalized, some very sick, intubated in the ICU, though Dr. Ioannidis of course also suggests these numbers are inflated. Happily, the vaccines can prevent hospitalizations in young people. A recent study by the CDC found that unvaccinated adolescents are hospitalized 10 times more often than vaccinated ones. Additionally, the CDC has tallied 4,661 cases of MIS-C, and children with this disease are often very sick, needing ICU-level care. Many thousands more children and young adults may have long-COVID, an entity we are still learning about.
Every doctor who is pro-vaccine should be very clear: The vaccine isn’t perfect, but it’s much safer for young people than the virus. We vaccinate young people to protect them, and we don’t need models to know the vaccine works. Unvaccinated teens have died this summer after the vaccine was available to them. It’s just a bonus that vaccinated children might not lose their mom or dad.
More claims of “improper mechanical ventilation strategies”
While Dr. Ioannidis’s notion that vaccinating children may lead to more disease in vulnerable adults is comical, what he said next isn’t so funny. Dr. Ioannidis said that the “future infection fatality rate may decrease with better protection of vulnerable children, more effective treatments, and avoidance of harmful treatments (e.g. improper mechanical ventilation strategies.)” In other words, Dr. Ioannidis expects that fewer kids will die from rushed intubations moving forward. No reference is given for this claim, as conspiracy theory sites that push this idea can’t be referenced.
Once again, an inflammatory accusation is being lobbed against frontline doctors not just without any evidence, but in direct contradiction to all of the available evidence. The fatality rate for children hasn’t decreased. Children are dying now at the same low rate as before. However, more children are getting infected now, so more children are dying now. About 500 children have died so far this pandemic in the US. The American Academy of Pediatrics added 102 deaths to its tally since July 29th, over 20% of the total pediatric deaths in the past 5 weeks. Despite what Dr. Ioannidis says, none of them died because they were intubated too early.
Sadly, highly-credentialed experts from prestigious universities making false claims in a public forum is now a routine part of this pandemic. Like the high daily death tolls, we’ve become numb to things that would have appalled us previously. Nonetheless, I still believe that academics divorced from patient care should be held to account when they falsely claim that overwhelmed frontline doctors killed their patients and then imply they put COVID-19 on the death certificates for money.