I thank Prof. Ioannidis for his second response (1) and am gratified that, as much as he disagrees with me, he considers me a talented science communicator. Although I am even more honored to realize that someone of Prof. Ioannidis' prominence is not only aware of the humble blog for which I serve as managing editor (2) but is sufficiently familiar with posts containing my much longer critique of his Kardashian index study (3) and that of one of my co-bloggers of some of his—shall we say?—less temperate assertions about the pandemic (4), to the point of having done actual word counts for both posts (5, 6), I am nonetheless disappointed to have to note that his response would seem to validate at least some of my criticisms (7, 8) of his study (9) and his prior responses (5, 6). Also, given that he has criticized one of my bloggers for "conspiracy theories," I feel the obligation to respond to defend him—and, of course, myself—for having used his blog post in my previous response (8).
What seems to have raised Prof. Ioannidis' ire the most was my observation about his having repeated a narrative that was an early conspiracy theory during the pandemic, which he described as facilitating weaponization of his words by linking him with conspiracy theories. I would counter that conspiracy theorists do not need me in the least; they were doing an outstanding job of "weaponizing" Prof. Ioannidis' words without my input, thanks to Prof. Ioan...
I thank Prof. Ioannidis for his second response (1) and am gratified that, as much as he disagrees with me, he considers me a talented science communicator. Although I am even more honored to realize that someone of Prof. Ioannidis' prominence is not only aware of the humble blog for which I serve as managing editor (2) but is sufficiently familiar with posts containing my much longer critique of his Kardashian index study (3) and that of one of my co-bloggers of some of his—shall we say?—less temperate assertions about the pandemic (4), to the point of having done actual word counts for both posts (5, 6), I am nonetheless disappointed to have to note that his response would seem to validate at least some of my criticisms (7, 8) of his study (9) and his prior responses (5, 6). Also, given that he has criticized one of my bloggers for "conspiracy theories," I feel the obligation to respond to defend him—and, of course, myself—for having used his blog post in my previous response (8).
What seems to have raised Prof. Ioannidis' ire the most was my observation about his having repeated a narrative that was an early conspiracy theory during the pandemic, which he described as facilitating weaponization of his words by linking him with conspiracy theories. I would counter that conspiracy theorists do not need me in the least; they were doing an outstanding job of "weaponizing" Prof. Ioannidis' words without my input, thanks to Prof. Ioanndis himself! His irresponsible and inflammatory claim 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," whether Prof. Ioannidis realizes it or not, couldn't have been better for conspiracy theorists if he had intende it to be! That's why it was a narrative criticized by my co-blogger Dr. Jonathan Howard, whose posts (4, 10) led me to the podcast interview in which Prof. Ioannidis made those remarks (11). Let me just ask how Dr. Ioannidis would react if he were one of these exhausted and overwhelmed doctors and found himself accused by someone of his eminence of “just going crazy and intubating people who did not need to be intubated.” Again, however he tries to walk those remarks back with "context," they remain every bit as inflammatory as Dr. Howard and I suggested.
I cannot help but note the quote that Prof. Ioannidis chose from a meta-analysis that I cited, "These results might justify a wait-and-see approach, which may lead to fewer intubations. Relevant guidelines may therefore need to be updated" (12). However, that was not the primary conclusion of the meta-analysis. The sentence before that was and read, "The synthesized evidence suggests that timing of intubation may have no effect on mortality and morbidity of critically ill patients with COVID-19." However Prof. Ioannidis wishes to spin this conclusion, I was correct in citing this meta-analysis as not supporting his assertion that doctors were "just going crazy and intubating people who did not have to be intubated." Again, his added context does not make his claim any less inflammatory. Indeed, his defense (6) of his statement by referring to ICU beds being "set up urgently with inexperienced staff who fought heroically but with limited means, support, and training" struck me as doubling down on the same point without reference to "going crazy." Moreover, Prof. Ioannidis' accusations that Dr. Howard had "missed the essence of my points and delved into conspiracy theories" and that I had facilitated conspiracy theorists linking his words to their conspiracies utterly missed the essence of Dr. Howard's and my points about how his arguments had echoed real world conspiracy theories.
In any event, it is not facilitating "weaponization" to try to educate Prof. Ioannidis, who was clearly—and apparently remains—blissfully unaware of the particular conspiracy theory to which I was referring. I am more than happy to continue his education with one example from the Natural News website, an article by S.D. Wells entitled "WHISTLEBLOWER: Medical device sales expert reveals 'morbidly unsuccessful' Covid VENTILATORS as 'deadly therapy' in this population reduction scamdemic." (13) I can list more examples, but encourage Prof. Ioannidis to read this article on one of the most prolific conspiracy and antivaccine sites in the world, just to see why it is not a good idea for someone as respected as him to echo, even partially and inadvertently, the sorts of things being promoted in the deepest, darkest conspiracy sites on the Internet.
This conspiracy theory has had real world consequences, too, as noted recently by Dr. Howard on Twitter (14) and referenced in his post (10) when he quoted UK intensivist Dr. Alison Pittard, who noted a year ago, "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." (15) Given that Prof. Ioannidis is all about "nuance" and takes such huge issue with a lack of civility, I find his lack of nuance in his statements on intubations curious. Still, I will assume good faith and that Prof. Ioannidis didn't know about this conspiracy theory—‚and thus did not intend to contribute to its narrative about intubations—when he made those intemperate remarks. I trust that, now that he is aware of this conspiracy theory and given his reputation for dedication to science, accuracy, and civility, he will be much more careful in the future on this topic, so that neither conspiracy theorists, on their own or "facilitated" by me, can "weaponize" his words.
Similarly, Prof. Ioannidis takes particular umbrage at Dr. Howard's statement that he "continues to promote a QAnon meme" about death certificates (1). Unfortunately, Dr. Howard was correct, and I am happy to continue Prof. Ioannidis' education about COVID-19 conspiracy theories, as I have been documenting them since the very beginning of the pandemic, including a conspiracy theory from January 2020 that blamed the new coronavirus on the influenza vaccine (16) and one of the very earliest versions of the claim that the new coronavirus was "engineered" (17)". As before, I will assume that Prof. Ioannidis was unaware of a viral conspiracy theory that arose during the summer of 2020 that did, in fact, turn into the very QAnon meme described by Dr. Howard (4). The idea that death certificates were being gamed by doctors for the nefarious purpose of inflating COVID-19 deaths and justifying extreme interventions (like lockdowns) arguably reached its apotheosis in what I originally dubbed the "6% gambit." This misinformation and conspiracy theory claimed that only 6% of COVID-19 deaths reported were actually due to COVID-19, the rest being due to "comorbidities" listed on the death certificates that really killed the patients but were not correctly listed as the primary cause of death (18). Whether Prof. Ioannidis realized it or not, his narrative in 2020 that COVID-19 death counts were likely highly overreported based on death certificates fed that conspiracy theory that became a QAnon meme and continues to exist today as a conspiracy theory about COVID-19. After all, there's no greater validation to a conspiracy theorist than to see a narrative similar to his repeated by a scientist as eminent as Prof. Ioannidis.
That's why, whether Prof. Ioannidis is willing to accept it or not, his promotion of the idea that COVID-19 deaths were being massively overcounted thanks to incorrectly filled out death certificates contributed considerably to this conspiracy theory, including one paper (19). In addition, as noted by Dr. Howard (10), when it became very clear that Prof. Ioannidis' early estimate of a COVID-19 death toll in the US to be around was incredibly low compared to what was happening, he wrote: "When I made that tentative quote, I had not considered the impact of the new case definition of COVID-19 and of COVID-19 becoming a notifiable disease (https://cdn.ymaws.com/www.cste.org/resource/resmgr/2020ps/Interim-20-ID-.... (Accessed 20 June 2020)), despite being aware of the Italian experience (Boccia et al., 2020) where almost all counted “COVID-19 deaths” also had other concomitant causes of death/comorbidities. 'COVID-19 death' now includes not only 'deaths by COVID-19' and 'deaths with COVID-19', but even deaths 'without COVID-19 documented'." (20). This was exactly the same sort of narrative that fused with the "6% gambit" and became the QAnon meme, an extreme version of which was that patients who died after car crashes but were positive for COVID-19 were counted as COVID-19 deaths.
Let me just emphasize that I do not expect someone who is not an expert in conspiracy theories to know all the latest COVID-19 conspiracy theories, particularly early in the pandemic. Again, most scientists do not share my penchant for refuting such misinformation. I do however very much hope that, now that he is aware of the "COVID-19 6% gambit" based on death certificates, Prof. Ioannidis will be a lot more careful about what he writes and says about COVID-19 death count estimates. Now that he is no longer ignorant of this conspiracy theory, again, based on his reputation for for dedication to science, accuracy, and civility, I have faith that he will be much more careful in the future about how he discusses this issue.
No one is asking Prof. Ioannidis to give up or change his political views as described in a recent op-ed (23). Nor is anyone trying to "cancel" or "silence" him. I would, however, suggest that Prof. Ioannidis has weaponized his high status among scientists against GBD critics with his poorly conceived Kardashian index article. Another example was his related—and equally poorly conceived—study published late last year (24) that denigrated science communicators using citation metrics (25). Taken in context with Prof. Ioannidis' oft-expressed opposition to "lockdowns," fear that public health interventions endanger democracy (23), and support for GBD-like policies, these studies still strike me more as a means of striking back at critics than as scientific exercises that answer important questions.
Finally, Prof. Ioannidis notes that it is not always possible to predict how one's words and work will be used. This is correct as far as it goes, but is also not the whole story. Such an defense might have been convincing near the beginning of the pandemic, but we are nearly two years past that now, and these conspiracy theories are now fairly widely known. Even so, I will conclude with one final suggestion to Prof. Ioannidis, taking him at his word that he does not want his work to be "weaponized." I suggest that he enter his name into the search boxes of some of the biggest and most virulent antivax and COVID-19 misinformation sites, such as NaturalNews.com, Robert F. Kennedy, Jr.'s Children's Health Defense (21), LifeSiteNews.com, and The Epoch Times (22). (I can suggest others, but these are good sites to begin with.) Let him read the articles that come up and see how his work and words are being cited and used. It is true that one cannot completely control how one's work is used, but that does not mean that Prof. Ioannidis has no control. He can, going forward, can make it harder for conspiracy theorists to cite his work in support of their antivaccine and COVID-19 minimizing conspiracy theories. I assume that is something he would want to do, as a fellow scientist.
This will likely be my last response, unless a new issue comes up.
We thank Professor Olds for his thoughts on our work and we are happy to respond accordingly.1,2 Our paper reporting the cohort study directly addresses the risk of bias associated with health care professionals being aware of trial allocation.2 In our Discussion we elaborate on the potential mechanisms and opportunities for such bias to effect study findings in the UK trial setting, use evidence from the trial’s process evaluation where applicable and contemporary service data where available. We invited readers to form their own view on the plausibility and likelihood of subversion and would particularly welcome reflection from contemporary service professionals. Second, it should be noted that notification about trial participation and allocation was required under ethical approval for the trial and not simply a design choice. Finally, we systematically captured a wide range of participant-reported health and social contacts including for health visitors.3 This reflected the complex publicly funded supportive care available across both trial arms. We consider this added a richer picture of the disaggregated support available to and accessed by first-time mothers in the trial.
The difference in reported health visitor contacts in the original trial report (which included imputed values) and in the subsequent process evaluation paper and our current report (which includes recorded values only) is already addressed in the first section of the paper’s Discussion sect...
We thank Professor Olds for his thoughts on our work and we are happy to respond accordingly.1,2 Our paper reporting the cohort study directly addresses the risk of bias associated with health care professionals being aware of trial allocation.2 In our Discussion we elaborate on the potential mechanisms and opportunities for such bias to effect study findings in the UK trial setting, use evidence from the trial’s process evaluation where applicable and contemporary service data where available. We invited readers to form their own view on the plausibility and likelihood of subversion and would particularly welcome reflection from contemporary service professionals. Second, it should be noted that notification about trial participation and allocation was required under ethical approval for the trial and not simply a design choice. Finally, we systematically captured a wide range of participant-reported health and social contacts including for health visitors.3 This reflected the complex publicly funded supportive care available across both trial arms. We consider this added a richer picture of the disaggregated support available to and accessed by first-time mothers in the trial.
The difference in reported health visitor contacts in the original trial report (which included imputed values) and in the subsequent process evaluation paper and our current report (which includes recorded values only) is already addressed in the first section of the paper’s Discussion section entitled Potential sources of bias.2-4
We previously addressed the question of whether families with higher baseline need may indeed be in receipt of enhanced care from health visitors.3 We cited this work in our current paper and which showed that potential predictors of greater home visits for women in the usual care trial arm by six months post-partum included personal subjective social status, ever being homeless, having at least one burden (an element of adaptive function), and trial site. While not all factors were entered into nor remained in a multivariable model, this does support the hypothesis that care was being tailored to need. It is true that we do not know whether this happened differently for families within the trial compared to those in receipt of care outside the trial. However, it is the case that both health visitors and midwives are required to provide enhanced care for more vulnerable clients as part good normal practice (eg via teenage pregnancy midwives working at most of the trial sites).
We addressed the choice of outcomes and included reflection on this in our Discussion section. This acknowledged the nature of several outcomes available via routine social and healthcare sources and that a breadth of outcomes were considered, consistent with the multimethod multisource approach. Our previous trial paper noted higher rates of safeguarding for children in the FNP trial arm as documented in primary care notes (a data source which was only able to provide partial cohort coverage).4 This was though not consistent with rates of children referred to social services and subsequently assessed as in need of additional support and reported in the current study where we had nearly comprehensive coverage. In our analysis of surveillance bias we focused on differences in baseline predictors of subsequent assessment as being a child in need. We generally followed the model used by Professor Olds in his own analysis of the Elmira trial sample but chose to avoid factors (as predictors) that would potentially or obviously occur after child in need assessment to avoid problems arising from reverse causality.5
We agree that how long children stay in hospital following an admission due to an injury or ingestion is important. What this represents as an outcome is nevertheless still subject to some interpretation and we expanded on some factors that may drive such differences in our Discussion section. What the data available for this outcome through routine records means, is also open to some interpretation. As available hospital episode statistics data includes dates for admission and discharge rather than anything more granular, any derived ‘overnight stay’ in hospital can include admissions of any duration up to 48 hours. This considerably overlaps with what would also be recorded for children admitted and discharged on the same day.
There is a difference in the number of children aged up to 24 months admitted to hospital summarised in the original trial report and in our current paper.2,4 The same ICD codes were used in both cases. In the trial publication we included admissions with such codes for primary diagnoses. For the current study, we also included any diagnoses field. This detail was not provided in the supplementary materials, and we are glad to add that clarification.
Some of above points were summarised in the Discussion section of the paper and in the supplementary materials. In addition, we would also note that further details are available in the Publication history for the paper where we responded to Professor Olds in his capacity as peer reviewer of this paper. We thank him for his constructive comments at each stage.
Michael Robling on behalf of the BB:2-6 study team
References
1. Olds D. Improving the Report of the Buildling Blocks 2-6 study (14th February 2022) [Letter] BMJOpen 2022
2. Robling M, Lugg-Widger FV, Cannings-John R, et al. Nurse-led home-visitation programme for first-time mothers in reducing maltreatment and improving child health and development (BB:2-6): longer-term outcomes from a randomised cohort using data linkage. BMJ Open 2022;12:e049960. doi:10.1136/bmjopen-2021-049960
3. Robling M, Cannings-John R, Channon S, et al. What is usual care for teenagers expecting their first child in England? A process evaluation using key informant mapping and participant survey as part of the Building Blocks randomised controlled trial of specialist home visiting. BMJ Open 2018;8:e020152. doi:10.1136/bmjopen-2017-020152
4. Robling M, Bekkers M-J, Bell K, et al. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (building blocks): a pragmatic randomised controlled trial. Lancet 2016;387:146–55.
5. Olds D, Henderson CR, Kitzman H, et al. Effects of prenatal and infancy nurse home visitation on surveillance of child maltreatment. Pediatrics 1995;95:365–72.
Mr Ioannnidis is close to the initiators of the Great Barrington initiative. He uses biased data and false logic to pursue yet another attempt at confusing the public on the scientific consensus regarding covid19 prevention and control.
I thank Meyerowitz-Katz, Rigby, Nurse and Grant for their comments, Gorski for his second comment and Bak-Coleman for his third comment.
Meyerowitz-Katz offers valuable insights. In-depth analyses of GBD and JSM scientists in diverse social media platforms is an excellent idea. Nurse and Grant also make astute suggestions on this issue. A collaborative effort may be launched, since Gorski and Bak-Coleman also make similar points in passim. Collectively the team has superb complementary expertise. Such studies could also perform in-depth content analyses and interviews of scientists, and then IRB approval is indispensable. I also fully agree that pre-pandemic social media activity and rate of growth during the pandemic deserve attention. Probably GBD has a more steep increase over time than JSM; this may associate also with increasing acceptance of its proposals. The pandemic exploded social media presence for many scientists (e.g. Jay Bhattacharya: no Twitter account in April 2021, 81,000 followers in November 2021, 170,000 in February 2022). Analyses should separate social media presence of organizations. Organizations serve too many purposes to fix them to one or the other document. Moreover, comparing dissemination of the 2 main documents across non-Twitter social media is biased: GBD attracted signatures also from the general public (close to 1 million signatures to-date), while JSM remained focused to experts. Given this different outlook, unsurprisingly GBD...
I thank Meyerowitz-Katz, Rigby, Nurse and Grant for their comments, Gorski for his second comment and Bak-Coleman for his third comment.
Meyerowitz-Katz offers valuable insights. In-depth analyses of GBD and JSM scientists in diverse social media platforms is an excellent idea. Nurse and Grant also make astute suggestions on this issue. A collaborative effort may be launched, since Gorski and Bak-Coleman also make similar points in passim. Collectively the team has superb complementary expertise. Such studies could also perform in-depth content analyses and interviews of scientists, and then IRB approval is indispensable. I also fully agree that pre-pandemic social media activity and rate of growth during the pandemic deserve attention. Probably GBD has a more steep increase over time than JSM; this may associate also with increasing acceptance of its proposals. The pandemic exploded social media presence for many scientists (e.g. Jay Bhattacharya: no Twitter account in April 2021, 81,000 followers in November 2021, 170,000 in February 2022). Analyses should separate social media presence of organizations. Organizations serve too many purposes to fix them to one or the other document. Moreover, comparing dissemination of the 2 main documents across non-Twitter social media is biased: GBD attracted signatures also from the general public (close to 1 million signatures to-date), while JSM remained focused to experts. Given this different outlook, unsurprisingly GBD must have been disseminated more widely than JSM in the general public. However, for important policy decisions and adopted official public health stance, experts matter the most. Many GBD and JSM experts shaped public policy as advisors to governments or states, leaders of public health organizations, and advocates. Moreover, while other platforms outnumber Twitter and predominate in personal/family/colloquial/political matters, Twitter is a scientific argumentation epicenter. The Altmetric score that tracks social media influence of published scientific papers is shaped largely by Twitter rather than other platforms[1,2]. Finally, Twitter WHO certification of infectious diseases epidemiologists is a hypothesis worth formal testing.
I agree with Gorski that divisiveness originates from multiple sources on all sides. I worry about divisiveness regardless of its origins. If even erudite communicators become divisive, we cannot have much hope for the rest of humanity. Gorski mentions several examples of divisive statements. One can certainly find millions of such comments coming from diverse ideologies, communities, and scientific expertise level. There are over 2 billion COVID-19-related tweets[3] and many may be inappropriate. Even the best communicators make occasional divisive comments, especially when very active. Importantly, short eye-catching sentences in social media often lack nuance and balance necessary for science. Conversely, reconciliation is a difficult art and requires patience. I have personally struggled for reconciliation, but even kind words and praise can be mistaken as attacks. We all need to try more to communicate with everyone. It does not suffice to reach only those who agree with us.
I cannot comment about statements made by others, but I listened to the podcast[4] where Gorski says that I made an irresponsible misstatement at 1:37. At 1:37 I referred to my article in Nature Communications, an international collaborative meta-analysis showing that hydroxychloroquine (at least in high doses) significantly increased mortality[5]. I believe this is correct. Later, I do mention that probably we had more deaths because of not knowing how to use mechanical ventilation. This statement is also correct. The paper cited by Gorski is examining early versus late intubations[6] and actually concludes that “these results might justify a wait-and-see approach, which may lead to fewer intubations”, however this was not the key issue discussed here. In many countries, due to chronic, limited spending in public healthcare systems, new ICU beds were set up urgently with inexperienced staff who fought heroically but with limited means, support, and training. This is particularly true with ailing health systems and/or austerity measures. E.g. in Greece, mortality rates in select ICUs was astounding and pressure on the system increased fatalities[7]. In the USA, despite enormous GDP spending on health, many people remain disadvantaged and under-served. In low/middle-income countries, 5 million deaths annually are due to poor-quality care[8]. The misinterpretation of my statement shows how difficult it is to pre-emptively eliminate possible misunderstanding. Sciencemedicine.org devoted a 1802 word blog to this issue[9], concurrently attacking a technical article I published[10]. Sadly, that blog totally missed the essence of my points and delved into conspiracy theories. Perhaps it is too facile for a blogger to make a stunning statement that “Dr. Ioannidis continues to promote the QAnon meme”[9] rather than explain carefully what my equation R=cPSm(t+d)X/PSF=c(t+d)Xm/F means for the calculation of COVID-19 deaths[10]. Conspiracy theorists can sadly weaponize all and any science. However, when a talented science communicator links me with conspiracy theories, this only facilitates weaponization.
Rigby mentions the limitations of both citation and Twitter markers. I agree, but not to the point of nihilism for them. No hostility meant to Bak-Coleman, I simply could not understand what more I could say about a 2x2 exact test and Mann-Whitney test. I thank Nurse and Grant for comparing me to Kanye. Very amusing! However, unlike Kanye, my performance in rapping is worse than my performance in research where I classify myself in the “struggling” category. Moreover, in contrast to Kanye, I have no social media platforms whatsoever. I do hope Nurse and Grant will apply their specialized knowledge to the important questions discussed here, my paper was only an initial effort. Causal statements are precarious, but social media presence in and about science is overwhelming and we should not shun from studying it. My work should hopefully stimulate knowledgeable people to engage more, not less.
We should be transparent with disclosures but not over-interpret conflicts. I worry when scientists use unfounded charges of conflicts of interest to trash arguments of scientists with different opinions. E.g., I was so fascinated by the comments of Nurse and Grant that I tried to find more about their work with the possibility of collaborating with them. Nurse’s webpage (https://cpas.anu.edu.au/people/students/matt-nurse) says that “he has also worked as a media adviser for two state premiers, two commonwealth front-benchers and for a major Australian political party during a national election” and Grant lists in his impressive CV (https://cpas.anu.edu.au/people/academics/dr-will-grant) that he is “sought for advice by a range of key government and non-government stakeholders, including the Department of Industry and Science in various areas including the Office of the Chief Scientist, the Research Infrastructure and Science Policy Branch and the Australian e-Research Infrastructure Council; the Department of Education; and CSIRO”. Perhaps some of these activities should have been disclosed, but it would be weird to invalidate one’s credibility because of legitimate activities. In communication, many stakeholders often have extensive engagements and may have allies in powerful government or private institutions. We should not demonize them or their allies. Open dialogue will always help. Thus I look forward to the possibility of GBD and JSM scientists engaging together in dispassionate dialogue, a sign that real progress has been achieved.
References
1. Thelwall M , Haustein S , Lariviere V, et al. Do altmetrics work? Twitter and ten other social web services. PloS One 2013;8:e64841. doi: 10.1371/journal.pone.0064841
2. Studenic P, Ospelt C. Do you tweet?: trailing the connection between Altmetric and research impact! RMD Open 2020;6:e001034. doi: 10.1136/rmdopen-2019-001034
3. Chen E, Lerman K, Ferrara E. Tracking social media discourse about the COVID-19 pandemic: development of a public coronavirus Twitter data set. JMIR Public Health Surveill 2020;6(2):e19273
4. https://podcasts.apple.com/us/podcast/3-41-building-a-meta-research-care... (at 1:37)
5. Axfors C, Schmitt AM, Janiaud P, et al. Mortality outcomes with hydroxychloroquine and chloroquine in COVID-19: an international collaborative meta-analysis of randomized trials. Nature Communications 2021 Apr 15;12(1):2349. doi: 10.1038/s41467-021-22446-z.
6. Papoutsi, E., Giannakoulis, V.G., Xourgia, E. et al. Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: a systematic review and meta-analysis of non-randomized cohort studies. Crit Care 25, 121 (2021).
7. Lytras T, Tsiodras S. Total patient load, regional disparities and in-hospital mortality of intubated COVID-19 patients in Greece, from September 2020 to May 2021. Scand J Public Health. 2021 Dec 13:14034948211059968. doi: 10.1177/14034948211059968.5 million
8. Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018 Nov 17;392(10160):2203-2212. doi: 10.1016/S0140-6736(18)31668-4.
9. Howard J. Intubations and Accusations: Doctors were “just going crazy, and intubating people who did not have to be intubated”, in https://sciencebasedmedicine.org/intubations/
10. Ioannidis JP. Over- and under-estimating COVID-19 deaths. European Journal of Epidemiology 2021 Jun;36(6):581-588. doi: 10.1007/s10654-021-00787-9.
In the latest response to his growing number of critics [1], Professor Ioannidis forcefully defends his record and continues to suggest that having signed neither the Great Barrington Declaration (GBD) nor the John Snow Memo (JSM), he is in an objective position. In a previous response [2], Professor Ioannidis has selectively quoted from interviews and events that occurred in the spring of 2020 to make a case that he has not lobbied for the positions espoused by the GBD and thus argues that he has no undeclared conflicts of interests. This is unfortunate, as there is evidence of his views at the more relevant time (the fall of 2020, when both the GBD and JSM were published).
In late 2020, the White House coronavirus czar was Dr Scott Atlas, a colleague of Professor Ioannidis at Stanford. The appointment was controversial because of Dr Atlas’s lack of experience with infectious disease control. It is a matter of record that President Trump held a roundtable in August 2020 that included Atlas and two GBD authors, Jay Bhattacharya and Martin Kulldorff [3, 4]. This was a secret meeting; details about it were only made public a year later, thanks to the work of the Select Subcommittee on the Coronavirus Crisis [3]. The day after this meeting, President Trump described his strategy as "sheltering those at highest risk, especially the elderly, while allowing lower risk Americans to safely return to work and to school...they have to get back to work," a strategy t...
In the latest response to his growing number of critics [1], Professor Ioannidis forcefully defends his record and continues to suggest that having signed neither the Great Barrington Declaration (GBD) nor the John Snow Memo (JSM), he is in an objective position. In a previous response [2], Professor Ioannidis has selectively quoted from interviews and events that occurred in the spring of 2020 to make a case that he has not lobbied for the positions espoused by the GBD and thus argues that he has no undeclared conflicts of interests. This is unfortunate, as there is evidence of his views at the more relevant time (the fall of 2020, when both the GBD and JSM were published).
In late 2020, the White House coronavirus czar was Dr Scott Atlas, a colleague of Professor Ioannidis at Stanford. The appointment was controversial because of Dr Atlas’s lack of experience with infectious disease control. It is a matter of record that President Trump held a roundtable in August 2020 that included Atlas and two GBD authors, Jay Bhattacharya and Martin Kulldorff [3, 4]. This was a secret meeting; details about it were only made public a year later, thanks to the work of the Select Subcommittee on the Coronavirus Crisis [3]. The day after this meeting, President Trump described his strategy as "sheltering those at highest risk, especially the elderly, while allowing lower risk Americans to safely return to work and to school...they have to get back to work," a strategy that is entirely in keeping with the GBD [5]. The announcement of Trump’s GBD-like strategy was at roughly the same time that Atlas was pushing to cut testing for Covid-19 [6], a push that was not supported by experts in infectious disease control. On the day that the GBD was published, October 5 2020, the three GBD authors met with Atlas and Health and Human Services Secretary Alex Azar to lobby for the GBD’s policy prescriptions [7]. Atlas was very outspoken in his praise for the GBD [8].
Since then Dr Atlas published a memoir, called “A Plague Upon Our House,” which praises Professor Ioannidis and the GBD authors multiple times throughout the book [9]. For example, in Atlas’s attack on Deborah Birx, President Trump’s White House Coronavirus Response Coordinator, Atlas writes:
“she [Dr Birx] insisted that all experts agreed with her. I shook my head, thinking of some of the world-class epidemiologists who agreed with me—John Ioannidis and Jay Bhattacharya of Stanford, Martin Kulldorff of Harvard, Carl Heneghan and Sunetra Gupta of Oxford—and wondered if she or Fauci had ever read a single publication by them” [9].
Atlas is stating that Professor Ioannidis “agreed with him,” and did so specifically during the period in which Atlas was dueling with Dr Birx on how to manage the US pandemic response following the GBD’s online publication.
Further, in January 2021, on an appearance on Tucker Carlson’s show on Fox News, Atlas specifically thanked Professor Ioannidis [10]. Atlas said:
“I just want to say, I have a shout out to my friend and colleague John Ioannidis at Stanford who kept reassuring me during that time, ‘Scott, the truth will prevail. Everything you're saying is exactly right,’” which further demonstrates the influence Professor Ioannidis enjoyed over the pandemic response.
If Scott Atlas’s statements are accurate, Professor Ioannidis has not been open with his views. At the very least, this lack of openness produces the appearance of a conflict of interest if one wishes to compare the GBD and JSM in terms of the merits of their supporters. If he in fact dissents from Scott Atlas’s public statements, then it is surely problematic that Professor Ioannidis’ reputation has been used in this fashion and he can certainly set the record straight.
Professor Ioannidis insists that the authors of the GBD have no conflicts of interest on the grounds that they have simply denied having any; indeed, he argues that it is wrong for the critics of the GBD to suggest that any such conflicts might exist. But these conflicts are very well described—in the BMJ itself—and are now a matter of public record. The GBD was supported by the AIER, a libertarian, climate-denialist, pro-tobacco, free market think tank. The AIER’s support for the GBD “came in the form of providing meeting space and lodging, arranging a meeting with journalists, editorial feedback, and amplification in the media (including videography, social media, and web services)” [11]. The AIER wined and dined the GBD. As previously noted, “’sponsorship’ in the US encompasses not just direct payments to featured participants, but also meals, lodging, travel, alcohol, meeting facilities, communication and organizational support, and other expenses.” [11] It is now public knowledge that the AIER covered the costs of the GBD authors’ lodging at AIER’s mansion in Great Barrington, MA, the town after which the GBD was named [2020]. All of this major support to the GBD from the AIER, which has a large monetary value, clearly represents a conflict of interest. I note that the since the JSM was published in a medical journal, The Lancet, the JSM authors were required to publish their conflicts of interest. In contrast, the GBD was not published in an academic journal—only online—and so its authors never had to disclose their conflicts.
Professor Ioannidis accuses GBD critics of divisiveness and says that such “divisiveness eventually hinders wide endorsement of life-saving measures like vaccines” [1]. Claiming neutrality, as he does, while accusing scientific viewpoints that threaten profit margins of being “divisive” is a strategy that has been used by the fossil fuel and tobacco industries, as Naomi Oreskes and Erik Conway describe in their book “Merchants of Doubt.” It is a political tactic, not a scientific one, to claim that push back on anti-science and partisan positions is “divisive,” a tactic in which the AEIR is quite experienced. The authors of the GBD now espouse vaccine disinformation and views on vaccines that are very far outside the mainstream [12-15]; to claim that criticism of these views is “divisive” is certainly not neutral.
In this paper, the primary ambition is stated as: "Here, an analysis is being performed to try to evaluate the scientific impact and the social media visibility of the key signatories who have led the two strategies… Concurrently, an additional analysis evaluated the social media visibility of signatories, as denoted by Twitter followers ". However, the methodology used is clearly inadequate for this stated purpose, with the ultimate consequence that the paper is largely meaningless as an analysis of social media visibility.
A key limitation not noted in this study is that the author has chosen to use a metric designed for one of the smallest social media platforms in the world. While precise figures may be opaquely calculated due to commercial interests, Twitter reported 192 million monetizable active users in 2020 (1), and according to the data aggregation website Statista has a total of 436 million 'active' users as of October 2021 (2). This is in stark contrast to other social media sites such as Facebook (2.9 billion users) Youtube (2.3 billion users) and even newer platforms such as Telegram (550 million users) Snapchat (538 million users) and Tiktok (1 billion users) (2).
On examining other social media sites, the inadequacy of using only metrics derived from Twitter becomes immediately apparent. Facebook shares can be analyzed freely through several websites linked to the API (3,4), and these show that the URL for the Great Barring...
In this paper, the primary ambition is stated as: "Here, an analysis is being performed to try to evaluate the scientific impact and the social media visibility of the key signatories who have led the two strategies… Concurrently, an additional analysis evaluated the social media visibility of signatories, as denoted by Twitter followers ". However, the methodology used is clearly inadequate for this stated purpose, with the ultimate consequence that the paper is largely meaningless as an analysis of social media visibility.
A key limitation not noted in this study is that the author has chosen to use a metric designed for one of the smallest social media platforms in the world. While precise figures may be opaquely calculated due to commercial interests, Twitter reported 192 million monetizable active users in 2020 (1), and according to the data aggregation website Statista has a total of 436 million 'active' users as of October 2021 (2). This is in stark contrast to other social media sites such as Facebook (2.9 billion users) Youtube (2.3 billion users) and even newer platforms such as Telegram (550 million users) Snapchat (538 million users) and Tiktok (1 billion users) (2).
On examining other social media sites, the inadequacy of using only metrics derived from Twitter becomes immediately apparent. Facebook shares can be analyzed freely through several websites linked to the API (3,4), and these show that the URL for the Great Barrington Declaration (https://gbdeclaration.org/) has been shared more than 700,000 times on the platform. The John Snow Memorandum (https://www.johnsnowmemo.com/), meanwhile, has seen just 10,000 shares, or roughly one seven-hundredth the number. This may be in part due to the large following of the American Institute for Economic Research (AIER) on Facebook (340k followers) the organisation that hosted the GBD in 2020.
Regardless, this reveals the inadequacy of the methodology used in this analysis - a single YouTube video may reach far more individuals than a Twitter account even with many followers. As one minor example, the video from the AIER official YouTube account marking the signing of the declaration has over 4700 likes as of writing (5), while the original tweet with the same information has only 162 likes (6). While not perfectly comparable, these metrics give some insight into the extremely limited information that relying only on Twitter when performing a social media analysis gives.
Furthermore, simple counts of Twitter followers are misleading. As with many social media platforms, Twitter prioritizes user access to output from accounts using opaque algorithms that are a closely-guarded commercial secret. It is impossible to properly measure how this has impacted the spread of either the GBD or JSM on Twitter without careful, in-depth analysis of measures such as retweets, likes, and similar. To show how misleading relying on simple follower counts can be, it is interesting to note that the current pinned tweet on Prof Jay Bhattacharya's twitter page directly links to the GBD website, and has >13,500 likes (7). Conversely, a tweet from Dr Deepti Gurdasani promoting the JSM in October 2020 has only 367 likes (8), despite the similar follower count between the two personal Twitter accounts. Perhaps more strikingly, despite having a higher number of twitter followers as of October 2020, Prof Bill Hanage’s initial tweets about the JSM in October 2020 attracted fewer than one-fifth the number of likes and retweets as Prof Martin Kulldorff’s tweets about the GBD in the same time period (9, 10)
It is also important to note that even the analysis of Twitter followers as a crude and misleading placeholder for impact is itself not sufficiently robust to derive conclusions from. Twitter followers among scientists have increased dramatically due to the pandemic, especially those engaged in social activism. For example, the personal account of Prof Bill Hanage currently has over 66,000 followers, but by January 2020 had attracted only 2,000 despite being a prolific tweeter with over 11,000 tweets (9). Failing to include an analysis of the situation pre-pandemic means that even the minimal meaning that can be drawn from the twitter follower counts as of April 2021 (6 months after the GBD and JSM were published) is likely fraught with uncontrolled confounders. Indeed, given that the World Health Organization partnered with Twitter to create and certify accounts for infectious disease epidemiologists and experts (10), one might argue that the higher Twitter following of the JSM simply reflects the higher proportion of relevant experts (and/or members of the WHO) who wrote and signed the document - as the author's analysis shows, a lower proportion of the GBD authors and signatories were themselves infectious disease epidemiologists at the advent of the pandemic.
The consequence of these limitations for the study is clear - all references to "social media" in a broader sense are incorrect as there has been no analysis of social media aside from one of the smaller platforms. Moreover, limiting the analysis to a crude count of Twitter followers means that statements such as "the data suggest that the massive superiority of JSM over GBD in terms of Twitter firepower may have helped shape the narrative that it is the dominant strategy pursued by a vast majority of knowledgeable scientists. " are unsupported - this study is not sufficiently rigorous to conclude that there was a "massive superiority...in terms of Twitter firepower" as it did not include any measurement of impact of either the JSM or GBD on Twitter. Indeed, crude analyses of the "firepower" of the GBD suggests that in fact it has been shared far more often and more widely on every social media platform (including Twitter) than the JSM.
In conclusion, while there may be more Twitter users in the JSM authorship group than the GBD, the numeric analysis presented in this paper is not sufficiently rigorous to infer any conclusions about the relative impacts of either petition on social media. In fact, the statistics from numerous sources appear to demonstrate that the GBD has had orders of magnitude more shares on social media websites, once we move beyond the flawed metric of Twitter followers as of April 2021. If nothing else, having 700x more shares on the largest social media platform in the world (Facebook) ensures that the social media reach of the GBD has vastly overshadowed the JSM, largely undermining the arguments presented in the paper.
I thank Prof. Ioannidis for his response. Although I am honored that someone of Prof. Ioannidis' prominence is aware of the blog for which I serve as managing editor—even so flatteringly noticing the word count of my blog post about his study (1).
Unfortunately, it is difficult for me not to notice that in his responses (the first of which he referred me to so pointedly) (2, 3), Prof. Ioannidis continues to show no indication that he understands the massive conceptual flaw at the heart of his analysis: The Kardashian index was meant as a joke. He even responds, "The Twitter presence of many signatories is loud (even if laudable) regardless of whether number of followers is expressed as absolute count, k-index, log10, square root, or sinφ. Twitter influence on public perception of science, media, and policy is large, an elephant in the room that needs better study. An elephant is an elephant regardless of whether one presents his weight in kilograms or in pounds" (3) This comparison not only mistakenly represents Twitter as the be-all and end-all of social media influence—leading me to suggest that at all costs he stay away from Tik Tok—but also falsely equates using a satirical measure for an inappropriately serious purpose with a simple choice between commonly accepted units of measure. Indeed, this failure to recognize the K-index as satire on the part of Prof. Ioannidis and the peer reviewers would seem to me to reinforce Neil Hall's very poin...
I thank Prof. Ioannidis for his response. Although I am honored that someone of Prof. Ioannidis' prominence is aware of the blog for which I serve as managing editor—even so flatteringly noticing the word count of my blog post about his study (1).
Unfortunately, it is difficult for me not to notice that in his responses (the first of which he referred me to so pointedly) (2, 3), Prof. Ioannidis continues to show no indication that he understands the massive conceptual flaw at the heart of his analysis: The Kardashian index was meant as a joke. He even responds, "The Twitter presence of many signatories is loud (even if laudable) regardless of whether number of followers is expressed as absolute count, k-index, log10, square root, or sinφ. Twitter influence on public perception of science, media, and policy is large, an elephant in the room that needs better study. An elephant is an elephant regardless of whether one presents his weight in kilograms or in pounds" (3) This comparison not only mistakenly represents Twitter as the be-all and end-all of social media influence—leading me to suggest that at all costs he stay away from Tik Tok—but also falsely equates using a satirical measure for an inappropriately serious purpose with a simple choice between commonly accepted units of measure. Indeed, this failure to recognize the K-index as satire on the part of Prof. Ioannidis and the peer reviewers would seem to me to reinforce Neil Hall's very point in conceiving it—specifically the obsession of some scientists with citation counts as indicative of scientific excellence (4).
More important than rehashing my original critique (5), however, is responding to Prof. Ioannidis' accusation against Gavin Yamey and me that our criticism of the Great Barrington Declaration (GBD) and AIER has been so "divisive" that it "hinders wide endorsement of life-saving measures like vaccines." Although I am humbled that someone of Prof. Ioannidis' eminence would even entertain the idea that Gavin and I have such outsized influence, I assure him that I, at least, do not. Quite the contrary, in fact! Given how wide and deep the contacts between GBD signatories and various governments in the US and the UK that we documented (6) and how large a presence GBD proponents have on "old" media like Fox News (7) our influence seems puny in comparison.
Nonetheless, I still argue that: 1.) we accurately reported connections between "merchants of doubt," the AIER, and the GBD (6), and 2.) our criticisms are actually relatively tame compared to the demonization of public health interventions flowing from GBD-linked sources. For example, surely Prof. Ioannidis must be aware of the Brownstone Institute (BI) (8). Described by its founder Jeffrey Tucker, former AIER editorial director (who has bragged about helping edit the GBD) (9), as the "spiritual child of the GBD" (10), the BI boasts of having all three GBD authors affiliated with it (11). Indeed, three months ago Martin Kuldorff himself left his tenured faculty position at Harvard University to become BI's Scientific Director (12), and Prof. Ioannidis' Stanford colleague and friend Jay Bhattarcharya is a Senior Scholar (13), with Sunetra Gupta having co-authored a number of articles (14). One would think that, if GBD supporters truly wanted "nuanced" and "civil" debate, there could be no better platform for them to demonstrate their commitment to that and lead by example than at the BI.
Unfortunately, the BI is hardly "nuanced" in its messaging about public health interventions against COVID-19 or its response to GBD critics. For example, articles on the BI website have likened treatment of the unvaccinated to "othering" that led to the Holocaust, the gulag, and the Rwandan genocide (15), vaccine mandates to prohibition (16) public health efforts to Nazi manipulation of crowds (17), and Dr. Robert Malone, who has promoted many antivaccine conspiracy theories, to a hero (18). Other BI articles liken vaccine mandates to atrocities such as the Chinese Cultural Revolution (19), all while falsely claiming that masks harm children (20) and cause "brain fog" (21), while and likening mask wearers to "tribes" (22) and masks instruments of slavery (23) and control (24) rather than public health. Worse, recent news report describes how the BI has spread antivaccine misinformation in Uganda (25). Let me suggest to Prof. Ioannidis that the messaging portraying vaccine and masking mandates as "tyranny" and ineffective is likely to be more harmful to widespread vaccine uptake than anything Dr. Yamey or I could ever do.
No doubt Prof. Ioannidis will have a hard time believing that GBD authors had anything to do with these sorts of "divisive" messages from the BI, although that denial would be rather unconvincing to me given Kulldorff's and Bhattacharya's continuing to serve in high ranking positions there. After all, if they so opposed to such "divisive" messages, why do they continue to lend their reputations to the BI and its message? An answer suggests itself. One only has to quote certain GBD signatories themselves to realize that, at the very best, they are not strongly opposed to BI's "divisive" messages. For example, Kulldorff and Bhattacharya have written, "The idea that everyone must be vaccinated against COVID-19 is as misguided as the anti-vax idea that no one should. The former is more dangerous for public health" (26) Does Prof. Ioannidis agree with this statement, which I view as a false dichotomy and quite inflammatory? Kulldorff and Bhattarcharya have also likened Anthony Fauci and public health officials who do not accept the GBD to a "'covidian' high priesthood" (27), a message repeated by Kulldorff on Twitter (28). I note from my long experience dealing with these issues that comparing scientists to priests or cult leaders is a common rhetorical technique by antivaccine activists and science deniers. Even the kindest description of such rhetoric would not include the words "nuanced" or "civil." Might I suggest that there is a valid reason why my criticism of the GBD and its signatories has at times been harsh, particularly given the appearance of GBD authors on The Epoch Times (29), a conspiracy site that is strongly antivax?
I am not asking Prof. Ioannidis to defend the many divisive statements that that Kuldorff, Bhattacharya, and Gupta have made since the GBD was published 16 months ago. I am, however, pointing out a rather obvious asymmetry in his criticisms in his BMJ Open study and his responses to critiques of it. I also note that Prof. Ioannidis himself has not always been above saying what I consider to be some rather divisive things himself. For example, he has claimed without evidence 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” (30). This is an irresponsible misstatement of a controversy early in the pandemic over whether early or later intubation was more effective for COVID-19 patients that portrays intensivists as incompetent and too eager to intubate, and there is no evidence to support it (31).
There are other examples that I can provide if the discussion warrants, they likely will not be necessary because Prof. Ioannidis' poorly conceived exercise in bibliometrics that portray John Snow Memorandum (JSM) signatories as social media "science Kardashians" driving the narrative about the GBD is in itself quite "divisive." Certainly GBD supporters, such as AIER (32) and its Interim Research and Education Director Phil Magness (33, 34) have used it that way, as have GBD-sympathetic traditional media (35), which brings me back to the question: Why did Prof. Ioannidis engage in such an exercise, if not as an attack on critics of the GBD, his grandiosely effusive praises of JSM signatories notwithstanding?
Dr. Ioannidis has responded to a request to disclose the statistical tests used to compute p-values by calling them a superfluous " focus on statistical testing." Given that such a simple request was met with deflection and hostility, it is difficult to see how further discussion will be productive or advance scientific knowledge in any meaningful way.
This paper serves as a powerful testament to how highly-cited scientists are not beholden to even the most basic standards of scientific research. They needn't follow ethical norms, disclose conflicts of interest, consider the validity of metrics, or even report which analysis they used.
They are free to publish numerically-glazed opinions in prestigious venues intended to house knowledge. For the rest of us, there's Twitter.
The paper by Ioannidis is fatally flawed by the assumption that citation counts and Twitter activity correlate with scientific quality or health and policy impact. No hypothesis has been presented to support this. Opportunities to publish at scale will be influenced by length of career, and by other academic commitments. Reasons for high citation of papers may be to challenge or seek more clarity as much to commend or build on them. This point has been demonstrated in a peer reviewed paper which contrasted the examples of publication of contentious views gaining high citations, while a research finding which quickly got applied in practice had a single publication (1); the high-cited author eventually had his licence to practice withdrawn, while he who led to many lives being saved globally had no profile. Ioannidis seems to confuse noise and twittering with good grounding and integrity of evidence.
(1) Rigby M. Citation Analysis in Health Care Sciences - Innovative Investigation or Seductive Pseudo-science?; Methods Inf Med 2014; 53(06): 459-463, DOI: 10.3414/ME14-05-0004
I thank Gorski, Dahly, and Pimenta for their criticism and Yamey and Bak-Coleman for their second round of comments. As already stated, I signed neither GBD nor JSM, my study did not aim to elevate or downgrade one or the other narrative, and I congratulate all GBD and JSM signatories. The 443 signatories from GBD include 4 scientists with whom I have co-authored, and 3 with Stanford affiliation. The respective first 443 signatories of JSM include 5 scientists with whom I have co-authored, and 15 with Stanford affiliation. I have co-authored COVID-19 scientific papers with both GBD and JSM signatories (more with the latter). I have more close ongoing collaborators and friends in JSM than GBD. According to Scopus I have 6590 co-authors and probably >200 have signed GBD or JSM. I have learned from both JSM and GBD colleagues and I thank them all for sharing their wisdom.
As I did in my original paper, I applaud Pimenta again for his amazing work. Additional studies of engagement, impressions and reach would be very useful to perform. Pimenta defends fervently but needlessly some of the JSM main points, since my paper attacked neither JSM nor GBD. It only showed that both lists include many stellar scientists and that JSM had overwhelming Twitter presence. This is emphatically obvious also in the Twitter reception of my paper.
Gorski apparently submitted his rapid response and his 7591 words long blog in his sciencebasedmedicine.org website before seeing my...
I thank Gorski, Dahly, and Pimenta for their criticism and Yamey and Bak-Coleman for their second round of comments. As already stated, I signed neither GBD nor JSM, my study did not aim to elevate or downgrade one or the other narrative, and I congratulate all GBD and JSM signatories. The 443 signatories from GBD include 4 scientists with whom I have co-authored, and 3 with Stanford affiliation. The respective first 443 signatories of JSM include 5 scientists with whom I have co-authored, and 15 with Stanford affiliation. I have co-authored COVID-19 scientific papers with both GBD and JSM signatories (more with the latter). I have more close ongoing collaborators and friends in JSM than GBD. According to Scopus I have 6590 co-authors and probably >200 have signed GBD or JSM. I have learned from both JSM and GBD colleagues and I thank them all for sharing their wisdom.
As I did in my original paper, I applaud Pimenta again for his amazing work. Additional studies of engagement, impressions and reach would be very useful to perform. Pimenta defends fervently but needlessly some of the JSM main points, since my paper attacked neither JSM nor GBD. It only showed that both lists include many stellar scientists and that JSM had overwhelming Twitter presence. This is emphatically obvious also in the Twitter reception of my paper.
Gorski apparently submitted his rapid response and his 7591 words long blog in his sciencebasedmedicine.org website before seeing my response to previous comments. I refer him to it. The Twitter presence of many signatories is loud (even if laudable) regardless of whether number of followers is expressed as absolute count, k-index, log10, square root, or sinφ. Twitter influence on public perception of science, media, and policy is large, an elephant in the room that needs better study. An elephant is an elephant regardless of whether one presents his weight in kilograms or in pounds.
Ben-Coleman additionally wants more focus on statistical testing, but this is superfluous in a descriptive design. I agree with him that the paper “establishes that many key signatories of GBD did not identifiably use Twitter at the time of data collection” and I have already acknowledged that some Twitter accounts may not be easily retrievable from Google searches, but the difference is so stark that it is unlikely to be a data artifact. “Addresses, family members, places of work, and identities of political dissidents or victims of hate crime” were not the focus of data collection here. Anyone can search and report numbers of Twitter followers, it would be absurd to have to request permission for this. Also should influential advocates who publicly aim to regulate the life of billions of people be incognito or invisible?
Yamey falsely uses the term “lobbying” citing a BuzzFeed News story based on a spuriously selected sample of my e-mails. However, even the Buzzfeed News story clearly contradicts the “lobbying” label. How could I ever “lobby” against lockdowns when those in favor of lockdown at that time included me (as testified by interviews I gave in multiple countries[1-3]) and most other scientists in our group? What we sought was better data for addressing this major crisis in the long-term. We never saw the president or anyone in the Task Force, and, worse, the quest for reliable evidence was ridiculed with tragic consequences. The interpretation that my “controversial studies claim that the coronavirus isn’t that big a threat” is contradicted by multiple of my published studies which can be found in the folder Projects> COVID-19 published work in https://profiles.stanford.edu/john-ioannidis?tab=research-and-scholarship. Conversely, at about the same time, Yamey argued in interviews that this virus was “less fatal than previous epidemics” and claimed that “if I get coronavirus …the chances of my dying are zero percent…” (https://www.france24.com/en/video/20200227-when-it-comes-to-other-viruse...). Yamey also falsely claims that I predicted in a March 2020 editorial[4] that roughly 10,000 Americans could die from Covid-19. This is not what that editorial says, Yamey seems to be reading only tweets about it. My calculation estimated on average 10,000 deaths for each 1% of infected population, a surprisingly accurate estimate given the large uncertainty at that time. I discuss this stunning distortion of my work in [5]. Then Yamey quotes another Buzzfeed News paragraph that dwells on conservative commentaries. The truth is that, being adamant to stick to the evidence and not to espouse any political narrative, I was attacked right and left, with variable predilection in each country. For example, in Greece, the same BuzzFeed News material was re-used in an attack launched against me by an alt-right politician who wanted immigrants dispatched to uninhabited islands.
We need tolerance and dialogue with people who have different views in order to find ground for the common good. Demonizing does not help. Yamey and Gorski have fiercely attacked GBD and even AIER. I am in favor of full transparency of potential conflicts, but I think that their specific attack was inappropriate and justifiably led the BMJ to correct their relevant blog[6]. I am not affiliated with any political party and I feel strongly that science should not be kidnapped by politics. I respect people regardless of what party they vote for and I worry when political affiliation (conservative, liberal, libertarian, or progressive) is invoked to erode credibility of opponents in scientific matters.
Calling scientists stellar, recording their great impact and eventually congratulating all of them for their sense of social responsibility is not “an exercise in humiliating”. Conversely, calling some of the most accomplished scientists in the world “fringe” or “unethical” and loading them with alluded conflicts that they don’t have is demeaning, regardless of whether these scientists signed GBD, JSM, or neither. I am concerned about the increasing use of belittling cartoons, inflammatory tweets with crude ad hominem material, and overt ridicule instead of scientific data. Both Yamey and Gorski are talented communicators and they can offer much to restore courteous dialogue, to elevate science and the public health effort empowering healing and reconciliation. Conversely, divisiveness eventually hinders wide endorsement of life-saving measures like vaccines.
Finally, I share with Dahly the same choice about the most important words ever written about our field: the eloquent phrase of the late Doug Altman about research. Doug was a close friend of mine and I miss our interaction. I wonder how he would have responded to this major global crisis with his calm and generous spirit.
References
1. Ioannidis, John P. A. Interview given in March and published April 1, 2020 in Der Spiegel: Ist das Coronavirus weniger tödlich als ange-nommen? Die drakonischen Maßnahmen, …sind natürlich sinnvoll und auch gerechtfertigt, weil wir noch zu wenig über das Virus wissen (the draconian measures … of course make perfect sense and they are appropriate, because we still know little about the virus. In: https://www.spiegel.de/consent-a-?targetUrl=https%3A%2F%2Fwww.spiegel.de....
2. Ioannidis JPA. Interview given at the Stanford University studio on March 24, uploaded as detailed 1-hour video, Perspectives on the Pandemic, episode 1, https://www.dailymotion.com/video/x7ubcws. “I am perfectly happy to be in a situation of practically lockdown in California more or less, with shelter-in-place, but I think very soon we need to have that information to see what we did with that and where do we go next”. The video had over 1 million views but was censored in May by You Tube.
3. Ioannidis JPAI. Interview given on March 22 to in2life.gr: (“The lockdown is the correct decision, but…”): (the stringent measures that are taken at this phase are necessary because it seems that we have lost control of the epidemic, https://www.in2life.gr/features/notes/article/1004752/ioannhs-ioannidhs-...
4. Ioannidis JP. A fiasco-in-the-making? As the Coronavirus pandemic takes hold we are making decisions without reliable data. STAT (2020) https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-corona...
5. Ioannidis JP, Tanner M, Cripps S. Forecasting for COVID-19 has failed. Int J Forecasting 2022 April-June; 38(2): 423–438.Published only ne 2020 Aug 25. doi: 10.1016/j.ijforecast.2020.08.004
6. Gorski D, Yamey G. COVID-19 and the new merchants of doubt. blogs.bmj.com/bmj/2021/09/13/covid-19-and-the-new-merchants-of-doubt/
I thank Prof. Ioannidis for his second response (1) and am gratified that, as much as he disagrees with me, he considers me a talented science communicator. Although I am even more honored to realize that someone of Prof. Ioannidis' prominence is not only aware of the humble blog for which I serve as managing editor (2) but is sufficiently familiar with posts containing my much longer critique of his Kardashian index study (3) and that of one of my co-bloggers of some of his—shall we say?—less temperate assertions about the pandemic (4), to the point of having done actual word counts for both posts (5, 6), I am nonetheless disappointed to have to note that his response would seem to validate at least some of my criticisms (7, 8) of his study (9) and his prior responses (5, 6). Also, given that he has criticized one of my bloggers for "conspiracy theories," I feel the obligation to respond to defend him—and, of course, myself—for having used his blog post in my previous response (8).
What seems to have raised Prof. Ioannidis' ire the most was my observation about his having repeated a narrative that was an early conspiracy theory during the pandemic, which he described as facilitating weaponization of his words by linking him with conspiracy theories. I would counter that conspiracy theorists do not need me in the least; they were doing an outstanding job of "weaponizing" Prof. Ioannidis' words without my input, thanks to Prof. Ioan...
Show MoreWe thank Professor Olds for his thoughts on our work and we are happy to respond accordingly.1,2 Our paper reporting the cohort study directly addresses the risk of bias associated with health care professionals being aware of trial allocation.2 In our Discussion we elaborate on the potential mechanisms and opportunities for such bias to effect study findings in the UK trial setting, use evidence from the trial’s process evaluation where applicable and contemporary service data where available. We invited readers to form their own view on the plausibility and likelihood of subversion and would particularly welcome reflection from contemporary service professionals. Second, it should be noted that notification about trial participation and allocation was required under ethical approval for the trial and not simply a design choice. Finally, we systematically captured a wide range of participant-reported health and social contacts including for health visitors.3 This reflected the complex publicly funded supportive care available across both trial arms. We consider this added a richer picture of the disaggregated support available to and accessed by first-time mothers in the trial.
The difference in reported health visitor contacts in the original trial report (which included imputed values) and in the subsequent process evaluation paper and our current report (which includes recorded values only) is already addressed in the first section of the paper’s Discussion sect...
Show MoreMr Ioannnidis is close to the initiators of the Great Barrington initiative. He uses biased data and false logic to pursue yet another attempt at confusing the public on the scientific consensus regarding covid19 prevention and control.
I thank Meyerowitz-Katz, Rigby, Nurse and Grant for their comments, Gorski for his second comment and Bak-Coleman for his third comment.
Show MoreMeyerowitz-Katz offers valuable insights. In-depth analyses of GBD and JSM scientists in diverse social media platforms is an excellent idea. Nurse and Grant also make astute suggestions on this issue. A collaborative effort may be launched, since Gorski and Bak-Coleman also make similar points in passim. Collectively the team has superb complementary expertise. Such studies could also perform in-depth content analyses and interviews of scientists, and then IRB approval is indispensable. I also fully agree that pre-pandemic social media activity and rate of growth during the pandemic deserve attention. Probably GBD has a more steep increase over time than JSM; this may associate also with increasing acceptance of its proposals. The pandemic exploded social media presence for many scientists (e.g. Jay Bhattacharya: no Twitter account in April 2021, 81,000 followers in November 2021, 170,000 in February 2022). Analyses should separate social media presence of organizations. Organizations serve too many purposes to fix them to one or the other document. Moreover, comparing dissemination of the 2 main documents across non-Twitter social media is biased: GBD attracted signatures also from the general public (close to 1 million signatures to-date), while JSM remained focused to experts. Given this different outlook, unsurprisingly GBD...
In the latest response to his growing number of critics [1], Professor Ioannidis forcefully defends his record and continues to suggest that having signed neither the Great Barrington Declaration (GBD) nor the John Snow Memo (JSM), he is in an objective position. In a previous response [2], Professor Ioannidis has selectively quoted from interviews and events that occurred in the spring of 2020 to make a case that he has not lobbied for the positions espoused by the GBD and thus argues that he has no undeclared conflicts of interests. This is unfortunate, as there is evidence of his views at the more relevant time (the fall of 2020, when both the GBD and JSM were published).
In late 2020, the White House coronavirus czar was Dr Scott Atlas, a colleague of Professor Ioannidis at Stanford. The appointment was controversial because of Dr Atlas’s lack of experience with infectious disease control. It is a matter of record that President Trump held a roundtable in August 2020 that included Atlas and two GBD authors, Jay Bhattacharya and Martin Kulldorff [3, 4]. This was a secret meeting; details about it were only made public a year later, thanks to the work of the Select Subcommittee on the Coronavirus Crisis [3]. The day after this meeting, President Trump described his strategy as "sheltering those at highest risk, especially the elderly, while allowing lower risk Americans to safely return to work and to school...they have to get back to work," a strategy t...
Show MoreIn this paper, the primary ambition is stated as: "Here, an analysis is being performed to try to evaluate the scientific impact and the social media visibility of the key signatories who have led the two strategies… Concurrently, an additional analysis evaluated the social media visibility of signatories, as denoted by Twitter followers ". However, the methodology used is clearly inadequate for this stated purpose, with the ultimate consequence that the paper is largely meaningless as an analysis of social media visibility.
A key limitation not noted in this study is that the author has chosen to use a metric designed for one of the smallest social media platforms in the world. While precise figures may be opaquely calculated due to commercial interests, Twitter reported 192 million monetizable active users in 2020 (1), and according to the data aggregation website Statista has a total of 436 million 'active' users as of October 2021 (2). This is in stark contrast to other social media sites such as Facebook (2.9 billion users) Youtube (2.3 billion users) and even newer platforms such as Telegram (550 million users) Snapchat (538 million users) and Tiktok (1 billion users) (2).
On examining other social media sites, the inadequacy of using only metrics derived from Twitter becomes immediately apparent. Facebook shares can be analyzed freely through several websites linked to the API (3,4), and these show that the URL for the Great Barring...
Show MoreI thank Prof. Ioannidis for his response. Although I am honored that someone of Prof. Ioannidis' prominence is aware of the blog for which I serve as managing editor—even so flatteringly noticing the word count of my blog post about his study (1).
Unfortunately, it is difficult for me not to notice that in his responses (the first of which he referred me to so pointedly) (2, 3), Prof. Ioannidis continues to show no indication that he understands the massive conceptual flaw at the heart of his analysis: The Kardashian index was meant as a joke. He even responds, "The Twitter presence of many signatories is loud (even if laudable) regardless of whether number of followers is expressed as absolute count, k-index, log10, square root, or sinφ. Twitter influence on public perception of science, media, and policy is large, an elephant in the room that needs better study. An elephant is an elephant regardless of whether one presents his weight in kilograms or in pounds" (3) This comparison not only mistakenly represents Twitter as the be-all and end-all of social media influence—leading me to suggest that at all costs he stay away from Tik Tok—but also falsely equates using a satirical measure for an inappropriately serious purpose with a simple choice between commonly accepted units of measure. Indeed, this failure to recognize the K-index as satire on the part of Prof. Ioannidis and the peer reviewers would seem to me to reinforce Neil Hall's very poin...
Show MoreDr. Ioannidis has responded to a request to disclose the statistical tests used to compute p-values by calling them a superfluous " focus on statistical testing." Given that such a simple request was met with deflection and hostility, it is difficult to see how further discussion will be productive or advance scientific knowledge in any meaningful way.
This paper serves as a powerful testament to how highly-cited scientists are not beholden to even the most basic standards of scientific research. They needn't follow ethical norms, disclose conflicts of interest, consider the validity of metrics, or even report which analysis they used.
They are free to publish numerically-glazed opinions in prestigious venues intended to house knowledge. For the rest of us, there's Twitter.
The paper by Ioannidis is fatally flawed by the assumption that citation counts and Twitter activity correlate with scientific quality or health and policy impact. No hypothesis has been presented to support this. Opportunities to publish at scale will be influenced by length of career, and by other academic commitments. Reasons for high citation of papers may be to challenge or seek more clarity as much to commend or build on them. This point has been demonstrated in a peer reviewed paper which contrasted the examples of publication of contentious views gaining high citations, while a research finding which quickly got applied in practice had a single publication (1); the high-cited author eventually had his licence to practice withdrawn, while he who led to many lives being saved globally had no profile. Ioannidis seems to confuse noise and twittering with good grounding and integrity of evidence.
(1) Rigby M. Citation Analysis in Health Care Sciences - Innovative Investigation or Seductive Pseudo-science?; Methods Inf Med 2014; 53(06): 459-463, DOI: 10.3414/ME14-05-0004
I thank Gorski, Dahly, and Pimenta for their criticism and Yamey and Bak-Coleman for their second round of comments. As already stated, I signed neither GBD nor JSM, my study did not aim to elevate or downgrade one or the other narrative, and I congratulate all GBD and JSM signatories. The 443 signatories from GBD include 4 scientists with whom I have co-authored, and 3 with Stanford affiliation. The respective first 443 signatories of JSM include 5 scientists with whom I have co-authored, and 15 with Stanford affiliation. I have co-authored COVID-19 scientific papers with both GBD and JSM signatories (more with the latter). I have more close ongoing collaborators and friends in JSM than GBD. According to Scopus I have 6590 co-authors and probably >200 have signed GBD or JSM. I have learned from both JSM and GBD colleagues and I thank them all for sharing their wisdom.
As I did in my original paper, I applaud Pimenta again for his amazing work. Additional studies of engagement, impressions and reach would be very useful to perform. Pimenta defends fervently but needlessly some of the JSM main points, since my paper attacked neither JSM nor GBD. It only showed that both lists include many stellar scientists and that JSM had overwhelming Twitter presence. This is emphatically obvious also in the Twitter reception of my paper.
Gorski apparently submitted his rapid response and his 7591 words long blog in his sciencebasedmedicine.org website before seeing my...
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