Evidence-Based Medicine: Why it’s important and why it's controversial
[Lucy Johnston]
Introduction of Speakers and Topic
Hello everyone, my name is Lucy Johnston and I'm Health and Social Affairs Editor at the Sunday Express. And I'd like to thank you all for coming here today to Oxford University's fantastic lifelong learning centre, Kellogg College. And it's great to know we have almost a full house today for a discussion on evidence-based medicine from two of the country's most eminent, yet sometimes seen as unfashionable, scientists, Professors Carl Hennigan and Tom Jefferson. Professor Hennigan is the Director of Oxford University's Centre of Evidence-Based Medicine, a practising urgent care GP, a clinical epidemiologist with a special interest in infectious disease. He also spends a large amount of time investigating the evidence base for publication bias in drugs and devices for which he's become an international expert. His extensive knowledge and experience means he's sometimes called on as an advisor to the UK and the World Health Organization.
[00:01:05]
Welcome Carl. And Dr. Jefferson is a medically trained doctor, also an epidemiologist who has enormous experience of assessing large medical data sets, carrying out systematic reviews, health economic studies, meta-analysis of drugs and devices. He also specialises in infectious disease. Welcome Tom.
[Tom Jefferson]
Thank you, it's a bit embarrassing though.
[Lucy Johnston]
Both of them do a sub-stack now, Trust the Evidence, and work very closely with the media, who learn and get loads of information from them, looking at things very differently. So in today's world, we assume that the drugs and medical devices that are approved would not get on the market unless the benefits were really outweighing the risks. We also assume that public health advice given by governments is based on solid evidence. However, throughout the COVID pandemic, Carl and Tom exposed huge evidence gaps and flawed assumptions in what was known as the science.
[00:02:08]
And today they will show us why such limitations matter so much.
What is Evidence-Based Medicine and Why is it Needed?
So I'm just going to ask you first, what is evidence-based medicine and why do we need it?
[Carl Hennigan]
Thanks Lizzie, thanks for the introduction. In about two weeks' time, I'll have been in Oxford for 30 years. And I came here as a medical student. And it's an interesting time because Tom and I discussed this a lot about the mid-90s. There was a lot of sea changes in sort of how healthcare was practiced and how it was done. It was a changing time from a very paternalistic, doctor-centric view to a change to a more formed approach where the patient was at the centre of the decision-making. And in 1995, a chap from Canada called David Sackett came to Oxford and established the Centre for Evidence-Based Medicine.
[00:03:04]
At the very same time in Oxford was the establishment of the Cochrane Collaboration led by Serene Chalmers. And at the same time, there's a Centre for Statistics and Medicine led by Doug Altman. So very important times in our ability to change and shape our view about how do you inform decision. And there are three important aspects to it. The first is using the best available research evidence integrated with clinical expertise. So both Tom and I are clinicians. We know how to diagnose, how to think about communicating, and how to elicit certain preferences about treatments. But the third important aspect is patient values. You can present two people with the same information and they'll come to very different views about what to do next. And that's incredibly important in terms of decision-making. Now, our skill is also always to say what's the best available research evidence.
[00:04:02]
And that's where lots of what Tom and I do comes in with the use of systematic reviews, which are an important aspect of how we make decisions and inform decisions in healthcare.
[Lucy Johnston]
OK, so I have another question.
Why Not Follow Models for Novel Viruses?
So we had recently, we all will remember, a novel virus. So it was impossible to predict how this would spread and the impact it would have. You didn't have, we didn't have evidence. So why did you not think at that time it was best to follow the models that we had in helping us inform our decision-making?
[Tom Jefferson]
If I just clarify something, novel virus, who says, where is it written? This is what we do. We ask questions and we pick up. You see the assumption, yeah, novel virus, so it's new. Is it or is it newly identified? See the difference? Yeah.
[00:05:01]
That's the kind of thing we do. We take assumptions which are just widely the latest miracle drug, the latest miracle test, the latest miracle. You're all going to die. Yeah, we're all going to die. We know that. And we ask questions. Now, coronaviruses are beasts which have been first identified. They were first isolated and identified in this country in the MRC Common Cold Unit in 1966. It wasn't called coronavirus, it was called something else. But they are ubiquitous. They are around the whole time and sometimes they do cause outbreaks, usually localized outbreaks. And we do know quite a lot about coronaviruses.
[00:06:00]
We know a lot less than 100 percent. We don't even know 2 percent. We don't know the ecology. We don't know how they mutate. We don't we don't know a lot. And so before we go and do drastic things, we should really think about what we're about to do. And my problem with models is that they're not evidence. The models that were initially used at the beginning were based on what information they had on influenza, which is a minefield. Influenza is a completely different RNA virus. We don't know whether transmission is the same. We don't know whether the people who are affected are the same. And they were using words like behavior, the behavior of the virus. There's another red card for you.
[00:07:00]
Viruses don't behave. Viruses are like this table. They're objects. They're not living things. So you put all this together and you start asking questions. And then we were absolutely horrified when the social butchery followed the introduction of models. A lot of people flipped over overnight. And that's how it started.
[Carl Hennigan]
Experience with Acute Respiratory Infections and Epidemiology
Well, I think there's a... So I'm going to come at you as a GP now. I am going to make an assumption that you've all had an acute respiratory infection and you probably have many in your lifetime. So when we talk about general practice, we talk about there's about 30 pathogens that potentially could give you a list of different ARIs at any one time. And the most ubiquitous we always talk about is one called rhinovirus, which is always going there.
[00:08:02]
That gives you the common cold. But there's a whole list that goes influenza, coronavirus, adenovirus, metadermal virus, could keep going. And this is what keeps driving lots of what's happening now. For instance, as we go back to schools, there's a brand new cohort of children arriving in primary school. There'll be a brand new cohort arriving here in the university who are susceptible. And so what you see right now is acute respiratory infections are going up in population in under 15-year-olds. The problem is they're about to arrive in the adult population. And if you're a grandparent, you're going to be more at risk. So once you become a grandparent, your acute respiratory infection burden increases. So one of the key things we do is discuss how these interact. What's the epidemiology and what they look like? So there is lots of experience in the world, in general practice, about how these interact, what epidemics look like, and how that goes through winter.
[00:09:12]
And so, you know, one of the key things, for instance, if it gets colder, it gets darker, we'll spend more time inside, your risk goes up. So that's where you get concertina effect, and there are more infections in winter. But what you do is you create immunity that you then take forward into spring and summer. So there are aspects that we could understand. What we couldn't understand is when what happens is you bring mathematical models into the equation. People who have a writing clinical experience, who then start talking to you about how you can then control this with no downsides. How you can restrict and lock down a whole country, and there will never be any problems downstream. Now, if you're reading the papers today, like the Telegraph, the Times, you'll see there are huge articles starting to come about about now the long term consequences of what we did.
[00:10:09]
A lot of people want to bury in the background and say, well, that was then and this is now. But I actually do think it's a bit like, I say, it's like the credit card that you might sell. This is going to take a long time to pay back. And therefore, there were lots of issues where we started discussing on a daily basis where we basically said, we do not understand why we're making this decision now. And who has looked at the consequences of this decision?
[Lucy Johnston]
The "Tipping Point" Substack and Lockdown Predictions
Well, it was in April 2020 that it was just weeks after the first lockdown that you wrote a substat called the tipping point. And lots of people at that point were terrified and the government was saying, stay at home.
[00:11:04]
And you said lockdown is going to bankrupt all of us and our descendants and is unlikely, unlikely at this point to slow or halt viral circulation as the genie is out of the bottle. What the current situation boils down to is this. Is economic meltdown a price worth paying to halt or delay what is already amongst them? How did you know that? Why were you able to say that to that point?
[Tom Jefferson]
I live in central Italy and I had a contact inside the Lombardy crisis unit. Remember, in Europe, it started in Lombardy around Bergamo and around that area. Through this contract, the contact, I knew that within a week, the thing had peaked.
[00:12:01]
Which is typical. Typical. Typical influenza-like illness, whatever you want to call it. Most of you use the F word, which I don't use the F word through. I would counsel you against using F words. Especially that particular one. We knew that after 10 days, the thing was peaking. That's what acute respiratory infections do. They go up. What goes up must go down at some stage. And this thing was coming down already a week before they locked the country down. And that was quite clear from the data that the crisis centre in Milan was producing. So fast forward about three weeks. The same thing was happening in the United Kingdom. That's why we were at that point.
[00:13:01]
But this is not rocket science. In fact, it was rocket science in the 1800s when somebody called William Farr espoused his law. The law of epidemics. Saying exactly what I said. What goes up must come down. The famous cholera, Broad Street epidemic. You've all heard about it, have you? Yeah? And the myth was that the pump handle, removal of the pump handle killed the epidemic. No. The epidemic started in that particular area on the 28th of August. And it was already over by the 2nd of September. It was already on the descending curve. And the two people who made the decision that this was the case or spotted it, which is John Snowman and Reverend Whitehead, they knew that removing the pump handle was just a gesture to stop people drinking the water.
[00:14:00]
So it's the way that things happen. I'm not saying bugs behave because they don't use behave. But you have to have that knowledge to understand. And these guys didn't have knowledge. They were going off and saying, oh, if this happens, then we're going to have half a million dead. If this happens, if we don't do this, we're going to have half a million dead.
[Lucy Johnston]
That was the modelers, yes.
[Tom Jefferson]
Yeah.
[Carl Hennigan]
As far as law is really important, actually, that's, you know, your experience and looking back in time, understanding what's come before, how it helps you inform what happens next. So the way that I try and talk about it is when you think about this epidemic, it's a bit like when you're going in your car on the motorway and you're accelerating. You start to go on the motorway and you go really fast, going to get 20, 30, 40 up to the speed limit. But one of the key things is when you get near the speed limit, your rate of acceleration slows down. So you go 60, 62, 64, and you're approaching your top level.
[00:15:02]
We can watch the data do that. And as soon as you get the slowing down phase, you're at the peak. And then as far as law tells you, what's going to happen is you're going to come off the motorway and it's going to drop roughly symmetrical compared to how quick it's gone up. So it's gone up really quick, it's going to drop really quick. Now, if you looked at the data in March, triangulating that because I'd be going into chaos to watch what happened, is that basically by the time we'd locked down, not only would we reach the peak, we were on the way down. But there are two problems that happen. One is when it gets into a care home or when it gets into a hospital as you pull people in, what happens in those environments, you create another mini epidemic. So the hospital data looks worse in the community. And particularly in care homes, what happens in care homes is there's a particular feature when we get older with our immunosuppression.
[00:16:01]
You can have an infection. And a very good example of this will be if you get an elderly person with a urinary tract infection, you don't get a high fever. You may get confusion, off legs, very difficult to detect because the signs are subtle. But you may have an ongoing infection for a week or two and nobody's recognised it. And in that period, it's going around the care home. And in doing so, what did we do? We decided to tip more people into the care home from hospitals. We had people contacting us like paramedics saying, we're dropping off people at a care home in full PPE. And when they get there, they've got nothing. And so we're seeding infection. So one of the key problems you notice is 40% of the deaths in the first wave were in care homes. So if you wanted to invest in where you put your solution, where would you go? Over here, you're restricting people as something that's naturally coming down.
[00:17:02]
Or over here, you go, let's start looking at care homes. How do we invest in this environment? We still have not done that. So we still have no way of viewing preparation for where the real problem is. So we understood these things and started writing about it, saying there are lots of things we do not understand that are happening because there's huge uncertainty and it doesn't match what's happening in the data. Compared to the problem that is, models are coming in and telling you it's still going to be peaking by June, July. And we're going, we can't understand that either. Where's this coming from? And that drives the fear and the problem that exists in the community.
[Lucy Johnston]
Discussion on Care Home Deaths During the First Wave
We worked on a piece, didn't we, about care homes. And I wanted to talk a little bit about the report that you did about the numbers of people who died in care homes in that first wave and what they died of.
[Tom Jefferson]
We will never know for certain exactly when people talk about COVID.
[00:18:07]
You have to distinguish the effects of viral circulation from the effects of the social butchery that followed. These two are two different things, but we will never be able to disentangle them because of the mess that they made with the reporting, with the analysis and so on. What we found is that there was evidence that, unfortunately, it was not nice to see that in the majority of cases, or a high percentage of cases, should I say, people died because they'd been abandoned. And there was a study in France, for instance, at the time that found a very high proportion of death by dehydration. This is not something which is very nice to talk about, think about. It's the way that we relate to our human beings, to our fellow human beings. People were just abandoned.
[00:19:01]
They either couldn't, didn't care, or they were sick, or they were afraid. I'm talking about the attendants. And they were left. We wrote a piece slightly later called Christine's Law on Trusty Evidence, where we said that every frail person, every disabled person, every person who's at risk, in fact, any of us, should nominate a champion, should nominate a representative who can make decisions for his or her. And nobody should be stopped from visiting somebody else who is ill, either at home, or in hospital care. And this should happen, and should be enshrined by law, so that what happened in the, what the Italians called, I would say, the nursing homes, will never happen again. Now, I've got one last, sorry, I'll let go.
[00:20:00]
I've just got one last piece of the puzzle, that's what I mentioned. You mentioned 40%. We know that up to 40% of hospital cases of SARS-CoV-2 appeared after eight days from admission. That is, people up to 40% of admissions in Wales, Scotland, and Northern Ireland, England wouldn't give us the data. Up to 40% of people who went to hospital for other reasons, and who tested negative when they were admitted, tested positive eight days later. So, that's where they got it.
[Carl Hennigan]
The care home thing, I think, is, if you really think about it, quite an emotional issue. The first thing he says, an urgent care GP, one of the things is, I do home visits around Oxfordshire, I work out Whitney, I've been doing Oxford, and about half my visits are into care homes.
[00:21:07]
And the first thing he's decided, I'm a pretty resilient and confident person, but when you turn up to a care home, remember back in 2020, it said, do not come in here, we've got COVID in here. The first thing is, you stop at the door and go, hmm, maybe I shouldn't come to work today. You just have these thoughts, maybe I should have stayed at home. But then you think about, look at the people working in here on minimum wage. People are prepared to go into these environments. But this point about what we call an advocate is, I think, something that should be campaigned for. And the purpose of an advocate is, you should be able to go anywhere, irrespective, nobody can override the law that you could go into a hospital, into a care home, and go, I'm visiting to check the care is okay for this person. That is incredibly important because what happens is, if you're elderly in a care home, you may have mild cognitive impairment, you may have dementia, you've got all sorts of problems.
[00:22:08]
You're about to give somebody an acute respiratory infection. What happens with that is, you lose your first sensation, you become confused, you can't feed yourself. You need somebody there, which is normally to say, I'm going to spend an hour a day with you to help you feed, help you drink. Now, if you go in to do that with a nurse in another care home, 30, 40% of them are off sick. Some people have just actually left the job. So you go into a care home and you go, there's one nurse here for 20 people. And they're all locked in the room and nobody's coming in. Also, what advocates do is they go, oh, by the way, I've just noticed grandma's got a red leg. There's something not right with her. She's got an infection. Ring the GP. So there's an advocate role that happens all the time. Now, what happens within about 48 hours is, that first problem means you're going to become dehydrated.
[00:23:01]
So the confusion compounds itself. And what happened in France is, when they went in and did clinical teams, basically gave them fluids, the mortality dropped substantially. And we already knew this because in Hong Kong, in the SARS-CoV-1 outbreak, they have clinical teams that go into care homes, don't do it the other way around. So these things exist. We're just not prepared to address where the problem is. I cannot understand why that is an issue. It's this out-of-sight, out-of-mind problem because people didn't see it and it wasn't visible. You had all these intensive care pictures. Nobody went into a care home and said, this is where the real problem is. Now, when you bring that up, it becomes a matter of controversy. And I don't understand why. We don't want to understand that societies that don't look after their elders probably deserve everything they get. Because the consequences are huge when you think of what you've got to do in the community to try and prevent it coming in the door anyhow.
[00:24:04]
And that didn't work. In Oxfordshire, 80% of the care homes got outbreaks in the first wave. So everything we tried didn't work. So now we should be prepared to say, yeah, I'm just going to ditch that for next time. But we haven't even considered that at this moment in time.
[Lucy Johnston]
The COVID Inquiry and Its Effectiveness
In fact, the inquiry, what do you think, Dean? We've got the inquiry going on, which is pulling in evidence and looking at what happened, but not what we should be doing in the future. Do you want to pull this?
[Carl Hennigan]
I'm going to go to Tom because I can feel his blood boiling.
[Tom Jefferson]
The inquiry is chaired by a judge with cases and all sorts. And some of you may want to watch the way that Carl was treated at the inquiry when he gave evidence. We have the clips on trustee evidence.
[00:25:01]
I think it was October, October time. And he was, first of all, they had a modeler. And I thought that Lady Hallett was going to lick his boots when he came out of the stand. She was fawning all over him. And then you watch the way that they behaved with Carl. They don't want to listen. They don't want to hear what we go say. They're not interested. And at the moment, what they're doing is a busy trying to color up the fact that they lost their heads. That's the most simple explanation, I'm afraid, for what happened. But it's not going to happen again. Oh, no. And because we're a civilized society and we don't do things like they do in horrible societies like Russia. In Russia, they started squealing Soviet style on neighbors who seem to criticize a special military operation, as they call it in Beijing or Ukraine.
[00:26:05]
And if you're trying, if I'm guilty, you're going to face consequences. In this society, we don't squeal. We do not report, do we? We don't squeal on our next door neighbors. Oh, yes, we do. I was just reminding Carl and Lucy about this. Do you remember? Does anybody remember the Mayor of Leicester? Do you remember the ladder? The Mayor of Leicester was filmed by somebody who then reported him to the police and the media, of course. He got a, came out of the car, got a ladder out, got up to the first floor to visit his girlfriend. He lived in the upstairs flat. And this was filmed and he was reported to the police.
[00:27:04]
So what's the difference?
[Carl Hennigan]
The thing about the inquiry is, it's going to cost, it's costing about £200,000 a day. £190,000 maybe, but there'll always be a few added costs, £200,000. By the time it's finished, it's probably going to go in excess of a quarter of a billion. Now, as I understood it, money's pretty tight right now. And my question is, for £250 million, what do you think you're going to get? Well, the first module reported with a series of recommendations. It said one of the problems was in the preparedness and the planning is that it was complex and convoluted. There were over 200 different bodies involved in the organisation and structure. And what we recommend to do this better next time is to create another body to oversee the bodies. And so, for all that money, the recommendations you could have come up with at the end of the day, we could have had a discussion at the end of the meeting and come up with better recommendations.
[00:28:09]
So one of the things that interests me is, we've got all this information and evidence. We've got access to information like we've never had before. But it's almost like people are drowning in the information. And it seems to become harder for us to make clearer recommendations to improve what we do in society than it's ever been. And therefore, what the governments do, I think Dominic Coleman's called it a dead cat scenario. You throw a dead cat on the table and everybody's distracted. We all have a COVID inquiry that could last for another five to seven years. And in doing so, it will distract us all because in about five to seven years, nobody's really going to care about what the recommendations are. And therefore, I can't see us coming up with a single recommendation that will be specific enough to help us prepare, do things better next time, or even do things better right now.
[00:29:03]
And that's the problem I think with the inquiry.
[Tom Jefferson]
Lack of Evidence for Interventions and the Need for Trials
Most of the, all of the interventions that were put in place during the social butchery phase lacked evidence. So, we're going to get prepared for the next time. We're going to generate the evidence to try and find out exactly whether N95 respirators work. We know that surgical masks are very unlikely to work. N95 respirators, there's no evidence that they work, but maybe they do in certain special populations. Maybe they do. That's uncertain. Handwashing, exactly. What is the role of handwashing? Is it a mixed handwashing that I put on an N95? How long can I wear an N95?
[00:30:00]
And then what do I do? Fall on my knees and pray to God? Let's test some of these interventions and other novel interventions. Gargling, for instance. We've only got two small randomised trials on gargling. Does gargling affect it? So, that's what we should be doing now. Are we doing it? Are we doing it? No. No. They're all busy covering up what they've done. And also busy saying, well, maybe there isn't that much evidence behind the use of face masks.
[Carl Hennigan]
So, just to say, this is a really important point. Because, as we said, all these viruses are circulating. We're going to be outbreaking winter. There's going to be points in this winter where there's going to be a winter crisis. And there'll be an NHS winter crisis. There's been one 17 out of the last 20 years. There's been headlines, a crisis is coming. You could do the trials in the winter period, like this winter, to reduce uncertainty.
[00:31:03]
In doing so, this is the bit that's really controversial about evidence-based medicine. It's the ability to say, we don't have the answer. It's uncertain. In this situation, what we normally should do is do the research. We get that for drugs. You can't simply just give drugs out and see what they do. Because you go back to thalidomide. There are huge examples where that was catastrophic. It's the same with non-pharmaceutical interventions. They are not risk-free. Therefore, if you want to understand how they work, you have to reduce the uncertainties by doing the clinical trials. And you can think of loads of clinical trials in care homes. We could do all sorts of clinical trials in care homes, in hospitals, how you reduce hospital-acquired infections. You could even try and see if you can get maths to work in schools this winter. And you could do the trials, comparing those that do that down.
[00:32:01]
There's something wrong with the MPI world, where we don't want to do that. People rely on what they believe, mechanisms and opinions about what works and what doesn't. That drives an approach that means people want a top-down approach to tell you what to do. As opposed to inform you what to do, which is where we started the conversation about evidence-based medicine.
[Lucy Johnston]
The Effectiveness of Masks and Censorship of Research
So, picking up on the masks, which you talked about. So, Tom, you've done a lot of work on that. Can you talk about the work you did on the mask and how you showed when everyone was told to wear a mask, this wasn't necessarily helping us. But then what happened when you tried to publicise your work?
[Tom Jefferson]
Okay, so Lucy referred me to a Cochrane review called Physical Interventions to Interrupt Respiratory Viruses. Which was first published as a protocol in 2006. And then in 2007, the first version of the review was updated five times.
[00:33:04]
It's been updated five times. Now, the review was utterly uncontroversial. It was things like gargling, hand-washing, masks, gowns, hats, gloves, quarantine, stopping people at borders and so on. Completely uncontroversial. Everybody fell asleep when reading the review. It was nearly 300 pages long. Until February 2020. And then all of a sudden, it became political. All of a sudden, people started reading it, started citing it, started attacking it. And our own editors undermined our work twice in the 2020 update and the 2023 update. Because they didn't like the conclusions. And the conclusions were that possibly the only good evidence we've got is for hand-washing.
[00:34:01]
Especially in children. And frequent hand-washing at the end of each lesson probably does interrupt the spread of some of these prognoses. Now, of course, the implication of that is that the contacts, fomites and contacts, were possibly the main means of transmission. We're not talking about SARS-CoV-2 because, of course, in the fourth update, there were no studies on SARS-CoV-2. Because it was from January 2020. It's the second update. And people don't like that message. Because they like certainty. They like to know. I know. And I tell you what to do. Because I'm an expert. And I don't tolerate it. I will not tolerate you arguing with me. The thing is, they don't know. Because the people who have really worked on respiratory viruses know that there is only one law with them.
[00:35:00]
Which is the unexpected almost happens. That's the one universal law with respiratory viruses. So we got attacked. We got attacked. But apparently they tell me that somebody has come to the same conclusions as yesterday.
[Lucy Johnston]
You got attacked in census, didn't you? Oh yes. So tell me a bit about that. And then we can talk about who did.
[Carl Hennigan]
So I think it's fair for me to say that Tom is the most knowledgeable person on the planet in terms of the evidence base for non-pharmaceutical, non-physical interventions. Because you have been the lead author. Nobody might not get that, but you've been the lead author of this review now 20 plus years. I'm a survivor. I'm still surviving. So I think the other thing that's interesting is, or which is outrageous, is that in that first wave, I think we spent about 8.5 billion on PPE. So if you think about the winter allowance, that's going at 2.2 billion, 1.4 billion, sorry.
[00:36:04]
So actually we spent about nearly five winter allowances on procuring masks, for which lots of people made a lot of money in the mail. The second thing is they're not risk-free. One of our colleagues, Jim Brassy, who runs a trip database off of census pieces and says, he's a whiz on searching. He says, I've been looking at all the news reports here. It's got over 150 news reports and studies that look at the environmental catastrophe of all this plastics going into the rivers and so forth. They're everywhere. And at one point, when you took your dog out for a walk, if you had a dog, it was eating masks every time you went for a walk. So they're not risk-free. And they have a consequence. But what was important is when you point out that there are problems with the evidence base, and I want, this is important. If you tell people that you are at risk, you can go to the shops today and this will reduce your risk of infection by 80%.
[00:37:03]
And we're sat here going, that size of effect is implausible. At best, if they do work, they'll only give you a minuscule. You're putting people at risk because you're not giving them the truth and informing the decision. Whereas if you say, well, you can do what you like, you can go to the shops, do what you like today, wear a mask. There are pictures of people doing all sorts of odd things. But actually, the truth is, we don't really know if it makes a difference to you. You may make a different decision about what you do next. What happened is, is in November 2020, Tom was communicating with me and we wrote an article in Spectator. Which basically said, the evidence coming out, there was Tom's update of the Cochrane review. But there was also a study called the Damask trial in Denmark, which was a randomised control trial of giving you 50 masks. And each mask, surgical mask, you would wear for about eight hours and then put it in the bin.
[00:38:03]
So that's why, compared to what everybody was doing, it's really way out there, isn't it, in terms of. And what it showed me is, there was no difference. So you could do that, you make any difference. Now, we wrote a piece saying, here we go, masks are making no difference. And here's why. And basically, at the end of the day, they don't work. I put that on Facebook and it got pulled down on Facebook and censored. Now, the connotation of that is, that's not me. This is us writing in a national newspaper and an entity deciding to censor the free news in a country. And if you follow through the logic of that, you start to go, we have real problems right now. Because there are people who want to censor the opinions of the news. But I also think we shouldn't be censoring people's free speech opinions.
[00:39:03]
But that happened all the time. And from there, we were slightly naive at the time. I just thought, oh, this was a mistake. It actually wasn't a mistake. It was a coordinated strategy to manage the message. And there's a Big Brother Watch report, which you can read, which I named it. Because the government had me under surveillance and monitoring. Every time we said something, there had to be a response and an approach. It's not just me. It was actually monitoring its own MPs. That was in Russia.
[Lucy Johnston]
Influence Despite Controversy and the Definition of a COVID Death
But at the same time, you were invited to meet with the cabinet, with Boris Johnson. You also, both of you, looked at figures like the COVID death and changed the whole way that we viewed a COVID death. So your influence was huge, despite the fact that you were seen as controversial.
[Tom Jefferson]
Let me just put something about deaths.
[00:40:03]
We found 14 different definitions across England, across the United Kingdom, of a COVID death. 14 different definitions. So one of them was recommended by the Care Quality Commission, who said, who decides if grannies die of COVID? The care provider, that means a nursing home provider. So a nursing home provider could be an administrator. They are a COVID death. So in other words, we will never know what role SARS-CoV-2 ever played in these deaths. Some of them may have even been positive, or they were positive 28 days before or something like that. And we didn't do, there were no PMs done. Why there was no PMs done? Because it's dangerous.
[00:41:01]
You're wearing protective clothing, aren't you? When you do PMs of infectious cases.
[Carl Hennigan]
There's a really interesting point about our strategy. And this emerged early on. Tom and I have spent a lot of time doing research articles. And between us, I think we've got about 900 published papers. We've got editorials. And we had a strategy where we worked with the journals. And what happened is we increasingly realised we're just talking to the same people. And actually we need to get out there and start talking to the public. So our strategy flipped into working with the media, writing a lot more articles in the news. We have about 40 articles in the Spectator. I think we've got a catalogue of them all with something like 280 articles we wrote or were part of in the pandemic. And by communicating with the public, you're also communicating with the policy.
[00:42:01]
We realised that most politicians get their information and what they're going to do from the newspapers. That's how they do it. And the flip side is, all of the advice was one way. So it's really important, I think, to mobilise your thoughts by writing them down. And if you've got a medium to put them out there, it can really help you. And what all we're doing is trying to work out what's going on half the time and then communicating to a wider audience. And in doing so, you're pointing out all these important points that people start to come on. What increasingly happened is there was a huge number of politicians and people who were on the sort of uncertainty side of the argument started contacting them. And I think it was Steve Baker, who was the MP who now was at Wickham, who's not an MP at the moment, said that basically one of the fundamental things you did was allow us to speak out.
[00:43:07]
Because what you need is a confidence to be able to say that's what I'm thinking. But over here, there are some people who are actually in the same ballpark. The problem is it was all in one direction. There's only one strategy and if you question that, you basically are a heretic and you should be locked up in effect. Now I think this is an important aspect because if you do have a society that plants down on free speech, you basically will still get there in the end. Because you know what, that chumminger got there in the end, but it takes longer. The consequences and the harms will be greater. So in any situation or any society, you need people, not just us, you need public people to speak out and question what's going on.
[00:44:01]
And at the moment in this current environment, there seems to be more pressure to not speak out than you've done in previous areas where people were much better prepared to speak out and face the consequences. And I think we call it the silence of science. There are very few people now prepared to say I'll stand up and question the status quo, the dogma of what's going on.
[Tom Jefferson]
I just smiled because I have the honour of the US journalist, Laurie Garrett, who's a universal expert on everything. She won a Pulitzer Prize, so she's got to be top notch. I have the honour of being called a bozo fraud by her for having done six versions of the same Cotton Review, looking at thousands of studies and coming with my colleagues, of course, I'm the only survivor of the original lineup, and coming to the same conclusion.
[00:45:06]
Evidence is poor where there is stronger evidence that shows no effect. And as I said before, the best effect is in hand washing, especially in children. But as Karl said, the effect is marginal. You're not going to get 70% reduction. Soon as you see 70%, 80%, throw the paper in the bin. It's impossible. Nothing is 70%, 80% effective. Nothing is, quote, safe and effective. Soon as you see that, throw it in the bin. I want to see the game well built now.
[Carl Hennigan]
This is a conversation Tom and I have on a daily basis. So what happened is, at the inquiry, Susan Hopkins said yesterday that when you look at the evidence for N95, the FFP mask, actually, it's actually pretty dodgy, poor quality, and they probably don't make a difference compared to surgical masks.
[00:46:06]
We know that because there's a study in Canada done by Mark Loeb. Tom knows him, I know him. He basically did a randomized control trial of using FFP masks in hospital for the clinicians compared to surgical masks, and it made no difference. Now, what's important about that is that after the event, people are starting to gain that. As Tom said, they've lost their heads. They're coming back to them. They've calmed down, and they think it's okay now to come and reflect the uncertainties. But in the midst of the panic and the anxiety and the fear, everybody was going, right, we have to do what we think may be the safest thing. Do everything. Rule of six. Telephone curfew. Wear your masks. Oh, download the app on your phone. Anybody signing in, telephone them. All of these things, when you look back, you think, they're ridiculous. So in the light of day, people are able to look calmly at what's going on.
[00:47:03]
But in the midst of the anxiety and the fear, people lost their heads, and he didn't have people of experience. And I saw this. It's a bit of a king to go into a cardiac arrest. What you really need in that situation is the head honcho, a doctor who knows what they're doing, and says, let's all calm down. We've got enough time. We've got two minutes to sort this out. What we're not going to do is panic. We're going to do A, B, and C really well. But when you panic in, you get people who flipped immediately to, oh my gosh, we must be doing what everybody else thinks. And then we all go in a certain way and direction. That approach, in the middle of fear and panic, is important. Because I can't see that changing the next time.
[Lucy Johnston]
No.
[Tom Jefferson]
If I can just explain the business of disease and syndrome, because this is important. Okay. If I have an infection and a particular agent is identified, let's say influenza, that's from a specimen that my doctor tells me the nurse takes from me.
[00:48:14]
Then I have influenza. I present with aspecific symptoms like fever and weakness and cough or something like that. And that's an influenza-like illness or ARI, acute respiratory infection, or what you would use probably the F word. That's a syndrome. But if I have a specific diagnosis because I've proved positive to rhinovirus or influenza taken from my body associated with these symptoms, then I have a disease. What they did is confuse syndrome with disease. They assumed, if you think of the ZOE app, do you remember the ZOE app? Yeah? If you've got a cold, you cough, then you've got to tell them.
[00:49:02]
And that's COVID. Well, it could be COVID. It could be SARS-CoV-2. But it could be rhino. It could be RSV. It could be influenza. It could be any of the hundreds of pathogens that we know of or the gazillion of pathogens that we know nothing of. Or it could be non-infectious because up to 40% of these episodes are non-infectious. For instance, indoor stress and indoor pollution can cause ILI symptoms, fever, cough, and all the rest of it.
PCR Testing, Costs, and Accuracy
All right.
[Carl Hennigan]
So I've got a couple. So there's one thing I think we have to mention, which I think Tom will say is PCR testing. Now, I'm not going to ask, is there anybody in the room who did not have a test in the pandemic? One person. Okay. So you all had tests at some point.
[00:50:02]
On average, you had about 22 tests per person in about a two-year period. So we did a lot of testing. The Test and Choice Program cost £37 billion. That's about two and a half years worth of the general practice budget. I remember being here in Oxford and I sent a picture to Lucy and Tom and I said, I've turned up at Urgent Care. There's four of us here in Urgent Care covering 170,000 people. And we're a surge centre. And on the grass outside is about 14 people for the COVID testing value. And there's not a single person turning up. Now, importantly, the way PCR testing works or the lateral flow is, when you have a bit of virus, it tries to pick up a little fragment of that virus. So if you have a lot of virus on board, the test works a lot less harder because what it does is amplify that little fragment.
[00:51:02]
So if you have one fragment, it multiplies it two, four, eight. And when it gets to a certain level, it says it's present. Now, in a mil of sample, one mil, which would take out e-mails, if you have about a million copies, you're likely to be infectious. Got that? But if you get one copy per mil, we can still detect that, but you're actually sort of walked in an environment like a hospital or care home would pick that up. You could take eight to 10 weeks to clear that viral fragment. So what could happen is, Tom's saying is, you could turn up for rhinovirus, have a test, and it says, oh, you're positive for coronavirus. You could do the same the other way around. So we spent a huge amount of testing on people. One of the things is we've actually done the research and systematic reviews and showed you could have actually delineated people into you're infectious, you're past infectious, contaminated, or it's just a coincidental test.
[00:52:09]
Because really what you want to know is, am I infectious right now? Now, importantly, if the viral load drops, that's a sign you're clearing the virus. So if you go from a million to 100,000, you're basically clearing it. You're better. You can go into the world. You'll still test positive with a PCR, but you're safe to go out there. You're not going to infect anybody. So we have said you could use this much smarter, save a huge amount of money. But actually, again, nobody wants to go there because the incentive right now is to get you to test more often for more viruses. And they call that multiplex PCR. That's coming to you sometime soon. And we were discussing this morning. We are going to bankrupt the NHS because there's a huge incentive to test you more and more, all the time, right from childbirth and keep testing because there's lots of money to be made in this space.
[00:53:12]
[Lucy Johnston]
Q&A Session Begins
We're coming round to the end, I think, if anyone's got questions.
[Tom Jefferson]
Very brief one. We didn't really know how PCR worked. So amongst all this traffic, this noise, we knuckled down three, four months and we studied PCR. We did a systematic review. We're still doing systematic reviews on PCR because it is an important test. But it needs to be used and reported properly. And this is the thing.
[Lucy Johnston]
So I think we've just got five minutes, haven't we, for questions. Has anyone got any questions? Yeah, someone over there.
[00:54:02]
[Audience Member 1]
Audience Question: Human Nature vs. Government Systems
Thinking about avoiding this happening again as a general point of sort of ignoring evidence and all of this. Do you think that the biggest problem is just human nature or psychology of any group of people in charge? Or is there something specific about the way our system of government with a small gene is set up, which makes this more likely to happen?
[Carl Hennigan]
So the first thing I often talk about is some of the previous pandemics. If you go back to 1968, that was when I was born. Tom was an old man by then. But in those cycles, we had pandemics. There were new viruses that had not emerged that had been detected and caused significant mortality. By the time it sweeped through the population and people were aware of it, it had already been and gone. So people went about their daily lives. I do think in this modern era with social media, 24 hour news, we are setting up a society for catastrophisation.
[00:55:06]
We are making people more fearful than ever. And I think the area that concerns us most, and probably you're aware of, is the mental health of young people is now in a really bad way. The number of people who are in the age group 18 to 24 has tripled, who now are off work with mental health problems. And so this messaging, which is fear settled, is getting through. So we are more anxious than ever, more primed. When something comes along that we say is going to kill you, I think we're going to react badly. The question is, how long will it take before what's happening now is we're in a period where everybody's like, you're not locking me down. We'll come back in five years, eight years, when the institutional memory has disappeared, we'll be in the same cycle.
[00:56:05]
And what's noticeable for Tom and I is the same actors are part of that fear machine. That we're here in 2009, been here in 2020 and we'll be here again, some of them will still be around. And they seem to have a strategy which says we can push the buttons of society really easy.
[Tom Jefferson]
To answer your question very briefly, I have some serious doubts about the people who will power, maybe appear to will power. I have some serious doubts about their intelligence, their integrity and their wish for democracy.
[Lucy Johnston]
Any other questions?
[Audience Member 2]
Audience Question: What Could Have Been Done Differently in 2020?
Just quickly, please. Given the level of knowledge and uncertainty and ignorance there was in 2020, what do you think should have been done?
[00:57:03]
Given that we now know we made some big, big mistakes, based on what we knew then, how could it have been handled much better?
[Tom Jefferson]
On the 8th of April, we said that there was no point in 2020. We got a date stamp, by the way, so no one can say that this was using the retrospective scope that we wrote this. We said it was pointless to do what they were doing because they were trying to manage an endemic respiratory virus, which is ridiculous. And a ridiculous idea to anybody who knows anything about the ecology of these microorganisms. I think what we can do now is generate the evidence that we still need. But that has a corollary or has got an assumption based behind it that they will ever acknowledge that what they did was social, based on nothing.
[00:58:10]
It was social butchery based on zero evidence or zero solid evidence. The uncertainty that was there in 2020 is still here in 2024. Can I ask you, what could have been done there?
[Carl Hennigan]
Okay, okay, okay. So if we go back in time, what could we have had in place that actually changed the sort of direction of travel? So in my inquiry submission, there were two things I talked about in Sweden that they had in place. The first thing is their Public Health Act says basically, very clearly, you can only intervene on the behalf of the public if the evidence is clear, the benefits outweigh the harms. You can't do that with, we think it's a good idea, it's uncertain. So that's why in Sweden they had a very different approach.
[00:59:01]
Their Public Health Act is very clear. And so what we did is overwrite our Public Health Act with the Coronavirus Act. That's where it all went wrong. So if we need a better public health strategy, that doesn't allow it to be overwritten. And that's on your behalf. It is important governments do not intervene in your lives unless it's clear evidence of benefit. Otherwise, you'll get all sorts of interventions coming now that will try and control what you do next. The second thing is, and there are two things, second is their laws are on the right to roam, are very clear. You can't prevent people in Sweden going anywhere. Again, unless there's very clear understanding there's harms in the way. So they couldn't stop you going into places like we could do here and restrict you and lock you down in the same way. And the third thing is all of their advisors are separate from government. The problem is the chief medical officer, all of these directors are civil servants.
[01:00:03]
So basically they're beholden to the government. So they're never going to challenge the government and lose the job. And we've seen that with people like David Norton challenged on drugs and alcohol. He got fired immediately. He said, you're a civil servant. You can't say that. So we have to separate out those functions. And if we don't do those three things, it doesn't matter what we say is the direction of travel. Nothing will change because it will come down to a small couple of ministers who will go and advisors. We now take control.
[Tom Jefferson]
Sorry, I didn't answer your question on the uncertainty. I do beg your pardon. We've known about this, at least since I've known about this since 2006, the uncertainty of physical interventions. We knew that antivirals were useless. We already knew that. So maybe what we should have invested is new antivirals. This is prior to 2020. But most of all, what we should have done is oven ready protocols for trials.
[01:01:04]
The minute there's a problem, you randomize half of the United Kingdom to this and half of the United Kingdom to that. Half of America to this and half of America, a third to this and this, that, the other. You test all these interventions during a pandemic. OK, that's what should have happened. That's what we wrote. And instead of which, well, you know what happened.
[Lucy Johnston]
Any other questions? This gentleman, Ian.
[Tom Jefferson]
Audience Question: BMA Rejection of the CAS Report
It was a different topic, Doc. What are your opinions on the BMA rejection of the CAS report?
[Carl Hennigan]
Yeah, interesting. So for those people who don't know, the CAS report is around the use of puberty blockers in transgender, particularly children and adolescents. Now. About just before the pandemic, most people won't know this, Tom and I wrote a review on the use of puberty blockers in children and adolescents.
[01:02:09]
And we did this with Panorama. And this is going back and we put this up in BMJ evidence-based medicine, where it was edited and published. It's still there now. You can go read it. And at the time, we basically said exactly the same as what we've said here. We look at the evidence. There's huge uncertainties. There's lots of harms. And actually, none of this should be incurring outside the context of research trials. Because if you're giving this to children, which is irreversible, this is a drug that potentially is life-changing, for which the consequences are dire. Five years later, the CAS review said exactly the same. They said, yeah, we've looked at the evidence base. We've come to the same conclusions. And importantly, the functions of doctors and regulation is first to keep people fed.
[01:03:02]
And it's enshrined in us as doctors. The first thing when it comes to medical students is, first do no harm. The problem is, you've got political organisations like the BMA who come along and say, this is the evidence, but we have opinions. And I think this is a society we live in where people are struggling to be relevant because we ask questions. What's the function of the BMA? What's the function of all these royal colleges? And they want to almost be deliberately controversial. And we're very pleased saying, this is a very clear evidence-based approach. But it's a very emotive subject. It's a lot of conversation. But particularly prescribing in children is incredibly important to keep children safe and first do no harm.
[Tom Jefferson]
We got a complaint about the 2019, I think it was, review. And the complaint was from a colleague who was prescribing puberty blockers to 12-year-olds.
[01:04:08]
12-year-olds. And they were starting on the road to the ultimate stage, which is surgery, which is irreversible. Adult wants to do that, that's fine. But 12-year-olds?
[Lucy Johnston]
Any more questions? I think we've got to wrap up, I think. Yeah, no time for one more. Yeah, okay. So, this gentleman here.
[Tom Jefferson]
Audience Question: Media Representation of Substack Content
Do you think you've got a fair write-up on your substat in the press? Or do you think they fairly represent your evidence base?
[Carl Hennigan]
I think the media's been, some aspects of the media have been pretty good, actually, as well. I was thinking to Lucy.
[01:05:00]
I mean, one of the things is, you often see academics who go, oh, I don't work with the press. It'll be stored by a story. And I go, well, they're going to write it anyhow. So, why not be involved? I work with trusted journalists. Lucy's one of them. She'll know one of the things, if you do work with them, you have to deliver. You know, Lucy will send me something and then it'll be on the phone. My deadline's four o'clock, can you give me a call? I'd say most of the press we work with, we write in the Spectator. Their editors are great. We think Fraser Nelson's been very positive throughout. Because what they're trying to do is understand the story and the force. Did I make mistakes? Yeah, there are a couple of times I've made mistakes with journalists who want to twist the story. And you notice that. They go, we're going to press in six hours, can you give us a quote? And often, can I speak to you? And then they want to, if you don't speak to them, they go, we asked him for feedback and he didn't respond. Or if you do, they'll take it out of context. So we don't speak to them, actually. Just let it fly like that.
[01:06:01]
On the whole, I think the press helped us get across where we are. We continue to work with them lots. At the moment, the reason we went to Substack though, and Lucy and I, we'll often write something. And at the last minute, it could get pulled. Why? Because Boris has had another party. And it's far more important than getting to healthcare questions. So the reason we now publish our own is because we know all the journalists follow us. And therefore, we can put stories out that we want to. If we think it's important to the press, we'll go to them up front. But actually, it helps us get our message out there and inform. And I think increasingly, people are distrustful of some aspects of the media and the press because they're not telling you the truth, giving you both sides of the story. And I think increasingly, going to areas where people will discuss in depth some of the issues is really important. And one of the things we're writing right now, which is blowing our minds around, is where does all the money go in the NHS?
[01:07:02]
And we are digging around and going, we can't quite believe where the money is being wasted, how many people are employed, what is going on. In an era where we remember a day when there was one or two managers and you couldn't understand what's going on. Billions are being wasted and we're trying to uncover that. And when we do that, we'll have to write about it.
[Lucy Johnston]
Closing Remarks and Thanks
Well, I think everyone would agree this could go on for a long, long time. It's fascinating. And just having worked with Karl and Tom over many years, I can say that as a journalist, you need to work with people you can trust. And I know that neither of them will overstretch themselves or say, I know this or I know that when they don't. And they reflect the uncertainties that are in science. And that's what science should be about. But thank you all for coming. It's been fascinating. There are teas and refreshments at the end, if anyone should want anything like that. And I'm sure we can continue talking afterwards. Thank you. Thank you, Karl and Tom.