Johns Hopkins Bloomberg School of Public Health held a debate on October 30, 2020. Locking Down or Opening Up? A Debate on the Best Path Through the Pandemic – Discussing the John Snow Memo and the Great Barrington Declaration.
The debate was part of a series that draws researchers from Johns Hopkins and around the country to learn more about emerging approaches to inform COVID-19 decision making.
I promised subscribers to the 33c newsletter (sign up here) that I would take notes. So I did. What follows are some of key segments that I took away with subheadings and comments. What I captured is not comprehensive but rather a curated selection of the discussion that captures the participant’s views.
The debate is available on YouTube and I would encourage you to listen.
For me the debate was less about solving COVID as much as it was about recognizing the different ways we might approach the pandemic. That understanding comes from hearing the different perspectives and weighing the tradeoffs. More specifically, the debate brought:
Leadership exemplified. Given the politicization and polarity around the COVID crisis, this debate exemplifies leadership in medicine. It’s a great example of how institutions like Johns Hopkins Bloomberg School of Public Health can bring value at a time when the media and politicians seem to be dictating our fate.
Authorities not TV experts. The panelists are not media influencers who decided to read about COVID and weigh-in. These are some of the world’s most talented public health experts whose lives are dedicated to understanding and controlling threats like COVID. Unlike television’s talking heads, they appreciate the importance of uncertainty around some of this.
A conversation defined by civility. What was most impressive was the sense of humility that these panelists brought to the process of discussing this wicked problem. The session was defined by civility, open mindedness, constructive conversation, critical thinking and respect for legitimate differences, all defining elements demonstrated by the participants. The conversation between these professionals contrasts so sharply with the hostility and zero-sum positioning that occurrs on places like Twitter.
And more than one of these panelist remarked on the value of having a respectful conversation. I’ll add that this debate would be immensely valuable for the public in order to understand that the approach to this pandemic does not fit what we see portrayed by physician commentators on prime time cable.
You might be interested in What the Great Barrington Declaration Says About Us.
A debate centered on two polarizing documents
As you can draw from the title, the debate centered on two approaches to the pandemic: The Great Barrington Declaration and the John Snow Memo. As described by moderator Colleen Hanrahan:
The Great Barrington Declaration was authored on October 4 by three career epidemiologists. The basic position of this declaration is that lockdowns to curtail COVID produce devastating effects on short and long term public health. The statement advocates an approach involving herd immunity where those who are younger are allowed to build immunity through natural infection. This then provides protection for those who are older and at higher risk for mortality. The concept is called focus protection and they advocate that life should largely return to normal for those who are not in the vulnerable groups, which includes returning to school work, sports business and cultural activities.
And the other side of this is the John Snow memo. This was published in Lancet on October 14 by a group of authors from throughout medicine and public health. The statement holds that herd immunity approaches a dangerous fallacy. There’s not yet evidence of lasting immunity to SARS COVID to infection and that approach would would cause recurrent covid epidemics. The John Snow Memo advocates for continuing restrictions that allow for suppressed transmission until public health efforts can effectively smother local outbreaks.
The debate participants were Drs Ajay Bhattacharya, David Dowdy and Stefan Baral moderated by Dr. Colleen Hanrahan. So here are some of the high points of the discussion broken down by participant. Their dialog is in ‘pull quotes’.
Ajay Bhattacharya | The Great Barrington Declaration
Dr. Ajay Bhattacharya, MD, PhD, is a professor of medicine at Stanford. He’s a health economist with research interests ranging from aging populations to health and medical spending. He’s one of the three authors of the Great Barrington Declaration and represented this position in the debate.
Three defining premises
Dr. Bhattacharya opened with the three premises that underly the Great Barrington Declaration.
The very first premise is and I think everyone on the panel will agree that there’s a very wide difference in the threat of the disease of infection for people who are older versus people who are younger. For people who are older, over 70, the evidence suggests that there’s about a 95% survival rate, which is a very very low survival rate for disease like this. It’s it’s a severe problem for older populations and also for people who have certain chronic conditions. For younger populations, under 70, it’s much milder. So the zero prevalence data from around the world now suggests that the survival rate is something on the order of 99.95% from infection. So that’s just a basic fact that I think everyone agrees with.
The second premise which is that a zero COVID outcome is not possible. It’s not in the feasible space. People point to places like New Zealand as counter examples. But even New Zealand can’t protect itself forever. I think it’s at this point a fantasy to think about zero COVID as a reasonable potential outcome. And in any case, the amount of dislocation and damage to human civilization will be enormous to try to get there. Because we’ve tried to get there and failed.
The third premise is that there is no such thing as a herd immunity strategy. Herd immunity is the endpoint of this epidemic no matter what strategy we pick. It’s not a policy to have herd immunity. Herd immunity is a basic biological fact. Denying that herd immunity will eventually be the endpoint of the epidemic is like denying that gravity exists. It will eventually happen. That’s how the epidemic will end.
Safely getting to herd immunity
So the only question at hand is how do you get there safest? How do you get there with the least amount of human misery, death and harm with the greatest respect for human rights and for the protection of civil liberties? How do you get there consistent with our values and in a way that protects people? So the Great Barrington Declaration does this. It’s actually a call for return to traditional public health principles.
For one, acknowledge who actually is in danger and devote enormous creativity, resources, and energy to protect them. So just concretely I’ll give some sense of who they are and how the current policy block has failed them. So, for instance, nursing homes. Much of the deaths in the United States and actually in many other developed countries has been in nursing home settings. We have failed to protect older people in nursing homes with this lockdown policy. The lockdown policy basically says if we control community transmission we can control transmission in nursing home and that’s evidently not true. We have asked older essential workers, the urban middle class, who are actually at risk from the infection high risk for infection, because they’re essential and poor we asked them still to go work and expose them to the virus because we haven’t adopted folks protection ideas. At the same time, we’ve asked younger people who faced very little risk from the virus itself to burden themselves with enormous costs from this disease. We’ve closed schools and essentially depriving our children of their right to an education. With absolutely devastating effects that will last a generation. We have asked young people to basically cease normal activity. In fact, public health has made such a mistake that what it’s done is it’s created a sense in people who don’t face a huge risk from COVID itself, the risk COVID is so high that people have stopped getting immunizations for their children. They stopped going to get chemotherapy or cancer screening, again with mortality toll to come….So I think the current policy we have is an immoral one. We are asking people who don’t bear a huge risk and disease to bear the burden of the disease, not in the form of COVID but in form of other other harm and damage.
So the Great Barrington Declaration says let’s respect the autonomy of them. Let them go about their lives. I’m not arguing against normal precautions that public health would normally argue. We’re not arguing to go infect yourself and we’re not arguing for covid parties. We’re arguing to let people do the things that they value — that are important while taking reasonable precautions. At the same time devote enormous resources to protect the old. The results will be better both for the old in terms of COVID deaths and also better in terms of non-COVID deaths and the respect of human rights.
David Dowdy MD, PhD | The John Snow Memo
Dr. David Dowdy followed. He’s an MD, PhD and associate professor of epidemiology at Johns Hopkins School of Public Health. His primary research interest is in tuberculosis and he works at the intersection of epidemiology, health economics and infectious disease modeling. While he disclosed that he had not signed either the Great Barrington Declaration or the John Snow Memo, he agreed to take the position of the John Snow Memo for the debate.
Critically representing The John Snow Memorandum
So I’m going to be defending the the John Snow Memo but I should start by saying I’m actually not a huge fan of certain aspects of this memorandum. I do worry that in signing this document and having it called the John Snow Memo and we were reading a bit of scientific orthodoxy .. implicitly shaming people who might have different perspectives. And I would not like to go about things in that way but I also feel like this memo doesn’t necessarily provide a clear path forward. And that’s something I’d like to correct or address.
Where do I agree with what Jay has said? First of all I agree 100% that the most important goal is to prevent misery, morbidity and mortality and that zero is not possible. Secondly, I also fully agree that lockdowns are a harm to be avoided if at all possible. And the current policies have failed multiple populations.
Separation of vulnerable and not vulnerable is not feasible
So what do I disagree about? First of all, I don’t think that it’s feasible or right to label some people as vulnerable and others as not vulnerable. I think vulnerability is a spectrum and not really just based on age. So should we label our President as being vulnerable because he’s 74 years old? What if you were 69? What if you were black rather than white? And so I worry about a specific age cut off. Are we really just talking about long-term care facilities. So like Jay said just 45% of all deaths COVID deaths in the US have occurred in long-term care facility or residence of long term care facilities, but that leaves 125,000 confirmed deaths outside of those facilities. That’s more than three times as many people who die in road traffic accidents in an average year. Nobody’s arguing, I think, that we shouldn’t be protecting residents of long-term care facilities. But, but once we start to expand the concept of vulnerability to age, I start to worry.
Secondly, even if we could identify the vulnerable the best way to protect those, I believe, is not just to isolate, them test them, and create an island, but rather to reduce transmission in the community. So, I’ll ask everyone here would you rather live in a wholly testing isolated nursing home in North Dakota, where they’ve had 6000 cases in the last week, or one with no testing at all in Taiwan where they have 30 times the population and haven’t had a single case in the past 200 days. So I think that reducing transmission in the community is the key to protecting the vulnerable. Everywhere you go deaths in vulnerable populations track with the number of infections. And so the best way to reduce the number of deaths is to reduce the number of infections. Finally, even if we could identify and shield the vulnerable, people panic. COVID is scary to people in a way that the flu, for example, is not. So let’s just say I don’t want to be the one looking for toilet paper in a place where the message is ‘COVID cases in your city are doubling every week but stay calm we’re protecting the people who are at greatest risk.’
I want to make a quick note on herd immunity. I agree 100% that that herd immunity is not a strategy, it’s an outcome. But we’re not very close to that. So a very recent study just this week published in The Lancet, estimated that about 9% of the US adult population is seropositive to Sars COVID2 as of January. So we have a really, really long way to go. Furthermore, the strongest correlate of seroprevalence was the cumulative COVID mortality rate. So, again, wherever infection is occurring people are dying.
Four ways the Australian response differed from the U.S. response
But how would I move forward? I would look to specific success stories. I’ll use the example of Australia that I think is somewhat similar to the U.S. culturally. Australia is not more locked down than the US. Schools reopened for the most part in May. …GDP predictions for for 2020 in Australia are in a decline of 4.1%, in the US is 3.8%. So very similar in those regards. But despite these similarities, Australia’s pandemic is one 20th the size of the US, both in terms of seroprevalence, which is at .5% in July, and in terms of death. So the cumulative death rate per capita is also about one 20th of that of the U.S.
And so I’m going to say that there are four main differences between Australia’s response and ours in the US and these point the way to a strategy. First of all, knowing your epidemic. So for every confirmed case in Australia they’ve performed 2000 tests versus 13 here in the US. Second, targeting response not based on vulnerability but based on where transmission is happening. So, for example, when an outbreak occurred in Melbourne they enacted restrictions not on a countrywide level, not on a statewide level, but at a level of 10 postal codes. So thinking where is infection occurring, and that’s where we need to enact restrictions. Third, enforcing laws that people can tolerate. So in those 10 postal codes, for example, there were fines for not wearing a mask, fines for missing a curfew. I don’t feel like masks and curfews are breaking the economy or breaking people in the same way that that large lockdowns are. And then finally, supporting people who need it most. So, Australia has has passed legislation to support people who are caring for elders, people who are holding on to jobs, not just in a blanket fashion.
So, in summary, I think we agree on the goal. We agree that lockdowns are bad and we agree to zero is not achievable. But I would argue that rather than trying to identify, shield and protect the vulnerable, we should try to be reducing the level of infection by knowing our epidemic by testing, targeting our spots to where transmission is happening, and forcing tolerable laws and supporting those who need it the most.
Stefan Baral MD | Resources before restrictions
Stef Baral is a physician epidemiologist also at Johns Hopkins School of Public Health. His work focuses on HIV epidemiology, prevention and implementation within the context of human rights for men who have sex with men, transgender women, and female sex workers across the globe. He also has not signed either statement but offered his free thinking position that he called resources before restrictions.
To reinforce Dan’s point at the beginning of this, the idea about being able to openly talk about this is a major advance because I think the moment we are afraid to speak as scientists about evidence-based and rights affirming interventions we do a disservice collectively to the response and surely we’re not saving lives.
Public health’s three core values: equity, social justice and participation
I’m gonna start with like a couple premises and those are basic premises of public health. I think of public health as having sort of three core values. Those are equity, social justice, and participation. So equity is that we do more for people who need more. Social justice is that we try to balance intervention benefit and burden. And participation is that we engage the public and people that we ultimately want to use our interventions. That we don’t single handedly, as public health, come up with things and then just push them on people.
No empiric interventions to date
I think when I think about interventions to date I don’t recognize a single empiric intervention to date. I don’t even think that social distancing are empiric interventions because they don’t react to individual or network level needs. And so they are what they are … they are interventions. I just don’t think of them as empiric interventions. Similarly, and I don’t know if lightning’s gonna strike, I certainly don’t think of masks as empiric interventions. I just say I recognize that they’re just like something that we feel we can do as a mandate and just kind of hope that it’s gonna work. But ultimately it represents a passive strategy that’s ultimately implemented by the police and by sort of collective blame and shame. And not necessarily because it’s an empiric intervention or I should say evidence-based intervention.
The public has assumed the social costs of COVID
I think the fundamental problem that I’ve seen within COVID is that we’ve wanted individual people to take on what should be social costs. And so we want people who are generally well to isolate and quarantine when they’re positive but we’re not providing them that means in order to do that. So we’re asking people normally already on the economic margins to absorb social costs and that disconnect between social costs and personal benefits doesn’t feel like a sustainable strategy to me. I think there’s a couple things that we should absolutely be doing. So I say that’s while I’m calling in from a homeless shelter where I work, and I wasn’t for effect, I’m just in clinic. Like, what have we done for the venues and the settings that are so disproportionately affected in the context of doing shutdowns? Should we be shutting down the area that is around this homeless shelter because we’re at such disproportionate risk related to the fact that we’re in a shelter, and that it’s just a congregate living setting? Or should we start thinking about what are the programs that we need to put in place to actually break those chains of transmission? As I think has been happening at individual venues and centers but it hasn’t really been taken the scale.
What we need to be doing that we haven’t done
I think there’s a couple core things that we need to be doing. So one is, it’s amazing to me that this far along we are not providing paid leave, particularly for workers in long term care facilities and in shelters that are like agency hires contract hires and this is kind of universal. It’s amazing to me. It’s like a fundamental failure that we haven’t done that when it’s a major source of thinking about how you’re going to prevent virus from ever entering the building. Because I think once this virus has entered a site, then it’s like testing and PPE and all those sorts of things and masks, obviously. But once virus has entered the site it’s like hope is your best strategy, as compared to really trying to think about how you’re going to prevent that. Housing support. Often when we’re testing folks, telling them to isolate I think the natural question is, ‘where would you like me to isolate?’ We set up programs in my own city for folks that lived in the homeless system but not for folks who were densely housed or couch surfing in an unstable house, etc. So I think this question about ‘where would you like me to do that?’ And particularly for people in multi-generational households, telling them to isolate without providing a means to do that feels like a disconnect that is just going to propagate transmission.
Address unmet needs with resources
And then finally, I’ll just say this idea that people have a tremendous amount of barriers to testing that are often designed for wealthier folks who can work from home, maybe even be able to do a conference call while waiting in line to get tested. Obviously not feasible for shift workers and others who are, as we know, disproportionately affected by COVID. So we’ve misaligned, the programs in general, from where the needs are. So I would say, indeed Colleen said I have this little thing about resources before restrictions, but it’s only because it feels like a very natural public health strategy that we try and address unmet needs with resources. And if people have higher unmet needs, we address those with higher and more resources. And if all of that fails, fine. Let’s close our society. But that should be something that we do when everything else has failed.
I’ll finish by saying that I think the precautionary principle has been and I don’t know if it’s a casualty of 2020 but it feels like it is used often. And people just talk about we need to close down Halloween because who knows, or we need to close down restaurants because who knows. I think we need to do a few things: One, we need to think about the precautionary principles as not just like what are the potential benefits from intervening, but also what are the potential harms and both of those should be along a continuum probability. And secondly, we have to get back to a time of empiricism. If we’re going to close restaurants it should be because we’ve identified clusters that are at a significant scale and make up a significant proportion of the epidemic in terms of attributable fraction, both in terms of immediate, as well as downstream infections. Fine, let’s intervene there and let’s think about how to address that. But I think we have to move away from this approach where the first time cases are going up, we’ve made it easy for governments. It’s like, what do we close now okay let’s close strip clubs. Let’s close restaurants. Let’s close you know what we say and public health is like, people just chasing unicorns and doing pandemic theater of just like closing something just to show action.
We need to let public health function independently
I’ll finish with that I think that I worry about a future where every time a pandemic arises because this isn’t our last pandemic. We might have another pandemic in the next two to three years. That is just the nature of our world at this point, where we move to these sort of grave close-down-the world restrictions, nationalistic close our borders, etc. as compared to by the way — that wasn’t universal across Sub Saharan Africa and Asia they’ve just been a lot more country to country coordination. But Europe and North America, we’ve just closed down and in a very nationalistic way. I worry about this future and I think we need to get back to a point when public health can function independently, do what it needs to do to try to mitigate the epidemic, and save lives.
How do we protect the vulnerable?
Dr. Dowdy | protecting the vulnerable
I think that, in general, the three of us are in in rough agreement that what we need are creative and focused solutions to protect the people who are who are at greatest risk. I do think that it is important to be responsive to the overall level of of infection in a community. I think that where infection levels are higher we need to be more proactive in our response. And by proactive I don’t mean locking down. Along the lines of what Stef was suggesting by providing more support, allowing people and enabling them to act in the ways that they need, to protect themselves and to protect their families. Also, being proactive about testing and seeing where transmission is occurring on not just a country or state level scale, but really down to locales. And this may be a controversial point but I do feel that focused and temporary restrictions in in areas where transmission is intense can be effective and can reduce both inequities and long-term morbidity, mortality, and misery at a population level. I think that we’ve seen, going back to the, to the example of Australia, First Nations people in Australia have one fourth the risk of dying of COVID as the average individual whereas in the United States, American Indians, Native Americans, blacks, Alaskan Natives have five times higher risk of of hospitalization due to COVID. And so by keeping transmission at a lower level and being focused for temporary, short periods of time I think that we can actually improve equality and make things more tolerable for the population.
The question of testing | Where, when and at what cutoff?
The question of testing was raised and each participant brought a unique perspective.
Dr. Dowdy | The question of testing
So, without getting into too many of the nitty gritty details of who to test and where to test, I think the key is you want to use testing in such a way as you know where to respond. And so if we see positivity levels going up in a community, for example, that’s where we should be pouring in more resources to do additional testing so that we can figure out where transmission is occurring and how we can be creative about responding to that. So if I if I know that transmission is occurring in one particular venue finding a way like to support the people who are engaged with that venue, making it such that they don’t have to continue to interact with each other, and get them through that. So there should be more and more testing and that helps to define the exit strategy too, because, because then you know when when admission has, has declined as well. And so, again, I don’t want to spend too much time on a response about the details of diagnostic testing but just to say that we should be using it to figure out where transmission is occurring, where cases are cropping up, and therefore how to focus our response. Without knowing that, it’s really difficult to come up with targeted or creative responses for reducing transmission. And by transmission, also morbidity, mortality, panic, the possibility of of lockdowns in session.
Dr. Bhattacharya | the question of testing
I took a pretty strong position about testing earlier so let me agree and disagree with David. I do think that testing to track community spread is useful but we should do it in a representative way. Right now the testing regimen identifies cases not randomly. It depends on who shows up, whether you test asymptomatic people or not. It doesn’t actually give an accurate picture of community spread.
The second thing I’d say about testing is that we can tune the test to be very sensitive or very specific. There’s a trade-off there, even for the PCR test. A very sensitive test used in schools to identify cases that most likely aren’t transmissible, and where you where you use it to close the school down is a is a terrible use of a test. We should think about the error properties of the testing and the use to which the test is being used when we’re thinking about testing. Not simply just test in order to identify cases. So I think that we sort of failed at that as well. We convey to the public this idea, we put up the case numbers beginning. Who’s infected? Is it older people is it, young people? That matters a lot more than just the total number. I think you want to you want to use test to protect people to save lives, you can use it in to guide medical therapy, obviously. But you know that you should think very carefully about how these tests are being used and the harms …The dictum that more information is always better is actually not true here. If you use the more information in a way that harms people then I don’t want that information. So, I think, in, in theory, one could imagine a world where more and more information is better but that’s not the world we live in right now. Those tests are being used to close down schools and to quarantine people. I don’t think only sort of indifferent link to actually controlling the harm from the epidemic.
Dr. Baral | the question of testing
This is just brilliant.
Testing is important for epi purposes. And I agree with Jay. I love data. We’ve started figuring out how to deal with these collider biases etc, but you know, some of the selection biases that exist in terms of how to test to start inferring what’s happening …. But I feel very strongly that tests as a diagnosis is not a prevention strategy. I think it’s indicative of how this whole response feels really well aligned for rich folk. Sure, if you’re rich, and you get a positive test and go into your home where you likely have at least one room per person in your household and isolate. Get food delivered to your home, do what you need to do, and that you’re fine.
If you’re lower income and you’re asking people to test, that’s not an intervention; the intervention would be making sure that they don’t if they’re well enough that they’re not in the ICU. Basically, you’re asking them to to quarantine and isolate. I think the fair question has to be, how are you making sure that that’s feasible for them? What resources are you providing them to safely quarantine and isolate from all of the various high risk people either in their occupation, or in their household setting. And if you’re not doing that then the test is not an intervention. It’s just like a piece of data. And people like me love data anyway so I think from a data perspective and writing papers it’s one thing. From a prevention perspective, I think we should have a very different kind of understanding of utility these tests.
Getting to a middle of the road approach
The conversation lead to the question of concrete ideas about what we could do going forward? This part of the conversation echoed the idea of tolerance and the need for real dialog.
Dr. Bhattacharya | The path forward with COVID
I’m a partisan in this so I have to defend my position, but I’m I wanted to come to this conversation to learn. I think we have to talk to each other. I think this tendency toward trying to suppress the opposite view or suppress basically one side of you we’ve seen basically. I mean we put the Barrington Declaration out and Google immediately banned it. It’s absolutely shocking to me that scientists cannot speak to one another — over disagreements over fundamental things we have to have an open discussion. And this attempt to suppress people you disagree with has to stop. So, I think I don’t think a balanced view is possible unless we have discussions. I have to say when you invited me I was very pleased. I mean, over the moon ecstatic because I wanted to learn from people that disagree with me. That’s the only way forward in science.
Okay, now let me do the partisan thing, I think focus protection is the balance thing. We have to account for the harms that we’re imposing with lockdowns on people. We shouldn’t ask people who don’t bear a huge burden of COVID to bear huge burdens from lockdown hands, it’s not right. At the same time we have to acknowledge that COVID is a deadly disease and there are groups that are that are at risk from it, and we have to do our absolute best to protect them if we can. This is not a possible to get to a utopian world where we have zero COVID and we’re back in 2019 again. It’s just a question of minimizing human misery and minimizing death. It’s going to require us to acknowledge that. Stop blaming each other, listen to one another.
Dr. Dowdy | The path forward with COVID
I’ve learned a lot from this discussion as well. And I think that the only way for us to find out where we agree on things and where might be a reasonable middle road is to have these discussions where we bring in people who might have different perspectives but are willing to talk and, hopefully, in a respectful fashion. And so just to give my own thanks to my co panelists in that regard because I feel like this has been a great experience for me. I also agree with Jay that we need to be thinking about how to be focused in our protection. I think we need to do it in such a way that is not necessarily a one-size-fits-all strategy. I think that when we have even a one-size fits all focus protection strategy that runs the risk of creating more inequity than it solves creating sometimes even more human miseries than it solves. And so I really do think that this has to be something that is done on a local level, or on a small level where people understand the context into which each of these interventions that we might be employing. They understand what that context is. Understanding what the history of transmission has been in that community, and figuring out how we can reduce transmission particularly transmission among those who are at greatest risk of suffering the worst outcome. And so without that sort of customized local approach, I think, like again one size fits all approaches are bound to fail.
Dr. Baral | The path forward with COVID
This is one of the most important chunks of commentary in the debate.
I alluded to this earlier: I have to say that I worry pretty gravely and I’ve actually had this happen to me personally. I think the first time in my career I was actually afraid to speak, which is crazy. And I think is crazy because I’ve all the perks. I have a lot of these elements of privilege and I felt a personal and professional fear that I think is inappropriate. I know a lot of folks that are more junior and earlier in their careers are feeling, in very real ways, and it’s hindering conversation. The idea of likening certainty around this brand new virus in this new dynamic to whether the earth is round and whether we orbit around the sun does such a disjustice to a lot of the uncertainty. And I think many of us are used to managing uncertainty, but I think this idea of pretending that there isn’t uncertainty, does a disjustice to the fact that science is a process, not a destination and surely not a popularity contest. I’ve laid out, I think, very sort of traditional public health principles. I continue to believe, as David said, if you get back to a process of local public health being able to manage resources from the feds, resources by those states and the provinces, and national governments to do local public health, you’re in a much better position. This idea of federal mandates and restrictions-based approaches is going to harm the relationship between public health and the public for decades to come. I even worry about people that don’t want to apply to be like MPHs anymore. They just look at what is public health — like is it the police, or is it really this empowering, oriented approach to solving the world’s problems? So, I will just say that I worry about a future where this is what public health has become and it’s surely not the public health I trained in. And I should know. Public health is all I’ve ever trained in and this all feels very foreign to me. So, thanks.
I can’t finish any better than that.