Sure enough, my long hiatus is coming to an end. I am again devoting more time to this platform - I have been rather preoccupied with work recently, as well as catching up with recent advances in hepatology, including recent studies done to show the lack of difference in efficacies amongst tenefovir and entecavir in maintenance therapy of hepatitis B, with regard to slowing progression to hepatocellular carcinoma. However, I do not wish to recommence on a case study or an analysis of a recent study. Nor do I wish to commence with a light-hearted scoping review of recent medical advances, especially those regarding COVID-19. I would like to make a brief statement regarding the comments made by Pierpaolo Sireli, Vice Minister of Health in Italy. Mr Sireli made hardly palatable remarks with reference to medical scepticism. In other words, medical professionals who express doubts regarding the vaccine. I am personally horrified by such comments. Such gross misunderstanding towards the essence of medicine, as portrayed by the words of a high-ranking government official of a sovereign state, is appalling. Worse still, his words encourage a sort of peer pressure which blunts the meaning of medicine and discourages meaningful and analytical discourse which benefits future studies on COVID-19 vaccines. I realise Mr Sireli will likely be too preoccupied with propaganda to read this commentary. Moreover, my Italian is rapidly fading (the one thing about living in the UK is that any attempt of learning a second language is futile - it's so easy to succumb to monolingualism). Both factors prompt me to write this commentary fully in English.
Quoted here is the passage in question: [1]
Così il viceministro della Salute, Pierpaolo Sileri, in un’intervista a La Stampa. C’è chi tra medici, infermieri e personale delle Rsa è restio al vaccino. ”È anche comprensibile che ci possa essere riluttanza da parte di alcune persone, perché questo è un vaccino nuovo. Ma se a mostrarsi reticente è il personale sanitario, che ha una laurea per capire che i rischi sono quelli di un qualunque altro vaccino, allora a quelle persone dico che hanno sbagliato lavoro. E metterei in dubbio - cosa ancor più grave - la qualità del nostro sistema formativo. Avere dei no vax tra i medici equivale a un fallimento”, sottolinea Sileri.
Here is the English translation (translated by me instead of Google Translate- Luckily I still know enough Italian to understand what he's saying):
[This is] what has been said by vice health minister Pierpaolo Sileri, in an interview with La Stampa (Italian newspaper). There are those amongst doctors, nurses and [healthcare professionals] who are reluctant to the vaccine. 'It is still understandable that some people can get reluctant, since this is a new vaccine. However, if the person who is reluctant works in healthcare, who has the ability to understand that the risks [of this vaccine] are those found in any other vaccine, then I say to those people that they have done their jobs wrong. And I would be in doubt of, a matter of greater severity, the quality of our system of formative education (primary education). Having anti-vaxxers in doctors amounts to a failure.
Before I elaborate, I want to make a disclaimer. The Vice Minister of Health might mean well. There are political pressures and external factors prompting him to have said what he said. This commentary is intended to be matter-specific, not person-specific. Moreover, there is a slight chance that his words are misinterpreted. This can be attributed to my wobbly grasp of Italian, or any other factor. However, the point of this commentary is to highlight the dangers of virtue signalling at the expense of dismantling the traditions of medicine.
Medicine is deemed as the confluence of the arts and sciences. It has a long history, dating back to Galen and his theory of the circulatory system. It goes back to the Renaissance, where dissections were made. It goes back to the time when Alexander Fleming discovered penicillin when working at Imperial College London. It goes back to the time researchers at UCL discovered the Epstein-Barr Virus, one that could cause multiple diseases including nasopharyngeal carcinoma (Very prevalent in the Far East), lymphomas (B Cell Lymphoma, Hodgkin Lymphoma, Post-transplant Lymphoproliferative Disorder) and so forth. All these events are united by the most significant tradition of medicine. Scepticism. The spirit of challenging old beliefs and erecting new ones. Daring to question the theories of thinkers of the olden days and not being fearful to voice out their opinions. Scepticism is the foundation of disruptive thinking. Without that initial spark, without that flame of enthusiasm that allows us to rethink a scientific concept, there can be no advancement. Without advancement, it is impossible for us to have come so far in medicine.
Scepticism is what we treasure, especially in crises. During COVID-19, the entire world was engulfed in the frenzy of lockdowns, quarantine and travel restrictions. Quarantine became the buzzword of the year, with Zoom and working from home being close second. According to Richard Horton, the editor-in-chief of The Lancet, there are many more submissions as compared to the same time in previous years. Many of these journal submissions are related to COVID-19. They come in all shapes and sizes - research articles, review articles, commentaries, correspondence and so forth. [2] There are many views and opinions elaborated, elucidated, argued and contrasted. Medicine has always been a sea of information. One, being in the medical field, can only trust the evidence that is the most convincing and replicable. One can do so by comparing the quality of evidence and analysing studies closely. However, COVID-19 is unprecedented. This explosion of data is very likely to cause confusion. It doesn't only perplex the lay population, but also healthcare professionals. For instance, it is still not conclusively known whether IL-6 inhibitors (such as tocilizumab) are beneficial to COVID-19 patients, since the answer varies with the severity of the disease. In such situations, scepticism is of vital and indispensable importance. We, as medical professionals, do not merely subscribe to the most popular belief. The most popular belief is not necessarily the correct one. Nor does it necessarily take into account the best evidence available. It can be advocated by the government for political reasons. It can be countenanced by the public due to sheep mentality. There is no scientific rigour behind the promotion of a belief to the status of high popularity. Other factors are inevitably at play. With a healthy dose of scepticism, we analyse different schools of thought. We develop our understanding towards the topic and start forming our own views. We critically engage in the discussion. Scepticism therefore encourages diversity in opinion.
This is crucial for the improvement of our current research on COVID-19. By having doubts regarding the vaccines, experts critically engage in high-level discussions where suggestions are proffered as to how the vaccine trials can be improved. In an editorial published by the Lancet Microbe, a new specialist journal in the Lancet family, readers are warned against the optimism attached to the COVID-19 vaccines. [3] Vaccines are lauded by politicians as the key to ending the pandemic. The panacea. The war that ends all wars. Sadly, medicine is not politics. It is fallacious and risible to compare vaccines with panaceas, since vaccines only provide individualised protection by stimulating one's immune system. There are also public health benefits. By increasing the proportion of vaccinated individuals in a community, this can enhance the effect of herd immunity so that more are protected. The rationale is laudable. However, it is also grossly overrated. As I have elucidated in my critiques regarding the Oxford and Pfizer trials (linked to this article), there are many issues related to the studies. One common issue is the follow-up period. It normally takes ten years to manufacture a vaccine and roll it out for public use. There is a reason for it. The longer the follow-up period, the clearer the entire picture gets. We can know more about the short-term and long-term adverse events associated with the vaccine, as well as effects on particular cross-sections of the community. Scepticism is the way we engage with higher-order thinking. It is the only way in which we can analyse these trials and provide constructive feedback. It is the only way where we can discuss the next steps pursuant to community vaccination.
What Mr Sileri is saying is gravely worrying. He is making the point that medical professionals command the basic scientific understanding to know that the vaccines are safe. The vaccines for COVID-19 have the same side effects as other vaccines. There is nothing to worry about and if there is even the slightest suggestion of reluctance, these medical professionals are unprofessional. They have done their jobs wrong. I regret to say I cannot accept any of these comments. These comments pander to public mood and are nothing but virtue signalling which blatantly ignores the crux of medicine. It denigrates scepticism, the one word which defines the tradition of medicine. It is the very fact that medical professionals know science that they voice their concerns and critically engage in conversations. It is the very fact they are fluent in biomedical concepts that they pose questions and doubt the fanciful vaccine efficacy figures. It is attractive to promulgate lovely figures of 95, 99 and 98 per cent. It is quite another matter to start realising what the numbers mean.
I am not sure whether Mr Sileri is vehemently criticising a subgroup of medical professionals who are simply ignorant to reason. He might be directing his words to anti-vaxxers amongst healthcare workers. However, this is unlikely since if he were doing so, he would be hard-pressed to find a target audience large enough to warrant his attention. Indeed, Italy is currently experiencing a surge of cases and deaths attributable to COVID-19. The public mood leans towards blind optimism - after all, the public do need some form of good news to let them forget about the horrendous challenges they face daily. Scepticism is not exactly the thing they need. However, by making these comments, Mr Sileri is also inadvertently committing himself to the task of destroying brilliant opportunities for the medical discipline to engage in higher-order thinking and more constructive dialogues. Dismantling scepticism is likely to have major ramifications, especially during a pandemic situation. 95 per cent may be an encouraging figure. However, tucked behind the façade may lie a string of very serious adverse consequences, such as neurological deficits (think about autoimmune conditions such as Guillain-Barré Syndrome and transverse myelitis) and autoimmune flares, especially in patients with greater predisposition of autoimmunity including lupus and scleroderma. These consequences may be serious enough to make getting infected by COVID-19 sound like a picnic in the countryside. Scepticism will not do away with these adverse consequences. However, it is the driving ingredient of change. It is the initiator of refinement of current studies so that these adverse consequences can be assessed, evaluated and even avoided. The day medical professionals blindly accept any vaccine that comes in their way signifies the death of scepticism. The day doctors blindly nod to the popular belief promulgated by the government and reinforced by the mass media heralds the imminent death of medicine.
Doubt. Question. Be sceptical. These qualities should be promoted, not disparaged, in the era of COVID-19.
References and Further Reading:
[1] Sileri: "Vaccino obbligatorio se uno su tre lo rifiuta." L'HuffPost. https://www.huffingtonpost.it/entry/sileri-vaccino-obbligatorio-se-uno-su-tre-lo-rifiuta_it_5feae85cc5b6e1ce833c38f0?utm_hp_ref=it-vaccino. Published 2020. Accessed December 30, 2020.
[2] The Lancet. Peer Review in a pandemic. The Lancet Voice.
[3] COVID-19 vaccines: the pandemic will not end overnight. The Lancet Microbe. 2020. doi:10.1016/s2666-5247(20)30226-3.
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