COVID-19 and the Need to Hear Out Devil’s Advocates

A nurse wearing personal protective equipment watches an ambulance driving away outside of Elmhurst Hospital in Queens, N.Y., April 20, 2020. (Lucas Jackson/Reuters)
Time after time, we seem to underestimate the possibility of the unexpected. We must recognize this tendency in ourselves and work to correct it.

NRPLUS MEMBER ARTICLE I n October 1973, every intelligence organization on the planet believed all was well in the Middle East. This included the much celebrated Israeli Mossad, which knew of formulated Arab plans to attack Israel and retake the Sinai Peninsula and Golan Heights, but didn’t really believe the Arabs had any immediate interest in going to war.

In the weeks leading up to war, Egypt and Syria both held “training exercises” near the Israeli border. Yet even then, the Israelis were more puzzled than threatened, because the Mossad and other intelligence services still were not convinced that either enemy was ready for war. Though several analysts disagreed, they were widely ignored by Israel’s military and political leaders in the days before the war began.

As a result, when the attack came on October 6, 1973, the Israelis were ill-prepared and were on the brink of disaster. Israel ultimately would beat back the Arab assault over the next several weeks, but only at incredible cost. Historical analysis has shown how close Israelis came to losing their nation because of their leaders’ inability to see the totality of the evidence.

In many ways, the world’s infectious-disease specialists and political leaders succumbed to a similar kind of groupthink in the critical months before the Wuhan coronavirus erupted into a global pandemic. Their failure of imagination and rejection of the evidence and data allowed the disease to emerge, and then, erupt from China outward.

It is, of course, undeniable that the Chinese Communist regime bears the lion’s share of the blame for this pandemic. Its lying and distortion of the facts about COVID-19 spread a false sense of security around the globe before the virus became a full-blown pandemic, and hampered other countries’ responses once that happened. The World Health Organization, by blindly accepting the Chinese narrative even as contrary evidence mounted, played its part in the catastrophe to come, too. But the simple fact remains that Western infectious-disease experts should have at least suspected that a major threat was lurking.

For as long as we can remember, the world’s experts have warned us about the possibility of a world-ravaging pandemic. From the Black Death to the 1918 Spanish Flu to the 1957 Asian flu to the 2003 SARS outbreak to the H1N1 Swine flu in 2009, there was no shortage of historical precedents for such a development. The American intelligence community has been sounding alarm bells about the threat for years:

We assess that the United States and the world will remain vulnerable to the next flu pandemic or large-scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support. . . . The growing proximity of humans and animals has increased the risk of disease transmission. The number of outbreaks has increased in part because pathogens originally found in animals have spread to human populations.

Yet despite all of these warnings, when the threat finally arrived at our doorstep, we were as unprepared as ever.

In many ways, the smartest doctors and scientists on the planet, who for decades have been raising fears about a pandemic that could decimate humanity, were caught as flat-footed as any of us. Part of this was of course a matter of Beijing’s intentional deceit, which greatly hindered the rest of the world’s ability to obtain data and develop effective responses to the coronavirus in the outbreak’s crucial early days. But much like the Mossad before the Yom Kippur War, our experts still missed the obvious.

The comforting news, if we can call it a comfort, is that the Mossad learned from its great mistake. After coming very close to losing their country, Israeli politicians and intelligence experts realized they needed to dramatically shift their thinking. In the years to come, Israel would condition its entire intelligence infrastructure to always consider the possibility of the impossible, using the concept of the Tenth Man.

The Tenth Man is similar to the devil’s advocate, which originated in the Catholic Church. Literally a Latin translation of advocatus diaboli, the devil’s advocate is a church official whose entire job is to make the case against individuals being considered for sainthood. In secular terms, a devil’s advocate is someone who argues an opposing viewpoint not because he truly believes in it but for the sake of debate.

The Israeli version of this, the Tenth Man, has become a centerpiece of Israeli intelligence and military thinking since 1973. The thinking is this: If there are ten people in a room and all agree, the last person to speak should play devil’s advocate, making the argument against the room’s prevailing viewpoint. He is an institutional check on groupthink, forcing the other nine men to scrutinize the assumptions on which their view of a given situation rests. And because that is his explicitly designated role, he is insulated from any criticism or retribution for playing it.

The lesson Israel learned after the Yom Kippur War is one that’s apparently still being ignored by American intelligence agencies and our bureaucracy as a whole. After 9/11, Congress went through an extensive study of the blunders and missed opportunities behind our failure to stop the attacks. One key problem it identified was institutional groupthink, which ensured that the smartest people in the room never considered there could be people living in caves planning such a deadly operation.

Today, every corner of the world’s health-care establishment is plagued by a similar denialism. Starting in late November, numerous infectious-disease experts repeatedly assured the public that the Wuhan outbreak would be controlled or burn itself out. They were blind, and they ignored a basic rule of epidemiology: Any virus that spreads from person to person takes time to reach an exponential-growth phase, and China had no evidence that such a thing had happened yet.

On January 5, Michael Osterholm, the director of the Center for Infectious Diseases Research and Policy at the University of Minnesota, who famously wrote an entire book on the subject of killer pandemics, stated that he didn’t think the new outbreak would turn into a pandemic. Even someone so attuned to the risk had deluded himself. By January 20, Osterholm he had realized the error of his ways and warned the large U.S manufacturer 3M, for which he actively consulted, that the virus would cause a pandemic. 3M immediately responded by expanding its production of medical devices. He waited another month to go public with his concerns, writing in the New York Times on February 24 that he believed this was a pandemic that could not be contained. And the response from colleagues seemed only to validate his reticence: He was widely criticized as a paranoid fearmongerer.

By late January, Osterholm had good reason to warn 3M of the disaster to come: China had already quarantined the majority of Wuhan, and thousands of cases had already been diagnosed. Yet the WHO was still proclaiming to anyone who would listen that COVID-19 could be contained. Even Wang Linfa, the doctor who discovered SARS and currently leads the infectious-disease program at Duke/NUS Medical school in Singapore, still believed that the coronavirus was less deadly and virulent than SARS. The international medical community was in denial of the truth staring it right in the face.

In fact, although it has taken much criticism, the CDC was ahead of the curve when compared to many of its international counterparts. Nancy Messonnier, the director of the Center for Immunization and Respiratory Diseases, has said that the CDC was preparing for a potential pandemic as early as January 24. But even Anthony Fauci, who has since become one much-lauded face of the federal response to the virus, was claiming as late as mid February that possibility of its reaching North America was low. Throughout February, specialists from countries all over the world still believed that the virus would die off without reaching their shores, not realizing that it was already too late.

In the US, it wasn’t until February 27 that experts truly accepted a pandemic was underway. Ann Schuchat, the principal deputy director of the CDC, who now runs the agency’s day-to-day coronavirus response, finally realized the severity of the risk when modelers from several academic institutions showed that if nothing was done, 1–2 million Americans could lose their lives within a few short months. “I remember sitting in that room and saying . . . ‘We’ve got to go on a pause. People have to stay home,’” Schuchat said later. “This seems like the time for mitigation.”

We are now in late April, well after the error of the groupthinkers’ ways has become clear, and yet rejection of the scientific community’s “conventional wisdom” about the virus is still typically attacked as detrimental to the public cause, even when it comes from respected scientific and medical experts. Although most experts admit that our knowledge of the pathophysiology of this disease remains largely hidden to us, the instinct to shut down dissenting views is a strong as ever.

In a March 2020 editorial in Stat News, Dr. John Ioannidis, a professor at Stanford University School of Medicine, suggested that COVID-19 was far less deadly than most of the commonly used models had predicted:

In the absence of data, prepare-for-the-worst reasoning leads to extreme measures of social distancing and lockdowns. Unfortunately, we do not know if these measures work. School closures, for example, may reduce transmission rates. But they may also backfire if children socialize anyhow, if school closure leads children to spend more time with susceptible elderly family members, if children at home disrupt their parents ability to work, and more. School closures may also diminish the chances of developing herd immunity in an age group that is spared serious disease. . . .

Flattening the curve to avoid overwhelming the health system is conceptually sound — in theory. A visual that has become viral in media and social media shows how flattening the curve reduces the volume of the epidemic that is above the threshold of what the health system can handle at any moment.

Yet if the health system does become overwhelmed, the majority of the extra deaths may not be due to coronavirus but to other common diseases and conditions such as heart attacks, strokes, trauma, bleeding, and the like that are not adequately treated. If the level of the epidemic does overwhelm the health system and extreme measures have only modest effectiveness, then flattening the curve may make things worse: Instead of being overwhelmed during a short, acute phase, the health system will remain overwhelmed for a more protracted period. That’s another reason we need data about the exact level of the epidemic activity.

One of the bottom lines is that we don’t know how long social distancing measures and lockdowns can be maintained without major consequences to the economy, society, and mental health. Unpredictable evolutions may ensue, including financial crisis, unrest, civil strife, war, and a meltdown of the social fabric. At a minimum, we need unbiased prevalence and incidence data for the evolving infectious load to guide decision-making.

Ioannidis followed up this opinion piece with a well-publicized research study of the coronavirus’s prevalence in Santa Clara County. The study suggested that 50–85 times more people are infected than have been confirmed by testing, and, therefore, the mortality rate is far lower than widely assumed, closer to 0.2 percent than to the commonly touted 1 percent. It immediately received widespread criticism from the media.

Like Ioannidis’s initial editorial, the study is worth scrutinizing, and its findings may or may not be valid. Many doctors and scientists, myself included, disagree with Ioannidis’s conclusions. But his conclusions are not the dangerous quackery so many treated them as; they were arrived at through a solid, evidence-based approach. The knee-jerk reaction to them was both unwarranted and telling. Those who have bought into lockdowns have done so for good reason, but seem unwilling to consider any possibility that the policy may be flawed.

Unless we as a society are willing to hear devil’s advocates such as Ioannidis out, we may continue to fall victim to groupthink in future crises. Time after time, when faced with everything from military threats to terrorism to natural catastrophes to microbial enemies, we seem to underestimate the possibility of the unexpected. Until we recognize this tendency in ourselves and work to correct it, we will continue to be caught unprepared for such Black Swan events, to our own great detriment.

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