The Lancet recently released its long-awaited COVID-19 commission report. The report well reflects the current state of public health science and addresses the business needs of the Lancet. It may have been naïve to expect more than that, but health is an important area and should be taken more seriously. The level of obfuscation of evidence, misrepresentation of prior knowledge, and disregard for diversity of scientific evidence and opinion does not reflect well on either the Lancet or the commission itself. It would be good if this reflection could be proven false.
Written by David Bell
The Lancet in context
Medicine and public health are particularly dependent on truth and transparency, as the lives and health of people cannot be entrusted to dogma and superstition. Clear and open debate is fundamental to minimizing mistakes, which can kill, and to building the trust that patients and populations need to follow guidance (as they must ultimately be the decision-makers). Medicine and public health are also increasingly lucrative for practitioners and for the companies supplying the wares they employ. These forces inevitably pull in different directions.
Private companies making these wares, such as those in the pharmaceutical industry, have a responsibility to maximize profits for their shareholders. This means encouraging more people to use their tests or drugs, rather than putting people in states of health where they do not need them (either good health or death). This is not an extreme position, it is a simple truth – it is how this industry is structured. If there is a wonder drug in a lab somewhere that resolves all metabolic disease with a single dose, and it is easy to manufacture and copy, then the Pharma industry would collapse. Pharma, in its current incarnation, has a duty to build a market, not heal people.
Transparency and truth, on the other hand, could mean admitting certain highly profitable drugs are not needed or even dangerous; that an alternative safe and cheap drug, previously available for other purposes, would be more cost-effective and lower risk. We cannot expect private companies to state this, as it will damage or destroy their income (their business). If they do not try to block a repurposed drug that puts their own investments at risk, they would be betraying their investors. What they should do, for their investors, is over-emphasize the advantage of their own product, maximize the desire of people to use them, and run public campaigns to ensure this situation is prolonged as far as possible. This is what any for-profit business does – it is their job. It is not unexpected.
We have long relied on medical journals to act as a conduit for information from researchers to medical practitioners and the public. This is a plausible model only if journals are independent and the staff and owners of the journal promote truth above politics or company profit. This was once the case; the Lancet, a subject of this article, was once family-owned and could therefore hold to the values of Thomas Wakley and his descendants, standing against medical authorities up to 1921. It has since been owned by other for-profit companies, and is now a subsidiary of a larger Dutch-based publishing conglomerate, ‘Elsevier’. Elsevier in turn is owned by RELX group ( in London), a large company with a typical list of major institutional investors including Blackrock (and therefore Vanguard through Blackrock), Morgan-Stanley and Bank of America – the same list as major pharmaceutical and biotech corporations whose products the Lancet publishes on.
The above does not tell us there is intentional wrongdoing or malfeasance, just intrinsic conflicts of interest of the type journals such as the Lancet are supposed to guard against. The Lancet’s ultimate ownership has a duty to shareholders to use their portfolio of assets to maximize return; on this measure alone the Lancet should favor certain pharmaceutical companies. The only thing that could stand in the way is lack of competence by the owners, or a moral code that rates investors below integrity.
In this context, the Lancet’s track record over COVID-19 has been chequered . In February 2020, the Lancet published a major letter on COVID-19 origins that ignored major conflicts of interest, wherein nearly all its authors were implicated in the alternative lab origin hypothesis. It published clearly fraudulent data on hydroxychloroquine that were significant in halting early treatment studies. A lack of early effective treatment was necessary to secure Pharma profits for later COVID-19 medications and vaccines. The later exposure of the fraud was subsequently described by The Guardian as one of the biggest retractions in modern history. In 2022, the Lancet published a weakly-evidenced opinion advocating medical fascism; dividing and restricting people based on compliance with pharmaceutical interventions. The Lancet’s top leadership has remained unchanged throughout. This is relevant context for understanding the report of the Lancet ‘commission’ on COVID-19.
The Lancet COVID-19 Commission’s Report
In mid-2020, the Lancet recruited people from various domains of public life to review various aspects of the COVID-19 outbreak. This ‘commission’ (a somewhat grand name for a privately-convened group from a private for-profit business) was headed by economist Jeffrey Sachs, who preceded the recent release of the report by publicly discussing conclusions on the potential source of SARS-CoV-2, highlighting the probability of a laboratory origin as opposed to direct animal-human spread. This part of the commission’s investigation had been halted early when Sachs discovered that several panel members had undisclosed conflicts of interest amounting to receipt of funding to conduct the very laboratory gain-of-function research widely suspected of promoting rapid human spread. Some had been authors of the earlier Lancet origins letter.
The Executive Summary provides a foretaste of the quality of work to come, noting IHME estimates of “17·2 million estimated deaths from COVID-19”, a “staggering death toll” as the commission notes, particularly staggering as it is higher than the WHO estimates for total excess deaths throughout the pandemic period. These WHO estimates include all deaths caused by lockdowns and those where virus detection was incidental. It is an implausible figure, even ignoring the lack of context here (nearly all in late old age, and with severe co-morbidities).
Ironically, the commission reports in its main text over 2.1 million excess deaths from malaria, tuberculosis and HIV arising from the COVID-19 response in 2020 alone. However, this is a mis-understanding by commission members of WHO’s actual estimates – WHO does report significant excess 2020 deaths from these diseases, but not this many – though many more will accumulate through subsequent years.
Reflecting the lack of inclusiveness of the commission itself, the report recommends censorship of the alternate approaches, considering “failure to combat systematic disinformation” to be a contributor to severity. The commission then inadvertently provides an example of disinformation in its characterization of the Great Barrington Declaration, misrepresenting it as calling for “uncontrolled spread of the virus”. This, based on the declaration itself, must be a lie, as the commission must have read the original declaration within the 2 years they had available). Did they not consider it pertinent to question those who wrote it or (over 900,000) signed it? Whether the declaration was correct or not, it reflected prior WHO evidence-based policy. Ignoring this is simply untenable for a serious inquiry.
The overall findings of the commission are extremely disappointing from the point of view of science, public health, and simple honesty. Its apparent lack of familiarity with prior public health norms and practice, including that of the World Health Organization (WHO), may have been genuine, or may be contrived to emphasize a narrative it was intended to support. Given the Lancet’s COVID-19 track record and business imperatives, the latter would not be entirely unexpected, but it is disappointing to see adults in positions of influence producing a document of this nature.
Summary of key findings
The Report helpfully provides a three page ‘Key Findings’ section. While missing aspects of the main body such as the euphemism “prosocial behaviour” to denote social exclusion, and extolling the “logic” of the completely illogical WHO slogan for mass COVID-19 vaccination “No one is safe until everyone is safe”, it generally captures the main thrust of the whole text. Reading the rest is however recommended to understand how modern public health thinking has so clearly gone off the rails.
Key findings are presented below. Anyone with a public health background is encouraged to refute the concerns raised, as many of the commission’s assertions appear to involve common traps that seem inexcusable for public health professionals. They hang heavily on a failure to grasp three fundamentals of COVID-19 and public health:
Public health interventions are about risk and benefit. Interventions have positive and negative impacts. Recommendations therefore cannot be given without considering the potential harms they may cause in the short and long-term, weighing these against perceived benefits.
COVID-19 mortality is highly skewed towards very old age, and heavily associated with co-morbidities. Therefore, it is imperative to consider COVID-19 disease burden relative to other diseases in terms of life-years lost, not raw mortality (from or with) COVID-19.
Prolonged lockdowns, workplace and school closures were not part of prior policy, or were partially recommended only in far more severe outbreaks. This is not implying the interventions were either good or bad, only that they defied public health norms and prior evidence. They were previously recommended against due to the harm they potentially cause. This lands most heavily, as WHO notes, on low income people and populations.
Highlights of the commission’s key findings
“WHO acted too cautiously and too slowly on several important matters: … declare a public health emergency… restrict travel … endorse the use of facemasks…”
The commission seems unaware of the prior WHO pandemic influenza guideline, nor is it listed among their 499 references. WHO specifically warned against restricting travel in this guideline. Travel restrictions can be significantly harmful to economies – cutting tourism income alone in low-income countries can increase mortality through poverty. The report fails to mention the costs that extending these response measures would impose. Where lockdown costs are mentioned at all, it is in context of the cost of ‘failure’ to implement earlier or heavier, never in terms of weighing harm avoided against harm caused. Ignoring relative costs, including the long-term health costs of increased poverty from longer lockdowns, is anathema to good public health policy.
The prior guidelines also noted that evidence on facemasks is “weak”. Meta-analyses of randomized control trials of community masking do not show significant benefit, and trials during COVID-19 showed similar results. At a minimum, WHO was therefore evidence-based when recommending against community-masking – the organization is yet to provide evidence to back its later endorsement of their widespread use. The Lancet commission appears to be specifically recommending against the use of evidence-based approaches.
“…most governments around the world were too slow to acknowledge its importance and act with urgency in response….”
Most people live in low and middle-income countries with low COVID-19 mortality and far higher burdens from other infectious diseases, which occur in far younger people. This statement therefore seems inappropriately Western-centric. If they had known earlier, what would countries have actually done? (If earlier implementation of poverty-inducing responses, then for how long?) The commission appears unaware of serological evidence of spread prior to January 2020, in some cases backed by PCR. This would negate any benefit from this recommendation, even ignoring the harms.
Citing the Western Pacific Region as an example of ‘lockdowns working’ similarly makes little sense, as comparisons elsewhere (e.g. Europe) did not show significant benefit, while in crowded slum areas they are clearly pointless. Evidence of early, wide transmission (e.g Japan) indicates that low mortality was due to other factors.
“Epidemic control was seriously hindered by substantial public opposition to routine public health and social measures, such as the wearing of properly fitting face masks and getting vaccinated”
This statement is either ignorant or disingenuous. If the commission members have experience in public health, they know that quarantine of healthy people, prolonged ‘distancing’ and workplace closures were never used at scale before, and that widespread lockdowns were not ‘routine public health and social measures’. If they did not know this, they had 2 years to find out. The world, including the Lancet, knew by March 2020 that COVID-19 overwhelmingly targets the elderly and has little impact on healthy working-age adults. The vaccines do not significantly reduce overall transmission – heavily vaccinated countries continue to show high transmission – so to suggest low vaccination hindered epidemic control is a vacuous statement. It may seem intuitive (e.g. it occurs with some other vaccines) but the commission had 18 months to observe COVID-19 mass vaccination.
“Public policies have also failed to draw upon the behavioural and social sciences”
This is an extraordinary statement to make regarding COVID-19. Governments have openly employed behavioral psychology in an unprecedented way during the COVID-19 outbreak, as has WHO. No public health campaign has ever gained such media attention or had such uniform suppression of non-official messaging from media outlets. It is strange to see a statement so removed from reality.
“Heavily burdened groups include essential workers, who are already disproportionately concentrated in more vulnerable minority and low-income communities”.
This appears to be a nod to compassion for vulnerable populations. It is true that certain groups did suffer higher rates of severe COVID-19, though these are highly correlated with rates of co-morbidities (obesity in Western countries is unfortunately associated with poverty, and poverty with certain ethnic groups). However, the burden was overwhelmingly on the elderly – to a rate several thousand times that in young people. It is the response that burdened these groups most clearly and the report does mention inequity-driving school closures, but this appears forgotten elsewhere in an apparent blind support for faster and harder lockdowns.
“In low income and middle-income countries (LMICs)… better outcomes were seen when previous experiences with outbreaks and epidemics were built upon, and when community-based resources—notably community health workers—were used to support screening and contact tracing, capacity and trust-building within communities”
This claim appears false. Sub-Saharan African countries did well irrespective of prior experience, with a relative exception of South Africa where obesity is more prevalent and there is a higher proportion of old people. Tanzania instituted very few COVID-19 specific measures but had similar outcomes. More than half the sub-Saharan population is less than 20 years of age, an age-group with extremely low mortality in the West. Actual spread in Africa, confirmed by WHO, has been very high.
“…the support for vaccine production in LMICs, for use in those countries, has come at a great cost in terms of inequitable access to vaccines”.
Nearly all people in low and middle income countries (except perhaps China) will by now have immunity. Post-infection immunity is equal or more effective to vaccine-induced immunity. Therefore, mass-vaccination of a whole population with COVID-19 vaccines that don’t significantly reduce transmission cannot plausibly provide much benefit, whilst resource diversion is harmful. This statement is therefore devoid of public health sense.
“Economic recovery depends on sustaining high rates of vaccination coverage …”
Economic recovery depends on removing impediments to a functioning economy (lockdown measures). Vaccinating immune people with a vaccine that does not stop transmission cannot help ‘re-open’ an economy. This statement parrots official mass-vaccination messaging deployed elsewhere. The Lancet’s commission rejected an opportunity to promote logic and evidence-based policy instead.
“The sustainable development process has been set back by several years, with a deep underfinancing of investments needed to achieve the Sustainable Development Goals”.
This is indeed true. Poverty is worse, malnutrition is worse, and preventable disease burdens are higher. Women’s rights are greatly reduced across much of the world, and school attendance has been denied to hundreds of millions of children, entrenching future poverty. Acknowledging this is important, but it also calls into question much of the remainder of the report. Recommendations that acknowledge these mass harms that are concentrated on populations with lowest COVID-19 risk, but go on to recommend more of the interventions that caused them, make little sense.
The remainder of the key findings recommend policies of mass-vaccination ‘to protect populations’, more money for WHO, and more money internationally for supporters of the growing pandemic agenda. This plays to the Lancet’s gallery, but does not consider the harms of resource diversion, the actual very low mortality from pandemics over the last 100 years, nor the heterogeneity of human populations and of disease risk . If vaccines worked in reducing mortality (for all-cause mortality the Pfizer and Moderna randomized controlled trials have not shown this to date), if vaccination was confined to highly vulnerable groups where benefit is most likely, and if the trillions of dollars spent on lockdown compensation, mass-testing and mass-vaccination had been spent on chronic and endemic disease burdens and poverty mitigation, does the Commission really believe more people would have died and outcomes been worse?
A travesty of public health and science
The commission members appear convinced that lockdowns and mass-vaccination were a net benefit, but it also appears that in 2 years of consultation they have not considered the alternative. The loss of decades of progress on infectious disease, human rights, and poverty reduction caused by lockdowns has not given sufficient pause for thought. A virus that mainly targets people over 75 years of age was addressed with a public health response that targets the children and the economically productive, cementing long-term poverty and inequity. They support this approach, but consider it should have been instituted earlier and that it was lifted too soon.
After emphasizing mandatory and restrictive measures throughout, and misrepresenting or ignoring alternative approaches, the report ends on a note that it should perhaps have started with. “We note the timeliness of recommitting to the Universal Declaration of Human Rights, the UN’s moral charter, as we celebrate its 75th anniversary in 2023.” This declaration includes rights to work, travel, socialise, and express opinions freely including, specifically, through any media. A quick read of the WHO’s charter would also have helped – health includes social and mental well-being (and physical well-being beyond a single disease). The report is void of such thinking – a travesty of both human rights and public health.
The report could well have been written based on slogans from WHO, Gavi and CEPI (whom the commission recommends should receive more money), from Pharma companies (on whose support the Lancet is heavily reliant, directly or indirectly) and from the World Economic Forum (who seem to be everywhere these days). Some will have hoped for careful and considered thought, wide consultation and a strong evidence base. It seems the corporate world may no longer have time for such indulgences. This is, in the end, a rich person’s club, seeking increased taxpayer funding for their favorite project. They are doing this in the name of public health.
It was reasonable to have hoped for better. What would Thomas Wakley have thought?
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Nuanced, yet thorough and expository, as usual for Dr. Bell!
As always--a masterclass from David, well worth re reading.