Jan 27 2022

The Problem with Ladapo

The Twitterverse is outraged, appropriately, it turns out, that Florida Acting Surgeon General Joseph Ladapo, who is undergoing confirmation hearings, refused to state when asked directly four times, that the COVID vaccines are safe and effective. At first he straight-up dodged the question, saying, “The question is a scientific one.” Uh, yeah, and you’re an MD, PhD with a degree in public health (i.e. a medical scientist) so answer the question. When pushed repeatedly he finally did answer that the vaccines have:

“reasonable effectiveness for the prevention of hospitalization and death” and “relatively low effectiveness for prevention” against transmission over time.

This is not accurate. They have extremely high effectiveness at preventing hospitalization and death. The risk of dying from COVID is 53 times greater for those who are unvaccinated vs those who are fully boosted.  Regarding prevention of transmission, Ladapo is narrowly correct but misleading through selective reporting. Studies show that a fully vaccinated person has a relative risk of 0.32 of passing on the virus compared to an unvaccinated person (so an unvaccinated person who gets COVID is 3 times more likely to pass it on). This is not “low effectiveness”, but the same data does also show that this protection wanes over time, and is mostly gone three months after the second shot. However, this is for vaccinated but not boosted individuals. Other studies show that boosted individuals have a 93% relative reduction in their risk of contracting COVID (even Delta), either symptomatic or asymptomatic, and of course people who never catch the virus cannot pass it on.

This is admittedly a brief treatment of a complex and evolving literature, while the virus itself evolves, but the consensus of expert opinion based upon the totality of the scientific evidence is that the vaccines, especially the mRNA vaccines, are extremely effective at protecting the individual who is vaccinated, especially from hospitalization and death but also from getting infected at all, and reasonably effective at preventing spread, but as the new variants emerge that protection requires getting the booster shots. Further, maximizing community immunity through a combination of aggressive vaccination and the natural spread of the virus is our path out of the pandemic toward a new normal where COVID is just another endemic respiratory illness, like the flu. Vaccines are also critical to minimizing the morbidity, mortality, and social disruption caused by COVID.

I would expect any doctor, in the middle of a pandemic, to have a working knowledge of COVID, vaccines, and the relevant data about prevention. I would expect a PhD in public health to have detailed knowledge, and I would expect someone being nominated for surgeon general of a large state like Florida to have nothing less than mastery over the relevant literature. Ladapo, rather, at first refused to answer the question and when pressed gave a razor thin answer that was ultimately misleading, downplaying the effectiveness of the vaccines. This was his opportunity to demonstrate that he has the relevant mastery of the science and knows how to translate that data into public policy and communicate effectively to the public. He failed.

This is not surprising considering that Ladapo has been downplaying the vaccines and other public health measures all along. He is an anti-masker, and refused to wear a mask himself even in a meeting with a colleague who was about to undergo chemotherapy. He also had promoted unproven treatments for COVID. In a Nov 2020 editorial for the Wall Street Journal, he wrote:

Testimony from the hearing underscored an important issue: Too many doctors have interpreted the term “evidence-based medicine” to mean that the evidence for a treatment must be certain and definitive before it can be given to patients. Because accusing a physician of not being “evidence based” can be a career-damaging allegation, fear of straying from the pack has prevailed, favoring inertia and inaction amid uncertainty about Covid-19 treatments.

I agree with the premise here, but as applied to the question of unproven COVID treatments (at the time, mostly hydroxychloroquine) this is a strawman. No one was demanding “certain and definitive” evidence, and that is not how medicine works. Medicine operates through a risk vs benefit analysis, not absolute certitude. At the time he wrote this article there was compelling evidence that hydroxychloroquine does not work and increases the risk of serious complications.

What is happening here is not just that Ladapo does not appear to be competent for the job (which I think he isn’t), it’s that he has apparently subjugated the science to a right wing political ideology. For Ron DeSantis (Florida’s governor), that is a feature, not a bug. This is a very dangerous phenomenon.

There are certain positions in government that are supposed to be apolitical, positions based on topic expertise rather than ideology, positions that often can span multiple administrations even from different parties. The Fed, for example, is supposed to be politically neutral experts in managing the economy, who makes their decisions based on evidence and economic theory, not politics. Surgeon General is another such position, offering scientific expertise on public health issues, and standing apart from any political calculations.

This is because those with any sense at all recognize that good policy needs to be based in reality. And that means we need experts who can give expert advice on what the best science has to say about a topic, to properly inform policy. If we distort reality to fit desired policy, rather than shaping policy to match reality, that is the road to disaster.

I have to bring up the iconic example of this, Lynsenkoism in the former Soviet Union. In this case experts were chosen not based on their expertise, but based on their alignment with the prevailing political ideology. This resulted in an agricultural disaster, and also hampered the science of genetics in Russia for generations. Ladapo is essentially Lynsenko for the far right’s attempt at minimizing the pandemic and public health measures to contain it.

If we are to function as a society, we need to have a baseline respect for facts, and the processes we use to determine which facts are reliable and more likely to be true. Without this anchor to reality, we will collectively drift off into a fantasy land, more made of our nightmares than our dreams.


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