^{(Disclosure: both my parents are medical specialists; my wife has a graduate diploma in family medicine though she no longer practices.)}

Over the past week an interesting informational contest has emerged in Singapore over the publication of an open letter by twelve doctors to parents in which they cast doubt on the value of the Pfizer-BioNTech vaccine—and broadly any vaccine that relies on messenger RNA technology—to children.

Their letter has been meet with ridicule by the establishment, including calls by Calvin Cheng, a former nominated member of parliament and conservative commentator, for their medical licenses to be revoked (as part of his broader critique of the knowledge and expertise of family physicians).

I disagree with some of the doctors’ views and methods, and am dismayed that their letter has probably stoked fears among some parents with regards to vaccination. However, I do wonder if there is a public interest argument in allowing such conversations to occur in the public square, as opposed to festering in tiny digital echo chambers. (The doctors first circulated this letter to church members.)

Before critiquing the letter’s content, we should try to understand its genesis. Though vaccine hesitancy here has fallen, there is still fear among some Singaporeans about the risks involved. This is partly due to the rapidly evolving global COVID-19 situation, including the emergence of vaccine complications, for example blood clots which have affected a handful of recipients of the AstraZeneca and J&J vaccines; the spread of coronavirus variants; and the growing evidence showing that vaccinated individuals and those previously infected are still vulnerable to the disease.

Local factors have also fed doubt around official COVID-19 narratives. This includes the perception that politics has stymied Singapore’s public health response. Sparked last year by the PAP’s desire to hold an early election at the start of the pandemic, it has been reignited over the past month by suggestions that Singapore’s second wave is partly due to politicians taking their eye off the ball amid leadership machinations. Legitimate queries by citizens about the delay in border closures have often been met with simplistic smears of xenophobia, further poisoning public discourse. 

The medical specific factor concerns messaging. Even in the best of times, information asymmetries mean that healthcare professionals are never going to be able to fully explain the risk-benefit calculus of a procedure to a patient. Your doctor will always have a better sense than you do (your midnight Googling notwithstanding). 

The demands of the pandemic have dramatically narrowed this space for discourse and deliberation. To contain its spread, society might deem that easy sound bites—“Mask or Don’t mask”; “Vaccinate or Don’t vaccinate”—are sufficient; and that we don’t have to engage in granular analysis of health and policy implications (which a fear-stricken population may not anyway comprehend).

Singapore has long had an informational power imbalance. The ruling People’s Action Party (PAP) and the government has always hoarded data and limited public access to it, for reasons of political dominance and/or worries that data will be misused by those seeking to sow public discord. This is the backdrop for the sense today that the government is not being forthcoming with COVID-19 related information.

For instance, there appears to be a lack of transparency around the vaccine approval process. Several doctors I spoke to wanted to know the reasons why the Sinovac vaccine has yet to be approved. 

It is in this informational vacuum that the twelve doctors’ letter must be situated. The doctors do not appear to be anti-vaxxers. Their concern, which appears like a reasonable one, is with the use on children of novel mRNA technology that by definition has not benefited from long-term testing. 

Their suggestion is for the government to approve a vaccine such as Sinovac that relies on “killed” (inactivated) virus technology, which has been used for decades in other vaccines for ailments such as flu and chickenpox.

Many of us might disagree with the doctors’ position—I do not believe, for instance, that the absence of long-term testing is a sufficient reason not to vaccinate. Nevertheless, I think the doctors’ position is a fair one for them to adopt. However, we must condemn the doctors for bolstering their opinion with misinformation.

Their argument is partly based on the different vaccine risk-benefit profiles for different age groups. This is a function of the fact that COVID-19’s mortality rate broadly tracks age: all else being equal, the older you are, the more likely you are to die if you catch it. 

In their letter the doctors say that for people over 65 ”the immediate benefits of vaccination for this high-risk group outweigh the risks of the unknown long-term side effects. For Children, however, it is another matter.” 

While their focus is mostly on individual benefits and risks—clearly there are also societal impacts—it is a fair line of inquiry. Societies everywhere are making judgement calls on the risk-benefit profiles of vaccines by age group, especially as complications emerge. 

However, by cheekily omitting the vast majority of Singaporeans (aged 16-64) from their assessment, the doctors leave the reader with the impression that the risk-benefit profile for this group is finely balanced.

“Old people should get vaccinated; young ones should not; and we have no comment about everybody else,” seems to be the message.

Another problem with their letter concerns the way they describe new research on the ability of the SARS-CoV-2 virus to, as this article in Science puts it, “slip its genetic material into human chromosomes”.

The doctors misrepresent the above research in several ways, but most offensively by the allusion that the research concerns the mRNA of the vaccine. It does not—it concerns the SARS-CoV-2 virus itself. In other words, they misused research about the virus to sow doubt about the vaccine (insinuating, awfully, that it might alter our DNA).

Are the doctors “good faith actors” who have made honest mistakes in their bid to provoke thought? Or are they “bad faith actors” out to deliberately spread misinformation?

The evidence thus far is mixed. On the one hand, the language they use suggests good intentions (“humble ponderings”; “grateful for the availability of vaccines”). 

On the other, their research efforts are deplorable. It is unclear if they consulted any paediatricians or infectious disease specialists or tried to send their message through official channels, as they should have done, before writing an open letter. After the government debunked the letter’s claims, even though eleven retracted their claims, ophthalmologist Dr Khoo Boo Kian has dug in his heels.

Society’s assessment of their intentions is important. Public discourse is still very much in its infancy in Singapore; we must incentivise good faith actors to engage, all the more so for any issue concerning SARS-CoV-2 and COVID-19, for which our collective wisdom is necessary. 

All that is not to imply that any doctor should use their authority at any time to peddle unverified contrarian views. “Dissent in private, united front in public,” some doctors say.

An autocratic impulse might suggest that only one voice in society should speak on medical issues. Nevertheless, events over the past eighteen months—from Delhi and Washington, DC to Our Beng belittling mask-wearing in Hong Kong—indicate that this would be folly.

Dominant power structures might snuff out lone voices, such as Li Wenliang’s, to society’s detriment. Some of the twelve doctors had last year advocated the wearing of masks even when the Singapore government was telling people not to.

One doctor friend has insisted that, regardless of their intent, the twelve must be punished for their irresponsible behaviour because that is the only effective deterrent. After all, global public health is still reeling from the fiasco sparked in 1998 by Andrew Wakefield, doyen of the anti-vaxxer movement. Countering misinformation is not easy.

The best way for the government to do so in the long term is through transparency and trust. If Singaporeans had been kept up to speed on the Sinovac vaccine approval process, the doctors may not have even written the letter. The PAP’s old tendency to hoard data and information is ever more counter-productive. An educated society deserves not only the binary directive—“Vaccinate or Don’t vaccinate”—but the detailed thinking behind.

Finally, Calvin Cheng’s seeming denigration of family medicine and general practitioners is highly unfortunate. (He subsequently edited his post, partly out of “care for strawberries”.) There are many reasons why Singaporeans need to establish even stronger relationships with their primary care physicians, including cost containment: the desire to seek specialist care for every minor ailment is one reason for spiralling healthcare costs.

In numerous fields including medicine and technology, there is growing recognition of the value of generalists, who can apply their multi-disciplinary skills to promote thinking across fields. GPs, who are on the frontline fielding questions, administering swabs and doing much else, are an invaluable informational node with regards to COVID-19. 

Ironically Calvin actually has something in common with the twelve doctors. Like them, he seeks to fill a perceived informational gap: conservative sociopolitical commentary, in his case. His flock likes his contrarian views that do not always please the establishment. And, like the doctors (and commentators everywhere), he opines on subjects in which he is not a credentialed expert. 

We should defend his right to do so. Yet how will he react when experts call him out for spreading misinformation?

It remains to be seen if Calvin’s prescription for errant doctors is one that he’ll administer to himself.

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top image credit: Brian Deer’s book on Andrew Wakefield, image from his Twitter feed

References

You can read the doctor’s original letter here:

Their retraction is here:

A response from Singapore’s expert committee on coronavirus vaccination is here.

A minister’s rebuttal is here.

On the research quoted by the doctors

The doctors cited a pre-print (yet to be peer reviewed) of research yet failed to mention that it is a pre-print. Science wrote about the research last year in an article, “The coronavirus may sometimes slip its genetic material into human chromosomes—but what does that mean?”:

”The work, only reported in a preprint, suggests the pandemic pathogen takes a page from HIV and other retroviruses and integrates its genetic code—but, importantly, just parts of it—into people’s chromosomes…Either situation may explain PCR detecting lingering traces of coronavirus genetic material in people who no longer have a true infection.”

The research has since been published by PNAS. It’s unclear if the doctors are aware of this.

The way the doctors selectively marshal data and evidence and sequence them to incite fear also suggests bad faith: the apparent high incidence of Hepatitis B in Singapore, the supposed higher presence of reverse transcriptase in individuals here, and the implied higher chance of DNAs being altered by the presence in their bodies of mRNAs from the vaccine.

On Calvin Cheng’s post

Cheng’s edited post included this at the end: “This post was edited to make sure there is no ambiguity that I was denigrating GPs. Primary healthcare is important.”

He repeated the same thing to me in private.

My response was that one must consider how the audience interprets the message too—which, as many doctors (and I) think, is demeaning to GPs.

An anti-vaxxer message can cause damage before it is rebutted or edited; likewise for an anti-GP message.

I reproduce below Cheng’s post and a series of conversations he had with doctors including Hoe Wan Sin (photos I grabbed from Siew Tuck Wah’s Facebook page).

Readers can decide for themselves.

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