“The problem is not that people are stupid, but that no one explains anything to them normally”: an interview with epidemiologist Anton Barchuk

Anton Barchuk is an epidemiologist and oncologist. In 2020-2021, he conducted research related to COVID‑19: he identified the percentage of people with antibodies to SARS‑CoV‑2, and also evaluated the effectiveness of vaccines. Lifehacker talked to Anton and found out when the pandemic will end, what threat vapes pose and what vaccinations everyone should get.

About the profession of an epidemiologist

Who is an epidemiologist?

- In the Russian understanding, an epidemiologist is a person very close to an infectious disease specialist. But this is not entirely correct. Because:

1. Epidemiologists don't always deal with infections. There are quite a lot of areas of work in this area, related, for example, to cardiovascular or mental diseases. First and foremost, I am an oncologist. And my interest is based on the epidemiology of cancer. Associating this science only with infections is the 19th century. Now there is no plague epidemic, but there is an epidemic of obesity, an epidemic
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   seated lifestyle and smoking epidemic.
2. Epidemiologists do not treat people, but are mainly engaged in research activities. For example, they study the causes of premature deaths and loss of quality of life in the modern world. Thanks to them, we know that smoking causes lung cancer, and the human papillomavirus causes cervical cancer. Also, clinical epidemiologists study the effectiveness of drugs, surgical interventions and any other interventions that can prevent the adverse effects of a wide variety of diseases.
3. Now epidemiology is moving further and further away from medicine and closer to the social sciences. Because in today's world it is quite difficult to separate the medical or social and economic factors that affect health.

How dangerous is this profession? After all, some epidemiologists go to the centers of infectious diseases.

- In fact, now epidemiologists work at a computer. Yes, there are specialists who go “to the fields”, but there are not many of them. And even there, only those who deal with infectious diseases, for example, analyze biosamples, are at risk. But basically our activity consists in planning research, collecting, processing, analyzing and evaluating the quality of data.

What separates a good study design from a bad one? What research can you trust?

- Let's imagine that there is some kind of causal relationship between a risk factor and a disease. Or, for example, between a medicine and the fact of a cure. The task of the epidemiologist is to conduct a study in such a way that this relationship can be objectively assessed. Unfortunately, quite a lot of systematic and random errors often interfere with the analysis of these relationships, which affect the result and conclusions.

For example, if you are analyzing a completely new drug, you should definitely conduct a randomized trial. Without doing this, you will not get an objective result. This is the fundamental basis of modern evidence-based medicine.

Randomization is a very conditional "tossing a coin", the distribution of patients between groups - experimental and control - randomly. If the doctor does this manually, then, consciously or unconsciously, he can choose healthier people - those who can more easily endure the effects of the drug. And then, when analyzing such data, you will conclude: the medicine helps. But only because the doctor initially selected patients with the best prognosis.

To understand whether the study is good or bad, specialized medical journals help. After all, the main product of epidemiologists is scientific publications. And they can be published in the journal only after the reviewers evaluate the quality of the research and ask the authors questions.

If you have a publication with a good reputation in front of you, this does not mean that it will not get into it. bad article. But, as a rule, this happens quite rarely.

Can an epidemiologist predict an epidemic?

— If we are talking about chronic non-communicable diseases, these are always some kind of stable trends that, in theory, can and should be predicted.

A simple example: people smoke, smoking causes lung cancer. And we roughly understand what the mortality rate from this disease will be in the future, depending on what percentage of the population smokes now. This is a stable forecast, but even it may not take into account some unexpected factors.

Suppose that at some point the state will introduce wild excises on the sale of tobacco. And the price of tobacco products will skyrocket. People will start smoking less. Then our prediction will not come true. But it will still be useful. After all, we will have real and potential trends in mortality from lung cancer in our hands, and we will indirectly be able to assess the effect of the introduction of excises.

In fact, we did the same during the coronavirus infection. When it started, everyone predicted what would happen if we introduced or did not introduce a lockdown.

The lockdown is not just some measure that fell on us out of the blue. Mathematical models have shown that without it, higher mortality awaits us.

However, COVID-19 itself was a surprise. Predicting the emergence of a new virus or a new strain omicronthat came from South Africa is much more difficult. This is more of a question for virology and the evolution of viruses.

- And what can you say about vapes in this case? Will there be an epidemic of vaping? Or maybe a new lung cancer epidemic?

- Good question! In the epidemiology of chronic noncommunicable diseases, the influence of risk factors is highly extended over time. In the middle of the last century, at least several decades were needed to assess the relationship between tobacco products and the development of lung cancer. After all, this disease does not appear the next day after you smoked.

In this sense, the epidemiology of infectious diseases is a little easier:

1. The man sneezed.
2. The second person was nearby, after 5 days he fell ill.
3. We counted how many people were next to the one who sneezed first.
4. Compared with those who were not around.
5. We were able to assess whether this virus is a carrier of the disease.

When we talk about chronic ailments, risk factors are much less pronounced and they are not the only possible ones. You will always find people who are diagnosed lungs' cancer and without smoking.

We are talking about differences in risks, probabilities of illness, and in order to understand why vapes are dangerous, we need some time. For example, it is possible that the pathology develops after 15 years of smoking. How old are electronic cigarettes? Years 10. This means that for now we simply do not have a sufficient period that would allow us to assess what risks vape smoking. Although now there are works that claimthat vaping causes asthma in young people. And it seems to me that this is enough to control their spread.

In the middle of the last century they said: “Cigarettes are like candy!” But in the end, the whole world was covered by an epidemic of lung cancer.

And by the way, this is one of the main factors of premature death in Russia. Many die from cardiovascular and oncological diseases, which, in turn, are associated with smoking. If not for cigarettes life expectancy in Russia would rise sharply. So saying “Let's smoke something else” is illogical.

How has your work changed during the pandemic?

The work itself hasn't changed much. We were studying the spread of the coronavirus in the population, but we might as well be studying the spread of dementia among the elderly. Because these studies are similar in design. We are currently evaluating the effectiveness vaccines in Russia.

At first, I did not want to investigate the coronavirus, but I had to, because in the Russian Federation almost no one did this at the level of international scientific publications, and the topic is relevant.

Although my main area of ​​interest is oncology. Luckily, I don't work in infectious diseases and I'm really looking forward to the end of the pandemic so I can get back to my old research.

About coronavirus

— What version of the emergence of COVID-19 (as an infectious agent) do you adhere to?

- As mentioned above, I am not a virologist, so I know about as much about this as the rest. There is, of course, a series conspiracy theories, but I treat them like all normal people: with distrust. And in general, I think now it doesn’t matter where he came from. What matters is when we get rid of it. And discussions are moving us away from the question of how to make fewer people die from the coronavirus.

- Are you afraid of getting infected?

I have already been vaccinated, I got sick easily and vaccinated again. So it's all right! In addition, I make reasonable efforts to reduce the number of contacts. And if this cannot be done, then I try to use means of protection.

- You said that the pandemic is influenced by the properties of the carriers of the infection - people. Some of them may be super spreaders, while others may not get sick even with close contact. What affects it? How to understand what properties of the carrier of the infection, for example, I have?

- We, epidemiologists, deal with the population as a whole, but when it comes to specific people, it is much more difficult for us to say something.

Let's move, for example, to a region closer to me. If a smoker asks if he will die of lung cancer, then I can say that out of 1,000 smokers, 800 people will conditionally get sick. And out of 1,000 non-smokers - 50 people.

We need to learn to perceive information in terms of probabilities and risks, and not in terms of deterministic phenomena.

An even more banal example. When a person goes out into the street, he understands that he has a risk of getting into an accident. And why not go out? The same goes for vaccination. Vaccination has rare side effects. But they are too small compared to the risk of surviving a severe course of the disease.

Now back to super spreaders. There are some biological mechanisms that determine the status of a virus carrier. But in fact, most often superspreaders are people who communicate a lot. And for example, they continue to go to work, even if they get sick.

Is it a myth that people with asthma or cancer should not get vaccinated? Why?

- This is a myth, which, unfortunately, is widespread even in the medical community. I think he appeared because of the fear of severe side effects, although they are minimal. And the truth is that people with chronic diseases need to be vaccinated first. Because the risks (again, returning to the probabilities) of a severe course of the disease and death are higher for them. And the vaccine at the same time works much more effectively for them - in terms of absolute risks.

— Do you plan to further investigate any aspect related to covid?

“I hope that the pandemic will end soon and this will not have to be done. But in general, an important phenomenon that should be studied is post-COVID. I think, one way or another, this will even affect my area of ​​cancer epidemiology.

And another important point is to study the impact of the pandemic on other diseases. Since now we see that the trends of other pathologies have changed dramatically. We need to understand why this happened, and this will take time.

What about the omicron? What can you say about it? Does existing vaccines work on it?

- With the advent of the omicron, vaccination began to protect not from the spread, but from the severe consequences of the disease. Perhaps the reports that omicron is a milder version of the coronavirus are due to the fact that many have already been ill or vaccinated. And due to this, the frequency of difficult cases has decreased.

Indeed, now in other countries we see a sharp rise in the incidence, but it is not accompanied by the same sharp rise in the number of hospitalizations.

- What scenarios for exiting the pandemic could you imagine?

1. Most possible. COVID-19 is gradually becoming a background virus that causes respiratory illness but does not lead to a large number of hospitalizations and deaths. Then the only question will be how often you need to be vaccinated against it.
2. Radical. There will be a new variant of the virus that will start the pandemic again. We really hope this doesn't happen.

Anything between these versions can also happen. It is possible that a virus will appear in which the vaccine will lose its effectiveness in protecting against severe illness and death much earlier.

About epidemics

- What epidemics are most common now, in the 21st century?

— If earlier we talked about epidemics of infectious diseases, today this word is more often used for chronic non-communicable diseases. And also for their risk factors (smoking epidemic, epidemic obesitysedentary epidemic).

Before the coronavirus, we, fortunately, did not have pandemics that affected everyone in the world so much. You can remember, of course, swine flu, but we did not react to it as sharply: there was no such lethality as with covid.

Therefore, our task now is to get rid of the risk factors that cause the largest number of diseases. Many of them are associated with way of life, therefore, unfortunately, they are difficult to change.

For example, no matter how many drugs are invented, physical activity remains the most effective in preventing diseases. You just need to move. Do not even play sports, but at least walk.

Therefore, more and more often we rely not on some kind of tough interventions - I ate a pill and it got better - but on behavior. People need to be pushed to the right way of life. We know from our own experience that it is not so easy.

In addition, the longer people live, the more they pay attention to diseases that used to remain in the shadows - for example, dementia is increasingly being detected in the elderly. Now it is not enough to live a long time - you need to do it also with the appropriate quality.

- Why didn't you say anything, for example, about HIV?

“It’s just that HIV is no longer news, it has been learned to control in many countries. Now, in general, there are good ways to deal with many diseases, but not all of them reach: there is a problem of access to effective medicines. In different countries, it can be explained either by a lack of money, or by the inefficiency of health systems, or by barriers in the population.

For example, many Russians do not vaccine against coronavirus, although there is an effective vaccine available to almost everyone. The situation is related to the fact that such population interventions require the study of perceptions and barriers in people.

After all, the problem is not that people are stupid, but that no one normally explains anything to them at the level of probabilities and risks. Therefore, they refuse, for example, to be vaccinated - they do not want to be guinea pigs.

There is another, more extreme example. At some point in South Africa, the government decided not to treat people with HIVbecause it doesn't supposedly cause AIDS. As a result, because of this conspiracy theory, hundreds of thousands of people died prematurely. The consequences are still raging there.

What vaccinations should everyone get? For example, little is said about the HPV vaccine, but, as far as I understand, it is very important.

Yes, we don't talk about it. Because the HPV vaccine is not yet included in national calendarand it costs a lot of money. But the human papillomavirus is really dangerous. It is the only cause of cervical cancer in women, and it also causes cancers (such as oral swelling) in men. It is transmitted sexually. Therefore, everyone should really get vaccinated against HPV in adolescence, before the onset of sexual activity. After immunization will not be so effective.

The success rate of timely HPV vaccination is about 90%. This is not comparable to any medicines that are in the world. We see that in countries where there is mandatory HPV vaccination for adolescents, oncological diseases associated with this virus.

Vaccines in general are becoming an increasingly effective tool for preventing disease.

I really hope that this area will develop, because if we eliminate the infectious agents that cause chronic diseases, it will become much easier for us to live.

A the calendar My colleagues from ANO “Collective Immunity” have mandatory vaccinations — I thank them for this.

Why is life expectancy lower in Russia than, for example, in Western Europe? Is it related to epidemics?

— Human health is affected not only by specific risk factors, but also by the level of socio-economic development of society. That is, many diseases come to us due to lifestyle, so when we conduct research, we try to evaluate this aspect as well.

Previously, researchers liked to use simple categories: race, gender. For example, to assess how different groups of people are affected by certain risk factors or how drugs work for them: for whites - so, and for blacks - so, for men - so, for women - so.

In some cases, especially when we are talking about public health, the difference is not at all in the color of a person's skin or biological field, but in what socio-economic status each individual person has, what position he occupies in society. This is essential as we look for the causes of inequalities (in terms of health and access to medicine) and how to address them.

And this status most often affects, among other things, making decisions on the implementation of preventive measures. For example, the UK has introduced a free cervical cancer screening program. Women from more affluent areas came to it more often than those who live in disadvantaged parts of the country. We don't know exactly what it is. Perhaps the second category of women works a lot, and they do not have time to go to the doctor.

For Russia, traditional risk factors are smoking and alcohol. And in the United States, for example, the number of people with colorectal cancer is on the rise. This may be due to inactivity and diet. So everything depends on the way of life, and these are not only questions of biology.

- What determines the course of the pandemic in each country?

“The course of a pandemic is determined by several factors. At the first stage, it depends on the country itself - large or small, dense in population or not. Of course, in densely populated states, where there are a lot of contacts, the coronavirus spreads faster. The same goes for big cities and small towns.

The second stage is determined by the protective measures that are taken in the country, and how people follow them. For example, in the summer of 2020 in Finland, almost not registered new cases of illness. The result was due solely to the fact that people stopped contacting each other. Also at the second stage, vaccination appeared - and the course of the pandemic depended on it.

In Russia, the course of the pandemic was also influenced by the number of people who were ill, and not just the number of those vaccinated. Now we are faced with a situation where there is a certain number of those who received the vaccine and those who suffered from covid — each of these groups has immunity. And because of this, we are probably now in the same position compared to other countries, and this will help us prevent the negative effects of omicron.

But such conditions, unfortunately, were achieved only due to a large number of deaths. The excess deaths amounted to more than a million - that is, compared to the forecast of demographers, in reality, a million more people died.

Is it possible to avoid epidemics or is it a utopian dream?

“For most modern diseases, we don’t know all the risk factors. We do not know why pancreatic tumors occur or brain. We don't know why diabetes occurs.

This is the problem: to eliminate all diseases, you need to know all their causes.

As a result, each new risk factor that is discovered becomes an important discovery. Because it helps to prevent a large number of deaths and diseases.

But it cannot be ruled out that some new factor will appear. When cell phones hit the market, people said they caused brain tumors. When microwave ovens were invented, they began to claim that they cause cancer. Now everyone is discussing the danger 5G towers.

It is normal when we perceive something new as a risk factor. But all this must be studied - usually innovations that people are afraid of do not harm health. But if we talk about risk factors recently identified through epidemiological studies that are really dangerous for humans, then an example is the story of glyphosate.

- When you are in front of an anti-vaxxer, what do you say to him?

- In fact, there are very few radical anti-vaccinators. They have a certain ideology, like people who believe that the Earth is flat. Probably nothing to discuss with them.

But most people are not anti-vaccinators, but doubters, vaccine-hesitants. And usually their doubts are understandable and justified. It's just that no one gives well-formulated answers to their questions.

But instead, they immediately call them anti-vaccinators and say: “Let's shoot you all, you are spreading the coronavirus here.” Accordingly, their reaction to this may be tougher than that of the same anti-vaccine - peaceful, with a cap on his head, who walks on a flat Earth. So the important point here is, of course, the dialogue.

When you meet someone who has doubts about a vaccine, you don't need to go to extremes and say: "If you don't get the vaccine, then that's it... The end of the world."

When there is such a rigid message and people do not have the opportunity to make their own decisions, it harms vaccination. Any decisions regarding the health of a particular person should be made only by him - this is the principle of autonomy within the framework of bioethics.

But, unfortunately, there is paternalism in our model of medicine. The population is seen as a party that receives information, but not decisions. However, if you tell everything clearly and accessible, then perhaps people themselves will do the right thing. choice. And it will be their own decision. And perhaps these very anti-vaxxers will want to get vaccinated against covid.