Dr. John Ioannidis: “Now, We Know…”

Distinguished physician-scientist Dr. John Ioannides, born in New York and raised in Athens, is one of the leading public figures in discussions about the impact and responses to COVID-19. He is  

C.F. Rehnborg Chair in Disease Prevention, Professor of Medicine, of Epidemiology and Population Health, at Stanford University School of Medicine and co-Director, Meta-Research Innovation Center at Stanford (METRICS). His interview with The National Herald Follows.

TNH: Dr. Ioannidis, in a previous interview with The National Herald you had expressed the assessment that the pandemic wave in Europe and New York is on the decline. Do you think that we are really on this path?

Dr. John Ioannidis: I think the epidemic is really on the decline. If you look at the data, the number of deaths, the number of available beds in ICUs and in general, it seems that the wave is over. In Europe, it is finished in almost all countries. The data show that we are close to this phase in the United States as well. This does not necessarily mean that we have … gotten rid of it once and for all. There will always be uncertainty about a possible resurgence. Also, no one can know for sure about a second wave, if it will come, when it will come, and how large it will be. However, the data so far in countries that are taking some steps and reopening are optimistic. We have not seen a serious resurgence – without this of course reassuring us 100% and make us believe that there is absolutely no problem.

TNH: We have had mass demonstrations with thousands of people in many cities during this period, over racial injustice and the murder of George Floyd. Are you worried about these large gatherings or do you think the risk is now reduced?

JI: The demonstrations were necessary because we live in social injustice, as well as inequality, which concerns us all and we must at some point deal with it with vigor and courage. On the other hand, mass demonstrations in which proper precautions are not taken are risky. I can't say that the risk is zero if the measures are not followed. Of course, we do not know the consequences. It all depends on the remaining epidemic load that remains active. When we say that an epidemic wave is "on the decline,” it does not necessarily mean that it is completely extinct. There is a possibility that there are some infected people who are still contagious. Where the transmission takes place is in large gatherings of people. Protests fall into this category. I hope this does not happen, that we do not have this bad development. On the other hand, because the virus is new and we don't know much yet, although I am optimistic that things will go well, I would not want to get caught up in various mass events with a lot of people – not just demonstrations – without taking precautions. We saw in the first wave that the areas most affected were through such large gatherings in Bergamo and New York. In Bergamo, we all remember the Atalanta-Valencia soccer match, where half the city participated, sang, and cheered. These are the ideal conditions for transmission. If, for example, in an area the epidemic wave is waning and there is left e.g. 1 in 1000 people actively infected, if we have 5, 50, or 100 people, for example, the chance of finding an infected person among them is minimal. If we have a rally or a game with 50,000 people in attendance, there will be 50 people in this crowd who will be infected. These 50 can infect others and then those infect even more people. Because, unfortunately, we do not have valid epidemiological surveillance to know if the remaining contagious people are one in 100, 1000 or 10,000, it is dangerous.

TNH: The mortality rate (IFR) officially given by the U.S. Centers for Disease Control (CDC) recently is very close to your estimates. What exactly is happening with IFR?

JI: I think these are the best appraisers we have right now. The CDC estimates asymptomatic patients at 35%. The mortality rate of the remaining 65% is 0.4%, so 0.26% in general, according to the prevailing scenario, because they also test scenarios with lower or higher mortality. The numbers are very close to what I had suggested as most likely. But what we see is that mortality is not a number. I had said it from the beginning. It's not the same everywhere. It will be very low if we have populations with mostly young people, who have good health care, and where the health system does is not hit with epidemic wave that catalyzes it. In this case, the numbers are smaller. If we have overcrowding, poor health, poor access to the health care system, hospital infections, as well as infections in nursing homes – which if affected by the virus can kill many – in these cases the numbers will be higher. I had given a range from 0.05 to 1%. It is largely up to us how to manage the epidemic in order to avoid high mortality rates. If we protect our nursing homes, if we avoid hospital infections so that doctors and vulnerable patients are not infected, as well as if we protect vulnerable population groups, we can minimize mortality. The data we have gives us enough optimism to be able to effectively manage the pandemic with targeted and surgically accurate protection measures.

TNH: In Greece, over the last four days there were 97 new cases and there were concerns. At the same time, the country has decided to open its borders to tourism. How can it prevent a resurgence?

JI: I think Greece should make efforts to open the country. On the other hand, it should be closely monitored epidemiologically. It's a virus we don't know much about yet. We do not know its ability to cause second waves. Whoever you ask about whether there will be second waves will speculate without having strong knowledge. As the days go by in countries and states where they have opened and we do not see a second wave, this is good news. Of course, we need to re-evaluate this news. I can't speak for sure. At the same time there must be close epidemiological surveillance. Greece has not used extensive testing. If you take few tests, you will find few cases. That doesn't mean they don't exist. If you take more tests, you will find more cases. This does not necessarily mean that there is an exacerbation; you have to take into account the fact that you are doing more extensive testing. I think at this stage a more intensive testing should be done so that, if there is a second wave, we catch it early. Also undertake regular representative epidemiological surveillance: Take 2,000 people this week, for example, and see how many are positive. We will repeat it after 1-2 weeks to see if the number has changed. At the same time, be very careful about the situation in the national health system: How many available beds do we have, how many new arrivals with COVID-19 and if we have room to deal with any second wave. If we do all this, even though I can't say for sure that a new wave will come, even if it does, we will be ready to face it.

TNH: Many Greek-Americans are asking, "is it safe to get on a plane?"

JI: As for planes, I can't say that the danger is the same in all cases. It depends on which area people are flying from. For example, in countries such as Brazil and Mexico, the wave is at its peak. In areas where the epidemic has passed, the chance of being infected is relatively low. If appropriate protection measures are taken, the chances are lower. The risk is manageable in these situations.

TNH: Recently an issue came up with the Stanford University study in Santa Clara, CA in which you participated. It was suggested that you acted on behalf of a specific donor. A statement by a representative of the University circulated saying that "Ioannidis is being investigated by Stanford." What is the case?

JI: I am not personally being investigated. The University has not checked on me for anything. Besides, I'm one of the 17 researchers. I wasn't even the lead researcher, and more than 100 other people collaborated on this research, and I'm proud of the team's commitment to making this study as good as possible. Personally, I haven't received a single dollar for this study. The study was a good and impartial research effort that provided significant insight. Funding was transparent and ensured maximum impartiality. It came from the University’s development office. You know, after all, Stanford itself was built on a private donation. These donations made to the development office were anonymous. A website that features scandals (Buzzfeed) found that one of the donors, who gave $5,000, was the founder of an airline. However, the research could not be influenced, either in its design or in its results, as was reported. Remember that the results of this research have now been validated by many other studies that show the same conclusions.

TNH: However, the death toll in the United States has risen higher. It is predicted that it will reach 147,000.

JI: One cannot predict the number of dead in such pandemics, let alone for a particular country. Even for viruses that we know well, such as influenza, so far we can't make predictions about the coming winter. The mathematical models have failed. They fell short both in their main estimates and in their measures of uncertainty. Most of them, from very good scientists, had deviated greatly from what finally happened. If you look at the forecasts for hospital and ICU beds, they were completely unrealistic. It was estimated in New York that up to five times more beds would be needed than were available. The predictions were very difficult to make correctly. Most of them fell short because at the beginning of the pandemic we had very limited and tenuous data. Now, the big picture (although every life counts and it is a great tragedy when someone dies) is not pessimistic. The 1918 pandemic (which was originally compared to the COVID-19 pandemic) killed 50 million people. They were typically very healthy and 28 years old, on average. In this pandemic we have 412,000 deaths worldwide so far, with an average age of close to 80 and almost all with underlying diseases. I don't want to diminish the magnitude of problem, but we just need to have a better sense of how big it is with respect to other things it was compared to in the beginning.

TNH: So, after all, do you think that the famous March article in Statnews turned out to be accurate?

JI: That article was a call for more valid data so we could know where we were going. It was a cry of anguish that we were facing a huge unknown danger with unforeseen consequences and uncertainty. In these three months that have passed, we have learned a lot. I do not see it as a justification, whether I was right or wrong. I see it as a breakthrough in science that has given us information to better manage the crisis. We have gained more knowledge, better documentation, and we can now do our best. The course of the pandemic (with respect to the great uncertainty that prevailed in March) now permits optimism, despite the number of deaths that are remarkable – but we are no longer talking about 50 million deaths (let alone a low average age like 28 years) which was the pessimistic initial scenario. If we apply the best knowledge we have in the future, even if there is a second wave, we can avoid many of the deaths we had in the first wave because we did not know what to look out for.


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