Pikuach Nefesh & Covid-19 Precautions - Questioning the Halachik Link - Part II

Part I of this three part series can be found here:

https://gershondistenfeld.blogspot.com/2020/10/pikuach-nefesh-covid-19-precautions.html

Part III will IY"H be posted later this week.

The following is the second of a three part series analyzing the applicability of halachic concepts like safek pikuach nefesh to the current social distancing mandates during the Covid-19 Pandemic. In the first part, the application of safek pikuach nefeshon on the individual level was discussed, specifically in how they may be limited by statistical probabilities. Additionally, with prior empirical studies finding limited if any benefit to social distancing reducing deaths, the stage was set for evaluating the results of the current global experiment being conducted.

 

Pikuach Nefesh & Covid-19 Precautions - Questioning the Halachik Link - Part II

Etan Golubtchik

Social Experimentation 

When evaluating a safek, or any scientific uncertainty, experiments are often used to help provide direction or resolution. In evaluating the application of safek pikuach nefeshto current social distancing measures, the world essentially just conducted a very expensive global experiment to help determine if communal actions like social distancing measures can effectively and reliably reduce mortality due to Covid-19 or other respiratory viruses.

No experiment can truly be considered valid without having a control group against which measurements can be compared, thereby validating the results of the activity in question. It is for this reason, if no other, that we should be thankful to countries like Sweden, Japan and Belarus and US states like South Dakota, Nebraska and Georgia which continue to provide a baseline control group against which to compare results. As the experiment is not being done in a controlled environment, it is always hard to truly isolate which factors contributed to the experiment’s outcomes and which did not. When examining outcomes though, one must be sure to include as many data points as possible, rather than anecdotally choosing selected data points to deceptively prove a position.[20]

When looking at the data set as a whole, the empirical evidence fails to demonstrate any clear evidence that social distancing policies did indeed reduce fatalities per capita from Covid-19 in the long run, or even in the short run. In fact, study after study continues to find that, after accounting for demographics, no evidence can be found in the data that social distancing measures correlate with mortality at all.[21] One study published in the Lancet definitively observed: “Rapid border closures, full lockdowns, and wide-spread testing were not associated with COVID-19 mortality per million people.” This is not to say that social distancing does not slow the spread from Covid-19, only that there is little if any evidence to support that this slowdown leads to lives being saved. Accordingly, many countries and doctors worldwide have stated they will not implement any new lockdown measures, even in the face of a new wave, and the World Health Organization has walked back their recommendation that these measures be implemented.[22]

On an anecdotal level, many will point to social distancing measures implemented in the New York area as key to limiting future deaths in the region, though when comparing to regions like Georgia, the Florida coast and Southeast Texas which implemented fewer restrictions over a shorter time period, the variance in total mortality due to covid-19 does not reflect the differing governmental approach. Others point out anecdotally that Sweden at first had a much higher death rate than its Scandinavian neighbors who had stricter lockdowns in place, though this analysis ignores the fact that other nearby countries like Belgium and the Netherlands did see large spikes in mortality despite quickly implemented, strict lockdowns. Additionally, these same Scandinavian neighbors quickly ended their lockdowns and did not see an immediate increase in deaths implying that the lockdowns had little influence on the differing outcome from Sweden. Many point out that Israel, after supposedly eliminating the virus from its midst with a low death toll, only experienced a resurgence after schools were re-opened and social distancing measures reduced. This analysis fails to account for many other countries including Sweden’s Scandinavian neighbors who did not have similar resurgence despite a simultaneous reopening to Israel. Concerning schools specifically, study after study from all over the world empirically show that re-opening schools does not lead to an increase in Covid-related mortality, and likely was not a contributor to the second wave of Israeli deaths.[23]

Meanwhile, many other countries in the same region of the Eastern Mediterranean are currently experiencing a similar second wave, regardless of their school and lockdown policies, making it even harder to demonstrate a causative relationship between Israeli policies and an increase in Covid mortality.[24] One of the most interesting regions of note is South America, where countries like Argentina and Peru implemented some of the earliest, strictest and longest lockdowns in the world, yet still experienced higher fatality rates than Brazil and Uruguay which had fewer restrictions and significantly shorter lockdowns.[25]

In short, results based on the experience of one country or state should be considered anecdotal, and scientific conclusions should not be drawn from these experiences, as compelling as we might want them to be. If the hypothesis based on one region fails to align with results consistently across the greater dataset, it should not be considered valid.[26]

Alternative Hypotheses

Why government imposed social distancing measures do not lead to lower death rates is a matter that is up for significant debate, though several hypotheses can be posited here. First and foremost, social distancing measures were originally designed and prescribed to slow down the spread of the disease in order to reduce the load on hospitals, but not to reduce overall mortality from the disease.[27] In the overwhelming majority of the world, outside of the New York City region and perhaps Northern Italy, no hospital systems were ever significantly above treatment capacity, regardless of whether or not the local region implemented lockdown measures.[28] While social distancing may delay deaths, it is unclear why it would be assumed that overall mortality would be reduced. Unfortunately, a portion of the population will always be vulnerable to certain diseases, and while our hospital systems and medical providers can be heroic, there is no evidence they can prevent death due to viruses to those who are most vulnerable. 

(Some have recently repurposed the concept of social distancing to delaying the spread of the disease until a vaccine is available. Unfortunately, there is significant uncertainty as to when and whether a rushed first generation vaccine would safely and significantly save lives either, especially among the elderly.[29])

Secondly, while SEIR models have famously simplified how viruses spread, and therefore assume mortality can be mitigated, it is not clear that the base assumptions we have about limiting viral spread, and consequently mortality, are correct.[30] For example, we assume that after transmission, viruses replicate in the body until they are defeated by the immune system or show symptoms within a six day period. Numerous examples of the disease popping up inside of strict lockdown countries like New Zealand seem to negate this understanding, as does a case of Argentinian sailors who began experiencing symptoms after 35 days at sea.[31] SEIR models also generally assume that there is a consistent relationship between an increase in infections or cases and an increase in fatalities, though there appears to be little correlation at all even within countries or states over time.[32] An argument has been made by Sunetra Gupta of Oxford that increased human contact and the spread of many viruses actually increases the ability of the human immune system, and in effect reduces mortality, achieving the opposite result of the intended effect of social distancing.[33] In short, we assume that a virus acts according to a consistent set of rules, and social distancing would interfere with those rules to curb the spread and reduce mortality. We have seen evidence that our understanding of the rules is incorrect though, and we probably do not yet know what the correct rules may be or how to mitigate them. 

Thirdly, we continue to make a strong set of assumptions that social distancing measures can actually limit the spread of a virus to begin with, even if that spread does not lead to death. This assumption is also highly specious. While people can possibly disengage from each other for a short period of time, need for distribution of food, clothing, medicines and generally just a functional society as a whole cannot truly social distance in a way that reduces viral transmission. By avoiding small businesses or groceries for a while, we have merely shifted the delivery of goods from in person ourselves to delivery by an intermediary. Amazon, UPS and Doordash drivers are still delivering packages that have gone through the supply chain. It is possible that we have merely introduced a middleman into the transmission network but not actually reduced viral transmission at all through lockdown measures. Meanwhile, at least two thirds of Covid-19 transmissions happen within the home, unmitigated and possibly intensified by lockdowns.[34] A recent report by the CDC also notes that the virus has been documented to remain airborne indoors for a sustained period, which would also would negate many of the social distancing practices that have been implemented.[35]

Respiratory viruses do not only spread through airborne aerosols. SARS Cov1 was documented to spread heavily through fecal matter on surfaces, which in our age of constant cellphone usage even in the restroom, has possibly played a role in the spread of Covid-19.[36] Food distribution may also play a role, as the virus has been found to remain active on cold storage fish for at least 8 days.[37] The infamous superspreader occurrences that have been blamed for the rapid spread of the virus have not been linked to a specific attendee, but rather to the event itself. If no specific attendee is associated with multiple superspreader events in differing locations, it would imply that a surface or food item at this event played a role in the spread of the disease. While we assume that social distancing does reduce our airborne exposure to the virus, that may only reduce the spread of the virus in one small manner relative to other manners of viral spread. Without being able to disengage from the world completely, and with multiple modes of transmission, it is unlikely that many of our social distancing policies play a part in reducing the spread of the disease.

All of these hypotheses may explain how or why social distancing measures are not strongly correlated with reducing the spread of the virus, but we still simply do not know, and there seems to be limited data to provide us clear answers. There is also no good way to measure if we have reduced the spread, as all of our testing case counts are riddled with sampling bias and uncertainty.[38] Even seven months into this pandemic, we simply do not know how fast or how widely this disease has spread and when.[39]

Finally, even if social distancing does in fact reduce the spread of the disease, it seems that this reduction of spread has a negligible effect on the total number of deaths incurred by Covid-19. Innate immunology due to previous exposure to other Coronaviruses, for example, seems to have a much larger effect on covid-19 fatality rates than any social distancing measures.[40] China, Japan and Taiwan all have had minimal social distancing measures in place since April, and have experienced no significant increase in Covid mortality despite documented spread of the disease.[41] Seasonality also seems to have a strong influence on where and how the disease spreads, with Northern US states and Northern European countries all seeing similar disease wave timelines regardless of government policies. Meanwhile, southern US states, and Middle Eastern countries for example all saw similar timelines to each other, which were distinctly separate from the northern European timelines.[42]

Seasonality in respiratory viruses was documented in the work of John Edgar Hope-Simpson who observed this phenomenon in flu viruses in his 1981 paper.[43] Hope Simpson concludes that “none of these seasonal characteristics can be explained by the current concept of influenza epidemiology”, which is used as the basis for modern SEIR models. Forty years later, SEIR models have still failed to integrate the empirically documented seasonal trends of respiratory diseases. 

When is a Safek no longer a Safek?

None of these hypotheses completely negate the effects of social distancing, rather they demonstrate that such measures only play a small part in a bigger picture, much of which we do not yet understand.

Moreover, it is not clear if government imposed social distancing measures reduce mortality at all, and if they do, if this is simply a matter of delaying deaths while the ultimate total will remain the same. From a scientific perspective using the empirical evidence available to us, the hypothesis that social distancing reduces mortality should be considered invalidated. Medically, the US Food and Drug Administration would likely never approve a medication for public use with such poor data support. Accordingly, more and more medical and science professionals around the globe have been speaking up about the failure of currently implemented social distancing practice to effectively reduce mortality.[44]From a halachic perspective, should this treatment method therefore be considered a safek pikuach nefeshimplementation that allows us to violate biblical commandments? 

The answer to this question is far from straightforward. The data is often noisy and never fully clear when aggregating from worldwide sources with different standards and resources. It is almost impossible to isolate variables outside of laboratory settings, and often within them as well. There is also no shortage of smart, capable and accomplished doctors and epidemiologists who believe that this practice should be effective, even if the data has not validated it.  At this point though, it is at best a safekif social distancing actually saves lives.

Maimonides, in his discussion on when we may violate the laws of fasting on Yom Kippur, creates a test as to how we should resolve a safekconcerning pikuach nefesh:

 

[If] some physicians say he needs to and others say he does not need to, we go according to the majority or [according to] the more expert ones. (Mishne Torah, Shevitat Asor 2:8)

For Maimonides, in the case of safekwe must search out doctors who have expertise in their field, and look for either the topmost expert or the majority opinion on how to rule. An extensive argument takes place in later commentators on which of these two issues takes primacy, expertise or majority. Concerning who should be considered an expert nowadays, much ink has been spilt on this debate, and one has to wonder at what point a declared expert on either side must be expected to provide data or experimental results to prove their position, rather than simply providing their opinion or intuition. Maimonides, in his medical writings and his Guide to the Perplexed, expects doctors to prove their treatments as experimentally successful in order to be respected as accomplished medical providers rather than witch doctors.[45]From a scientific or medical perspective, it should be expected that an expert should be able to predict with some statistical certainty the outcomes of their recommendations, and it is questionable how many experts on either side have been able to do this with regards to the effects of social distancing measures on the spread of this disease.

With all of that said, once a majority of experts or a topmost expert provides a definitive opinion, the matter does not leave the realm of safekto become a certain form of pikuachnefesh. A later majority vote after more doctors familiarize themselves with the data, or the entry of another more expert doctor can reverse the previous consensus and change what would be allowed in the case of pikuach nefesh. For example, Rabbi Akiva Eiger is widely quoted as a source for many of our current social distancing rulings due to his implementation of them during the cholera outbreak in the early 19^thcentury.[46]It must be assumed that had he known the scientific evidence that later showed cholera to actually be spread by water tainted with human fecal matter, he would have voided all of his social distancing edicts and instead instructed his congregants in proper bathroom hygiene and to boil all water before drinking. 

As more data becomes available, doctors, experts and rabbinic leadership must always be prepared to reassess if the treatment method that had previously been considered a safekfor which Biblical commandments should be set aside, should still be considered a safek. In the case of social distancing measures as prescribed to reduce mortality for Covid-19, we should reconsider the applicability of safek pikuach nefeshand its resulting lessening of the performance of other mizvot, considering all new data that has been aggregated.

In Part III, we will explore in what cases the entire concept of pikuach nefesh may no longer have relevance or control in Jewish or halachic decision making, even outside of the realm of safek, in light of the unintended side effects that come from social distancing measures.

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[20]This method is commonly used when trying to mislead with statistics and graphs. A prime example of this would be the widespread graphic that compared Spanish flu deaths in St. Louis and Philadelphia in 1918 and the supposed related social distancing measures that were implemented. This graph specifically left out all other US cities, their mortality rates and social distancing implementations, in which the full data set fails to show any strong correlation at all between social distancing implementation and lower mortality. 

[21]April 15^th- https://thecritic.co.uk/does-peak-infection-sync-with-lockdown-enforcement/

April 21^st– https://arxiv.org/abs/2004.10324

April 21^st- https://www.thepublicdiscourse.com/2020/04/62572/

April 24^th- https://www.medrxiv.org/content/10.1101/2020.04.24.20078717v1

April 26^th– https://www.wsj.com/articles/do-lockdowns-save-many-lives-is-most-places-the-data-say-no-11587930911

May 1^st- http://bristol.ac.uk/maths/news/2020/peak-lockdown.html

May 16^th- https://threadreaderapp.com/thread/1261705308302270466.html

May 20^th- https://www.bloomberg.com/graphics/2020-opinion-coronavirus-europe-lockdown-excess-deaths-recession/

June 16^th  - https://advance.sagepub.com/articles/Comment_on_Flaxman_et_al_2020_The_illusory_effects_of_non-pharmaceutical_interventions_on_COVID-19_in_Europe/12479987/1

July 2^nd- https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30208-X/fulltext

July 20^th- https://www.heritage.org/public-health/report/comparative-analysis-policy-approaches-covid-19-around-the-world

July 31^st- https://www.aier.org/article/the-virus-doesnt-care-about-your-policies/

August - https://www.nber.org/papers/w27719.pdf

September 1 – https://www.wsj.com/articles/the-failed-experiment-of-covid-lockdowns-11599000890

October 4^th- https://www.nationalreview.com/2020/10/stats-hold-a-surprise-lockdowns-may-have-had-little-effect-on-covid-19-spread/

October 6^th- https://www.telegraph.co.uk/news/2020/10/06/scotland-isnt-faring-much-better-england-despite-nicola-sturgeons/

Of these, I consider the Lancet and NBER studies to be the most robust. Numerous other studies exist, and any person should feel free to peruse websites like ouworldindata.org or the CDC website to run their own analyses. I personal have run multiple regression models and has found no correlation at all between school closures, work closures or any other lockdown stringency with Covid mortality. 

Other studies do exist that challenge this conclusion. Those that I have read are often dependent on modeled data as a control rather than empirical data, or tend to focus on potential responses to an implemented measure within one region without any baseline or control group, all while ignoring conflicting results in the total dataset that is available. At minimum, the matter is unprovable in either direction, though it is my opinion that the available dataset demonstrates that the hypothesis to be demonstrably false, and that we can conclude that there is zero evidence that social distancing saves lives. 

[22]https://www.news.com.au/world/coronavirus/global/coronavirus-who-backflips-on-virus-stance-by-condemning-lockdowns/news-story/f2188f2aebff1b7b291b297731c3da74#.7daqw

[23]Results from studies on the effect of schools in viral transmission around the world almost uniformly show the exact same result, that schools do not spread the virus or increase mortality:
China: https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30105-X/fulltext

Korea: https://adc.bmj.com/content/archdischild/early/2020/08/06/archdischild-2020-319910.full.pdf

Finland:  https://www.folkhalsomyndigheten.se/contentassets/c1b78bffbfde4a7899eb0d8ffdb57b09/covid-19-school-aged-children.pdf

UK: https://www.bmj.com/content/371/bmj.m3588

Denmark: https://www.reuters.com/article/us-health-coronavirus-denmark-reopening/reopening-schools-in-denmark-did-not-worsen-outbreak-data-shows-idUSKBN2341N7

The Netherlands: https://www.rivm.nl/en/news/initial-results-on-how-covid-19-spreads-within-dutch-families

Iceland: https://www.sciencemuseumgroup.org.uk/blog/hunting-down-covid-19/

Greece: https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.26394

Ireland: https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.21.2000903#html_fulltext

Germany: https://www.theguardian.com/world/2020/jul/13/german-study-covid-19-infection-rate-schools-saxony

A summary of Europe & Asia by the Washington Post: https://www.washingtonpost.com/world/europe/schools-reopening-coronavirus/2020/07/10/865fb3e6-c122-11ea-8908-68a2b9eae9e0_story.html

A summary of the US by the Atlantic: https://www.theatlantic.com/ideas/archive/2020/10/schools-arent-superspreaders/616669/

Childcare providers in the US: https://pediatrics.aappublications.org/content/pediatrics/early/2020/10/12/peds.2020-031971.full.pdf

Even Disneyworld: https://www.nytimes.com/2020/10/09/business/disney-world-coronavirus.html

And an interesting study showing how child exposure reduces severity and mortality in adults: https://www.medrxiv.org/content/10.1101/2020.07.20.20157149v1

And here is a dashboard screenshot showing no variance in teacher covid cases either between zoom-schoolers and physical-schoolers: https://twitter.com/boriquagato/status/1313113007342452738/photo/1
The fact that Israel seems to have experienced a wave after reopening schools should therefore be considered the exception, and likely not causative at all. 

[24]See notes on seasonality below. Also, explore Ourworldindata data on Turkey, Lebanon, Greece, the PA and even some former Yugoslovian countries. 

[25]Peru: https://www.telegraph.co.uk/travel/destinations/south-america/peru/articles/peru-strict-lockdown-excess-deaths/

Argentina: https://jordanschachtel.substack.com/p/200-days-the-worlds-longest-lockdown

[26]Another unfortunate side effect of this pandemic is the completely disregard for the scientific method outlined by greats such as Francis Bacon, Isaac Newton and Karl Popper. This framework requires a scientist to test a hypothesis by making a prediction of the result of an experiment. If observed empirical results differ from the prediction, the hypothesis is considered invalid. The fact that SEIR models are still used to make public policy decisions nowadays despite their inability to make a single accurate prediction to date speaks to the poor understanding some of our experts and leaders seem to have of what was once considered the basis of scientific progress. No person can legitimately proclaim they “believe in science” while simultaneously ignoring the framework and lessons of the scientific method. Somehow the IHME still seems to be making failed predictions of future Covid mortality in the US demonstrating that it has learned nothing from its failed predictions. See: https://www.afr.com/world/north-america/ihme-revises-lower-again-its-us-death-projection-20201006-p562b6or this screenshot of their August forecast vs. reality: https://twitter.com/youyanggu/status/1305937874194440192/photo/1

[27]See original Imperial College Paper advocating for lockdowns stating: “The more successful a strategy is at temporary suppression, the larger the later epidemic is predicted to be in the absence of vaccination, due to lesser build-up of herd immunity.” (https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf) C

onfirmation analysis here: https://www.afr.com/policy/health-and-education/lockdowns-beyond-two-months-do-more-harm-than-good-20200909-p55ty9. 

Additionally here is an analysis showing how the CDC mixed outputs from two different models to imply that lockdowns would save 2 million lives: https://www.cato.org/blog/did-mitigation-save-two-million-lives- in private industry, this would be considered fraud. 

[28]https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00980, 

Also, it is not rare for some local hospital systems to be slightly overwhelmed during a flu season: https://threadreaderapp.com/thread/1281080665685934081.html, 

and many have significant flexibility: https://justthenews.com/politics-policy/coronavirus/texas-government-counting-every-covid-positive-hospital-case

A case can also be made that hospital systems were overused when outpatient care would have been warranted: https://www.israelnationalnews.com/News/News.aspx/288980

and finally, there are some who make the case that New York’s system was also never overwhelmed: https://nypost.com/2020/10/14/cuomo-says-ny-hospitals-were-never-overwhelmed-at-covid-19-peak/

[29]On efficacy:  https://www.theatlantic.com/magazine/archive/2009/11/does-the-vaccine-matter/307723/

On Safety: https://edition.cnn.com/2020/09/01/health/eua-coronavirus-vaccine-history/index.html  

On the effectiveness of vaccines among the elderly who would be most vulnerable to Covid-19, see: https://www.healio.com/news/primary-care/20200302/flu-vaccination-does-not-reduce-hospitalizations-death-in-older-adults

[30]After analysis of 14 randomized control studies, a CDC policy review found that even though we have mechanistic support of how we think viral epidemics spread, randomized trials have not demonstrated that limiting those mechanisms does in fact protect the virus from spreading: https://wwwnc.cdc.gov/eid/article/26/5/19-0994_article

[31]https://www.batimes.com.ar/news/argentina/surprise-over-covid-19-cases-onboard-fishing-vessel-after-35-days-at-sea.phtml

[32]https://www.anhinternational.org/news/is-there-a-waning-pandemic-behind-the-casedemic/, https://www.medrxiv.org/content/10.1101/2020.09.05.20188953v1

[33]https://reaction.life/we-may-already-have-herd-immunity-an-interview-with-professor-sunetra-gupta/  A confirmation of this analysis can be seen here in which a prolonged epidemic leads to increased mortality due to the young healthy portions of the population not achieving immunity quickly enough: https://www.bmj.com/content/371/bmj.m3588

[34]https://www.acpjournals.org/doi/10.7326/M20-2671

[35]https://www.cdc.gov/media/releases/2020/s1005-how-spread-covd.html

[36]https://www.cebm.net/covid-19/sars-cov-2-orofecal-transmission/

[37]https://www.biorxiv.org/content/10.1101/2020.08.17.255166v1.full

[38]Indeed, it has been fascinating to watch case counts published daily on news sites as if they were accurate representations of total cases, while simultaneously political polls are published on the same site with detailed explanations of how the pollsters adjusted the results of their polls to reflect the sample size and potential bias in oversampling or undersampling certain groups who responded to the poll. Similarly, the amount of Covid tests administered should always be calibrated towards what percentage of the population was tested, and the fact that those tested were not a random sampling, but rather those who were most likely to be serious cases (due to symptoms, or being near someone else who tested who was highly contagious)

[39]The World Health Organization has recently stated that over 750 million people, or 10% of the world has had the disease to date, though this appears to be a wild guess. We simply do not know: https://apnews.com/article/virus-outbreak-archive-united-nations-54a3a5869c9ae4ee623497691e796083

[40]Multiple sources include: https://jamanetwork.com/journals/jama/fullarticle/2770758, https://www.nature.com/articles/s41590-020-00808-x, https://www.cell.com/cell/fulltext/S0092-8674(20)30610-3, https://www.jci.org/articles/view/143380, https://www.medrxiv.org/content/10.1101/2020.09.28.20202929v1, https://immunology.sciencemag.org/content/5/51/eabe1670, https://mbio.asm.org/content/11/5/e01991-20   

[41]This study tracked an increase in seroprevalence in Japan from 5.8% to 46.8% despite little noticeable increase in country deaths: https://www.medrxiv.org/content/10.1101/2020.09.21.20198796v1.full.pdf  

[42]This is the best graphic form I’ve seen Covid-19 seasonality portrayed: https://www.patreon.com/m/2403032/posts?filters[tag]=Seasonality&sort=published_at, though other sources are available

[43]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2134066/pdf/jhyg00034-0042.pdf 

[44]Here is a letter from the medical community in Belgium, which experienced one of the highest mortality rates in Europe: https://www.aier.org/article/open-letter-from-medical-doctors-and-health-professionals-to-all-belgian-authorities-and-all-belgian-media/

And here is the conclusion of German minister based on numerous internal government studies: https://summit.news/2020/09/25/german-minister-lockdown-will-kill-more-than-covid-19-does/

For a growing movement reflecting the changed opinions of numerous doctors worldwide, including those in Israel, see the Great Barrington Declaration: https://gbdeclaration.org/

[45]See: “Maimonides philosophy of Science by Gad Freudenthal in The Cambridge Companion to Maimonides edited by Keneth Seeskin pg134-166

[46]https://www.timesofisrael.com/how-rabbis-social-distancing-edict-saved-his-community-from-pandemic-in-1831/