A Doctor Comments on "America's FrontLine Doctors"

Art is long; life is short; opportunity is fleeting; judgement is difficult; experience is deceitful. 

- Hippocrates

If you look hard enough you can always find something, and someone, to support your biases, no matter how extreme – and doctors are not excluded.  

The Guassian “bell” curve reproduces itself frequently, and medical school class rankings are no exception. Some - like Tony Fauci – end up on the far right of that medical school curve, and some skim by on the far left.  Importantly, regardless class standing, even a magna cum laude medical degree does not prevent delusional or misguided thinking – as the way we view the world is positioned along a separate “normal” distribution as well, admittedly with the caveat that when you are at either extreme on this curve, you may not to be viewed as "normal".

Some of the speakers at the recent "America's Frontline Doctors" press conference this week were impassioned, and the physicians who participated likely all care a great deal about their patients.  However, these characteristics neither qualify them to make statements unsupported by fact, nor excuse the fact that these types of statements could, and likely will, hurt people. One of the immutable dictums of medical practice, after all, is the latin term:

“primum non nocere”

That is... "first, do no harm".

It is important to also note individual opinions, while not worthless in medicine by any means, can be dangerous if not backed up by the carefully studied experiences of others.  As William Osler, the father of modern academic medicine once said:

“We are constantly misled by the ease with which our minds fall into the ruts of one or two experiences”

With this in mind, here are some reactions to statements made at the event (participant statements lightly paraphrased or condensed):

Statement: Children are not at significant risk, do not spread COVID19 and no cases of transmission from a child to a teacher have been documented.

We know that most children do not develop severe disease when they contract COVID19 – but some do become very ill and there have absolutely been documented deaths in children with no pre-existing conditions. In addition, hundreds have experienced a COVID19 post-exposure inflammatory syndrome that has again led to the loss of young lives, and left some with possible permanent disabilities.  Children under the age of 10 do appear to be capable of transmitting the virus to others.  They may be less likely to do so as they are less likely to have respiratory symptoms and they may have lower viral loads but this is an observational theory that has not yet been proven. In addition, at age 10 and older, the ability of these individuals to spread to one another and to adults appears to be more like other adults. The statement that “there have been no transmissions to teachers”? This is simply impossible to prove or support. Where is the actual study? Haven’t most schools been closed or shut down around the world since the pandemic started? How would you know a child was or was not the source of an infection with no contact tracing? You wouldn’t.

Statement: Hydroxychoroquine is effective in patients with COVID19 and there is a politically motivated concerted effort to prevent its use.

Hydroxychloroquine simply does not appear to work in COVID19, based on the best studies we have so far, despite some that suggest otherwise. In the rush to find answers, a lot of things have been published that under careful examination just do not stand up well from the standpoint of generalizing results. In addition, the scientific (pathobiologic) basis for how this drug might work, if it did, is also lacking despite a number of theories. What appears somewhat certain is the following: (1) use of this drug in moderate to severe disease in a number of age groups does not help, and may actually cause complications in these compromised patients, and (2) use of this drug to prevent the development of disease in those with high-risk exposures is not likely.  While some studies have suggested no benefit for early disease, there are are ongoing active trials to answer this more definitively. There is actually a science to clinical research methodology, and a “case series” (“I treated these patients and this is what I saw”) is not the best way to evaluate a drug or another treatment for a number of reasons, including “selection bias”.  The fact that a doctor at the press conference forcibly announced she successfully treated “350 patients” with this drug without a death is actually somewhat meaningless. Her patient experience at best represents a (undocumented) “case series” rather than a “study”. As a theoretical example of one of the problems her statements present - if the average predicted case mortality in her treated population based on age and other factors was around 1% (still 10X greater than influenza, by the way), then there is around a 5% probability that no deaths would be noted at all in her group (if the mortality rate was lower than 1%, the chance of missing it goes up even higher - it’s just math). Also, there are questions we cannot know the answer for unless more data are examined or disclosed, such as whether all patients she treated tested positive for COVID19, or were treated for symptoms alone. Lastly, there is no way to verify or qualify statements like this without external validation - and human beings (even doctors) are not immune to hyperbole.

Statement: A paper in the journal Virology proved in 2005 that hydroxychloroquine (chloroquine) prevents the spread of COVID19.

The virology paper the doctor quotes is (almost comically) misattributed. First of all, it is Virology Journal, not Virology, and the data are from primate cells treated in a petri dish, for heaven’s sake… It prevented the spread of another coronavirus (not the virus that causes COVID19 – it didn’t exist then) from cell to cell in a plastic dish in this study. There are a lot of things that look good in plastic dishes - what researchers call “in vitro” - that just do not work beyond this point.  I was a molecular cancer therapeutics investigator for almost 20 years (gene and related therapies), funded by the NIH and other sources. Most experiments that work in petri dishes do not work when tested in living creatures, unfortunately.  One of my favorite past things to tell junior researchers when they were excited about petri dish experiments was:

“that’s great that it kills cancer cells in vitro.., but don’t get excited yet - so does gasoline”.

Statement: Sweden has done well with no lockdown... lockdowns don't work.

This is simply false. And related, a “lockdown” in any country cannot be examined as successful or not without knowing anything about compliance. If you want to know how a country manages spread by uniform public health measures and compliance – look at the experience of South Korea  thus far. Simply put - lockdowns, stay at home orders and other public health recommendations do not work well if there is an unwillingness to apply uniform recommendations and enforce mandates among citizens when they are provided by authorities, and there are acts of non-compliance by citizens themselves.  Cases such as California also prove that even if you do lockdown somewhat successfully for a time, and then open up with abandon, you get a lot of cases.

Statement: We should allow individuals to make their own decisions about wearing masks, etc., and other public health measures.

This is literally crazy-town. We did that experiment in Texas, Arizona, Florida and Georgia, and a hyperlink inserted here to any of these recent experiences should not even be necessary. It did not work, at all. The United States continues to be a poster child for the excesses and downsides of relatively unlimited personal freedoms. Karl Marx would be very happy to see how we are handling this as "the world’s leading democracy" and not surprised. Unfettered freedoms always impinge on the freedoms of others. Someone didn't wear a mask around my 10yo son at some point, and so he tested positive for COVID19 two and a half weeks ago. Yes, he was sick for a few days, and we were both very worried about him, and about the rest of the family. He is fine now, but is still inside the window for development of multisystem inflammatory syndrome.

This entire issue about how to approach and deal with a pandemic from a public health perspective is not that complicated. We have learned many of these lessons before – repeatedly - during previous epidemics and pandemics. We would just “like” for this one to be different.  

It isn’t.  

This is also not a master plan hatched by Bill Gates to reduce the population, a plot to force people to take a vaccine that will harm them more than the disease itself, or an effort to unseat any elected official.  It is viral biology.  A biology oblivious to our desires and relentless in its pursuit of its goal of making more of itself in the world regardless the consequences for our species - one it views simply as a means to that biologic end.

It does feels as if the entire biomedical science:public acceptance axis of the world has tilted off its center, and this is disheartening.  However, we human beings have a historically reproducible habit of abandoning reason when stressed.  We also have a predictable habit of messing things up and then having to learn from the messes we create.  

My humble suggestion is that we all do the right things now so we and those we care about can actually live to enjoy the fruits of the difficult lessons we will learn, in retrospect, from this time.

And to all of America's frontline doctors, nurses, and others who are working at the edge of this pandemic, thank you. We owe you a lot more than this.