COVID-19 and Bell’s Palsy: I wish she was my patient.

When a friend sends me a video about a vaccine reaction and the next day multiple patients mention the same video to me in clinic, it’s probably time to watch it, and write about it. The video I’ve linked to below is of a registered nurse named Khalilah Mitchell who lives in Nashville Tennessee, who warns about developing Bell’s Palsy, paralysis of one side of her face, after receiving a COVID-19 vaccination. It is impossible to watch the video without empathizing with her, and I encourage you to watch it if you possibly can; I’ve supplied the link below, assuming it’s still up.

Video: RN Took Vaccine: This is What Happened

Instead of going through it minute-by-minute like we’ve done so often in the past (it is very short, at just one minute and twelve seconds), I want us to dissect a few different aspects of this.

Contents:

Healthy Incredulity
Bell’s Palsy: Medical Facts
Bell’s Palsy: Why I Wish She Were My Patient
Healthcare as War on Black Bodies


Healthy Incredulity

I want to start by stating that I believe this person’s story, for reasons we will get to in a moment. I think that when we develop the disposition to refuse to believe people’s stories about themselves and their experiences we place ourselves in grave peril. This is one of the common and insidious effects of the disinformation campaigns (both medical and not) that we have seen escalated over this past year; whenever someone hear’s something that doesn’t fit into their chosen narrative, they can simply say “but how do we even know if that actually happened?” Certainly, when someone (I won’t name names) consistently proves themselves to be a source of falsehood, their word becomes worthless; but to automatically treat a stranger that way, especially a stranger who is clearly hurting, is to shut ourselves off from compassion and reason in the name of protecting our own biases.

This individual is clearly distraught and deserves our empathy. But there is a balance and a tension here, because the 340,000 people who have died from COVID-19 in the US, and the 1.8 million people who have died from it around the globe, and their families and friends and communities, also deserve our empathy; and so do the many more who are still at risk. We can love both, and that may mean accepting someone’s narrative about themselves and their experiences without agreeing with their scientific conclusions. And that’s ok.

And so while I believe this person’s experience, I would be remiss if we did not start with a very brief survey of what we do and don’t know to be true from this video, for the sake of encountering this sort of viral information with our eyes fully open.

  1. We know this woman has Bell’s Palsy, or at least has visible symptoms consistent with that diagnosis.
  2. We know she is an African American woman, a group who among all demographics in the US probably has the most reason to be cautious and skeptical towards the medical field.
  3. She identifies herself as Khalilah Mitchell, a Registered Nurse in Nashville, TN
    • The Tennessee nursing board does not have any record of a registered nurse by that name.
  4. She reports that she developed Bell’s Palsy shortly after receiving the COVID-19 vaccine.
    • We do not have evidence that she received the COVID-19 vaccine.

Let’s talk about that 3rd bit, which has been homed in on by multiple fact-checking sites. There are multiple reasons Khalilah Mitchell might not be listed on the Tennessee nursing board’s online records:

  • She may be a recent graduate or have recently received her license in that state; we don’t know how long it takes for those licenses to be searchable online.
  • We are in the middle of a pandemic; she may be a nurse licensed in another state who has special permission or an emergency/temporary license to do travel nursing in Nashville.
  • She only states in the video that she is “in Nashville Tennessee.” She may well be licensed in and work in another state while living in (or even visiting) Nashville. This is not uncommon.
  • She may go by Khalilah but actually have a different legal first name; Khalilah may be a middle name or a nickname.
  • She may be Khalilah Mitchell but be registered under a different last name because of a recent marriage, divorce, etc; changing your name on your nursing license is a beast of a process, as my wife can tell you first hand.
  • She may be using an assumed name or placing herself in a different city and state, or both, to protect herself from reprisals in case this video goes viral (which it has).
  • She may be lying.

Only one of those reasons, all of which are feasible, negates her story; only one causes us to mistrust the only unprovable/non-falsifiable aspect of her story, that she did indeed receive the COVID-19 vaccine prior to developing her symptoms.

Sadly, hiding among the many people with legitimate fears and uncertainties about healthcare in general and vaccines in particular, there are dishonest people who are not above creating misleading and blatantly false information to deceive others. If this person were a known producer of anti-vaccine propaganda, disbelieving her entire story would be warranted; but I have no reason to believe that’s true, and thus have no reason to disbelieve her story, as some have done, merely because certain aspects of it cannot be verified.

So I believe her story. However, because there have been and will continue to be elaborate, malicious attempts to deceive the public about these COVID-19 vaccines, I believe we are justified in maintaining a healthy degree of incredulity each and every time we encounter one of these types of videos; the intellectually honest and important work of discerning whether the information presented is true in no way negates or cheapens our compassion for the speaker.


Bell’s Palsy: Medical Facts

I want to talk about the clinical side of medicine, and the human side of medicine. In reality we can never separate them, but we can compartmentalize them for a few moments for the sake of discussion.

Bell’s Palsy is a temporary paralysis of the Facial Nerve, the seventh cranial nerve which controls the muscles of the face. This paralysis occurs without warning, usually gets worse over 2-3 days, and then starts to improve after about 2 weeks. Usually it is entirely improved by 6 months and does not cause long lasting symptoms; but sometimes it does, and the extent of damage to the nerve likely plays a role in the symptoms lasting longer. The cause is unknown. It’s an area researchers have studied for years. A leading theory is that, like shingles, it is caused by a reactivation of a herpesvirus that lies dormant within your nerves. In that case it can be triggered by any compromise of the immune system, but also by physiologic stressors; it has been associated with diabetes, high blood pressure, pregnancy, acute viral infections, and vaccines, all of which tax the immune system (the latter two temporarily). Another theory says it is the immune system itself, in the act of fighting the virus, that causes ‘friendly fire’ damage to the nerve, and this would also explain why it is not just associated with herpesviruses but with other viruses like flu, hand-foot-and-mouth, common colds, and even COVID-19 infection itself. The immune system is also activated by vaccines (that’s how they work; they teach your immune system how to fight new viruses and bacteria it has never seen before), and so also have the theoretical potential to cause Bell’s Palsy, though careful studies have not supported an actual link between vaccines and this condition. But these are still just theories, and we don’t actually know. I treated a patient last week whose Bell’s Palsy, as far as we can tell, occurred seemingly at random.

So, do the COVID-19 vaccines cause Bell’s Palsy? It’s a difficult question to answer. In the vaccine trials, the rate of Bell’s Palsy was incredibly low: 4 in the Pfizer trial and 3 in the Moderna trial; 7 cases out of over 70,000 participants. That’s less than half the normal rate of Bell’s Palsy in the general population, which is about 35 cases per 100,000 people. The rate was higher in the vaccine group than in the placebo group, though the numbers are far too small to draw definite conclusions.

If I were to sum up the evidence for my patient or my family member, I would tell them this; getting the COVID-19 vaccine might carry a tiny increased risk of developing Bell’s Palsy compared to not getting the vaccine; but the risk is still about the same overall as it would be just going about your every day life.

Maybe that feels like a paradoxical answer, but truth is often like that. About 40,000 Americans have had Bell’s Palsy this year; very, very few of them have had the COVID-19 vaccine, but those that did may blame it on the vaccine. Those who didn’t may blame it on something else; another illness, their flu shot, stress. They may be right or they may not be, but until we understand the condition better there is simply no way to perfectly avoid it, and it is so rare and typically so benign a condition in the long run that basing our medical decision making on it is unreasonable, both as physicians and as patients (and please remember, I am both, just like every other doctor you know). If you get the COVID-19 vaccine, you are extremely unlikely to develop Bell’s Palsy; no more or less likely than you are to develop it in the coming year anyway. What you are much, much less likely to develop is a severe or fatal case of COVID-19.


Bell’s Palsy: Why I Wish She Were My Patient

Reading that last section, you may think I’m going to say “I wish she were my patient because I could help her understand that her Bell’s Palsy probably wasn’t from the COVID-19 vaccine.” Um, no. My experience has taught me that, for better or for worse, once someone has formed a firm mental association between an event or intervention and deeply distressing symptoms, that association is incredibly difficult to break; even when there is absolutely no plausible link between the two, which is not the case here. Not to digress too far, but I commonly try to break those associations in exactly two situations: first, when my patient has linked their negative experience (or that of a loved one or friend) to a medication or treatment that is actually going to be life-saving for them, or relieve a great deal of their suffering, and there is actually no causal link between them. And second, when the patient has incorrectly linked a negative medical outcome to some perceived failure of theirs. I have at least one or two conversations a month with women who have had miscarriages and have definitely assigned the blame for that tragedy to themselves for some action or omission that couldn’t have caused it; some bump they went over on the road a few days before, a drink of alcohol or a cigarette they smoked before they knew they were pregnant, getting their nails done or taking a dose of an over the counter cold medicine. We spend a long time talking about the causes of miscarriage, because if possible I want to help them let go of that shame and self-blame they’ve have been carrying, and will carry, their entire lives. Those are the circumstances where it is worth it to me to really try to convince my patient that the medical facts really do override their perceived association. With this woman in the video, if she were my patient and we developed a trusting relationship over many years, maybe at some point we would be able to have a frank and honest discussion, looking back, about whether or not that Bell’s Palsy was really caused by the COVID-19 vaccine, and help her loosen that association; but telling someone who is suffering “you are probably wrong about why you are suffering!” is not just an exercise in futility, but a failure in empathy as well.

No, the reasons I wish she were my patient are twofold; first, because I treat Bell’s Palsy all the time and there really are some things you can do to give the patient the best possible chance at recovery. There’s evidence for early steroids and anti-virals, and there are supportive care measures, like synthetic tear eye-drops, to protect from some of the potential long-term complications. We also talk about adjunctive treatments like facial massage, stretching, and facial muscle exercises that have never been proven but are not likely to do any harm either, and will help the patient feel they are an active participant in their treatment (I am always explicit about that last goal; we are not trying to ‘trick’ the patient into thinking they are helping to make them feel better). I print handouts for my patients all the time to help guide their own reading and research at home, and have one I like for Bell’s Palsy because it carefully explains the possible causes, the symptoms, and the prognosis. Medically, Bell’s Palsy is somewhat satisfying to treat because it usually does get better, and in general walking through an illness with someone as it improves is a lot less of an emotional burden for me than sitting with someone in the grief and pain of an illness that isn’t going to improve, which is vital work I wouldn’t give up, but is laden with moral injury.

And second, I wish I were her doctor because in this video she is clearly emotionally distraught. That is the aspect of this illness that the fact checking sources have seemed to ignore; the fact that this illness is incredibly distressing, even though it does have a good prognosis. I have read article after article in the few days since this video came out explaining that 1. the vaccine didn’t necessarily cause the Bell’s Palsy, and 2. it doesn’t matter because it’s a benign condition. But watch the video; it definitely matters to her. The embarrassment of having half of your face paralyzed, but people thinking you’ve had a stroke when you haven’t, of feeling self conscious everywhere you go; a condition can be benign medically but not benign psychologically, socially, or emotionally. When I visit with a patient for a condition like this, our time together is spent as much in counseling as it is in devising a medical plan. We sit in that sorrow, even as we provide hope that it will be short-lived. We offer reassurance but we know that our patients are not thinking about the low rate of long-term complications when they look in the mirror and see a face they don’t recognize. It’s hard. Maybe Khalilah Mitchell would still have been this distraught after our visit for her Bell’s Palsy, and maybe she would have felt some solace and reassurance; I can’t say. But as a physician, when I watch someone who is absolutely grieving over their medical condition, my heart goes out to them and I wish we had the opportunity to just sit down and talk about it.

These vaccines are the best hope we have of ending the pandemic compassionately, with less loss of life. I believe in them. They are safe, and your chances of developing a significant reaction- including Bell’s Palsy- is incredibly low. I absolutely disagree with Nurse Mitchell that these vaccines are “the worst thing ever”. She is very understandably thinking about her own symptoms and not about the millions of lives they will save. Yes, as a medical professional there is a tension between our own distress and the need to think of others before spreading information that can cause harm, as this video certainly will; as a Nurse, she may indeed be failing in her calling to care for the vulnerable by disseminating claims about the vaccine based only on her own negative experience and not on solid scientific facts. But that’s her right as a patient, and the reality is that most of us will put our own anecdotal experiences above facts when push comes to shove; if this video is sincere, then she sincerely believes she is doing the right thing by trying to protect others from what she has suffered, as ungrounded in the medical realities as that concern is.

As a human being created in the Image of God, Khalilah Mitchell deserves our empathy and compassion for what she is going through first and foremost, even as we work to undo the harm this video is going to cause.


Healthcare as War on Black Bodies

There is one last, vitally important issue that comes up in this video, and if you are privileged to have a long history of the medical field treating people who look like you extremely well, as I am, it may be so subtle that you miss it entirely. Towards the end of this short video, after discussing her personal distress and her opinion that the vaccines are terrible, she closes with this heartfelt appeal,

“Please, America, They do not care about us. Do not take this vaccination.”

I will not claim to speak for her, or to make assumptions about who she includes in “they” (big pharma? medicine? doctors? She states she is a registered nurse herself, so I do not think she can mean the entire medical field), or who she includes in “us.” Certainly she addresses all Americans, but we would be naive to think that her message of “they do not care about us” would resonate equally with everyone. People who have historically experienced and currently experience inequitable medical treatment, poorer access to high quality care and lifesaving treatments, systemic discrimination, and even therapeutic, malicious medical experimentation are going to understand this video in the context of a shared cultural narrative that already teaches that you cannot trust the medical field to have your best interest at heart. This includes women, LGTBQ+ persons, the disabled, those who are obese, non-native English speakers, Hispanics, Native Americans, and at least one group Nurse Mitchell seemingly belongs to herself, African Americans. If you need evidence of this, the instagram tag on this video, @DTR360BOOKS_, is connected to an online bookstore that specializes in works about racial justice, black empowerment, and racial conciliation. If anyone, and particularly any white people, are asking why this one minute video has been shared hundreds of thousands of times on social media, read on.

Before you click over to the ‘About the Author’ page, I’ll let the cat out of the bag; I am a white, able-bodied, English speaking male (I am not neurotypical [ADHD], but I know few doctors who actually are). Healthcare justice, especially in the area of race, is something I was able to casually ignore for a long time because it simply didn’t affect me. But it affects my patients every day (and because of that it certainly makes my life harder too, though obviously to a lesser degree), and in the last few years it’s an area I’ve come to learn more and more about. Suffice to say, I absolutely do not feel adequate to the task of writing about this topic; but I am going to try anyway.

The long history of medical experimentation and abuse of African Americans, of which the notorious Tuskegee Syphilis Study is only a link in the chain, is documented in historian Harriet Washington’s book Medical Apartheid, and elsewhere. If you have time to read this long and rambling blog post you definitely have 7 minutes to listen to her explain the connection between this long history (the word “history” does not here imply that it is over, as the recent COVID-19 death of one of my Black Physician sisters tragically illustrates) and the skepticism, doubt, and fear about the COVID-19 vaccines that exist in communities of color.

Race And The Roots Of Vaccine Skepticism

Of all the wisdom she shares in this brief interview (you should really read her books), this is the one that I think is closest to our purpose:

“I think this is a good thing to do because I think this vaccine looks as if it’s going to be safe, efficacious – just what we need. So anything that’s done in terms of encouraging African Americans to benefit from it, too, I think is a good step. However, it’s not a substitute for reforming the health care system. If we don’t reform the system, if we don’t make real, large steps toward addressing the inequities that cultivate distrust, then we’re going to have to do this every time we have a new health initiative. That’s a complete waste.”

Because of the systemic healthcare discrimination and poorer access that Black Americans still suffer from today, the COVID-19 pandemic has specifically devastated those communities, causing a disproportional number of deaths and severe illnesses greater than in any racial demographic besides hispanic/latino persons, and far greater than the impact on white communities. It is not hyperbole to say that African American communities are among those that need very high rates of COVID-19 vaccination the most to stem the tide of this pandemic and prevent further loss of life. And yet, the long history of broken trust on the part of the medical field is now paying dividends, and many in the communities that need the vaccine the most are reasonably mistrustful of a great deal of medical interventions; and especially of anything that seems new or experimental.

There are a great number of reasons to trust the safety and efficacy of the COVID-19 vaccines; they are outside the scope of this post, but I am addressing this piecemeal in my COVID-19 Vaccine Q&A. Just as Nurse Mitchel believes based on her very distressing personal experience that it is good to encourage people to avoid the vaccine, I believe based on the overwhelming scientific data that it is good to encourage my patients, friends, and family to get vaccinated. But Harriet Washington’s work was instrumental in my deciding to get the vaccine myself, which I did last week.

I am low risk, and would much rather have reserved my dose for one of my patients who needs the vaccine more than I do. I’ve written about this tension at length, and the great discomfort I have in receiving any medical treatment not available to all of my patients. But ultimately it was this quote from Medical Apartheid that made me decide to get vaccinated:

“Western physicians have adhered to a long and noble tradition of following animal studies with limited self-experimentation by researchers. This tradition may not always have been prudent, but by testing substances or procedures on themselves before experimenting with appreciable numbers of human subjects, doctors symbolically conveyed their belief that the measures were not inordinately harmful and also signaled a researcher’s willingness to share the risks as well as the glory of discovery.”

I am not a vaccine researcher, and there is no glory at all for me in people getting these vaccines. But they will protect my patients from COVID-19, and I deeply believe that as a medical field our solidarity with our patients, especially those who have been historically and actively marginalized by the medical industry, is an essential component of rebuilding trust. That means not only saying something is safe and encouraging our patients to have it done, but whenever possible taking on the potential risks within our own bodies alongside, and when necessary ahead of, our patients.

Yesterday two patients asked me about the COVID-19 vaccines and about this video specifically, both of them African American. In each case we talked about Bell’s Palsy, the vaccine safety trial data, the way vaccines work, and the history of medical abuse of Black folks in America; a condensed version of the contents of this blog post. We also talked about my experiences getting the vaccine, and my definite conviction that I would never ask my patients to consider a medical intervention I wouldn’t be willing to have done for myself or my family. Both left considering the vaccine, and at least one had definite plans to get it as soon as it was available. I am thankful, because both had risk factors for COVID-19 independent of the risk factor of belonging to a group marginalized by the healthcare sector.

This viral video is going to convince a lot of people not to get vaccinated. It shouldn’t, as we’ve discussed, but it will. My getting vaccinated will convince only a very few to get vaccinated themselves. But if I can show the band-aid on my arm to my patient and look them in the eye and tell them I believe so strongly that these vaccines can help protect our communities that I’ve had it done myself, maybe it will help a few. I can’t look you in the eye through this blog, but I hope you hear my heart, and I hope you decide to get the vaccine yourself to protect those you love and your own community, just as I’ve done.

COVID-19 Vaccine Questions & Answers

Contents:

How do these vaccines work? 12/24/2020
Will the vaccines have any lasting effect on my body? 12/26/2020
What about infertility? 12/26/2020
Aren’t the vaccine ingredients toxic? 12/29/2020
If I get the vaccine, can I still transmit/spread the virus? 1/7/2021

Other COVID-19 vaccine posts and links


Intro: Talking about vaccines as a Family Medicine doctor

As a Family Medicine Physician, helping patients navigate uncertainty and doubt around vaccines has been a part of my day-to-day job since long before the COVID-19 pandemic. I have always tried to approach those conversations with patience and understanding (not that I’ve succeeded each and every time), knowing that behind their questions and even suspicion there is, without exception, a deep desire to do what is best and safest for themselves and their families. I get it; vaccines can feel scary. They are pretty mysterious for most people, and there is so much controversy over them that our intuition tells us surely some of it must be true (even though the people who creating it are often intentionally deceitful). I am a father of 4 myself and understand how strange and frightening it can feel to have your child undergo any medical procedure; but unlike an infusion of antibiotics or a dose of tylenol, or the sedated lumbar spine MRI my daughter needed for tethered cord syndrome when she was 1 year old, vaccines are given to children who are healthy to prevent future illness; it makes the decision harder, because the reason for the treatment isn’t readily apparent or at the forefront of our minds.

Vaccines are also one of the single most important innovations of modern medicine, and have saved millions of adults and children from dying of some of the worst and most painful infectious diseases that afflict humanity.

That’s why it’s incredibly important to me that my patients have the time to ask their questions and why I believe they deserve careful, sincere, and thorough explanations. So when I think about all of the medical misinformation that is out there right now around the COVID-19 vaccines and how we can possibly alleviate those fears, I start by imagining a patient sitting across from me in my clinic exam room with doubts, uncertainty, or even trepidation about these new and rapidly developed vaccines, and try to write out how I would try to answer their questions.


𝐇𝐨𝐰 𝐝𝐨 𝐭𝐡𝐞𝐬𝐞 𝐯𝐚𝐜𝐜𝐢𝐧𝐞𝐬 𝐰𝐨𝐫𝐤?

Updated 12/24/2020

When discussing vaccines with my patients, I always, always start with a brief discussion of how they work. It’s not uncommon to hear someone say “I think it’s better to rely on my own immune system” when discussing vaccine preventable illnesses. We’ll talk about this in more detail later on, but my first response is usually to help my patients understand that that is exactly how vaccines work; by relying on your own immune system.

Our immune system is designed with two strategies for fighting infections. The first is non-specific but immediate; in addition to our innate protective barriers like skin, hair, and mucous, we have cells like macrophages, mast cells, and natural killer cells that are able to detect and attack any foreign invader that the body recognizes as not being part of itself. This is a good system and prevents you from getting sick all the time; without it, we would be constantly fighting illness and infection from normal everyday exposures, just as many do who have compromised immune systems.

But even more powerful is our adaptive immunity, which is directed specifically against infections our body recognizes and has dealt with before. This is an incredibly robust system of B and T lymphocytes and antibodies that recognize the invading pathogens and kill them with a higher degree of efficiency and precision. The only problem with it is that it takes time to kick into gear the first time your body is exposed to a new infection; and then it’s a race to see whether it can become active enough, fast enough to prevent an illness from becoming severe. On subsequent exposures, that response is much, much more rapid; so much so that you usually don’t even know you’ve been re-infected with that bacteria or virus because you don’t get sick.

The principle behind vaccines is simple; what if we could safely teach the adaptive (specific) immune system to recognize the deadliest infectious diseases, so when someone is exposed the first time they can mount that powerful, targeted immune response right away and not even get sick?

And that’s exactly what these COVID-19 vaccines are designed to do, just like all of the vaccines before them; they give the body the information it needs to mount a robust immune response with the adaptive immune system as well as the innate immune system, without any possibility of causing an infection in the process. So when someone asks, “wouldn’t it be better to rely on our own immune system?” my answer is, “Yes, absolutely! And vaccines allow us to rely on our entire immune system, not just the weaker half, without even getting sick.”

We will talk about the differences between how traditional vaccines and the mRNA vaccines accomplish this later (and whether or not they re-write your DNA). For now I’ll just say that the new vaccines are even closer to naturally acquired immunity than traditional vaccines, because they trigger our immune system almost exactly like the viruses themselves do.


Will the vaccines have any lasting effect on my body?

Updated 12/26/2020

Hopefully! That’s sort of the idea. While the messenger RNA only survives for a few minutes before degrading, the antibodies that are produced will circulate for months, and some of the other cells of the adaptive immune system, specifically the antibody-producing plasma cells, will hopefully migrate to the bone marrow and lie dormant for decades, which is how vaccines given in childhood continue to provide protection many years later. This is true of the annual flu vaccine too, by the way; the issue isn’t that those vaccines don’t provide lasting immunity, but that influenza is a rapidly mutating virus and different strains are more common every flu season. So your flu shot from 1997 or 2008 is still providing you with protection… But only against the flu strains that were chosen for the vaccine in 1997 and 2008. They’ve even done studies that showed people who survived the Spanish Flu Pandemic of 1918 could still produce an antibody response 100 years later! Coronaviruses mutate much more slowly than the flu, but it is too early to know whether SARS-CoV-2 will mutate enough or in the right way to require additional, regular vaccinations. If we can judge by the SARS and MERS epidemics of 2002 and 2012, it seems unlikely.

As far as other changes to our bodies, thankfully there is no plausible mechanism by which the COVID-19 vaccines could cause other chronic changes than the desired immune response. The mRNA only codes for a few specific proteins and cannot produce an active virus, and the fats, sugar and salts in the vaccines do little else than package the mRNA and help it get into the cell.

What about Infertility?

There has been misinformation circulating online about the vaccines causing female infertility, but these are baseless. The original claim can be traced back to Michael Yeadon, a former Pfizer researcher and COVID-19 denier who has also posted videos claiming that the pandemic really ended in late Spring, at least in the UK, because most of the population was already immune due to having antibodies to other coronaviruses, which cause the common cold (as of today there have been over 70,000 deaths in the UK from COVID-19). This is an extremely ironic idea in light of his claims about the vaccine causing infertility, as we shall see shortly. He has not worked for Pfizer since 2011, and calling him the “Head of Pfizer Research” is just as deceptive as the rest of the headline and article.

The vaccine does not contain a spike protein called Syncytin-1, at all; the article above is simply lying at that point. The actual theory claims that the COVID-19 spike protein the vaccines code for shares similar amino acid sequences with a human protein, Syncytin-1, which is important in placental development. They reason that antibodies trained to attack COVID-19 would also attack Syncytin-1, causing infertility. This is illogical and scientifically invalid for a few reasons. 

First, we have already had 80 million cases of COVID-19 worldwide and there has been no evidence of infertility as a side effect; yet the body of any infected person is going to produce antibodies against multiple COVID-19 proteins, including the spike protein in question. If the antibodies we develop against the spike protein from having the virus don’t attack Syncytin-1, there is no logical reason to believe vaccine-induced antibodies would either.

Second, we have evidence from the COVID-19 vaccine trials themselves that pregnancy occurs at similar rates between those vaccinated and those not vaccinated. The vaccine trials did not include pregnant women or women who intended to become pregnant, and all women of child-bearing age that participated had a negative pregnancy test before their first dose and committed to using a method of birth control throughout the study. Thirty-nine women became pregnant anyway; twenty-three in the Pfizer trial and sixteen in the Moderna trial, and the rate of unintended pregnancy in those who received the vaccine was about the same as in the placebo group. Those numbers are too small to draw serious conclusions, but the point is that we already have examples of women who became pregnant after receiving the vaccine, even though they were actively preventing pregnancy; in the coming months as more and more people receive the vaccines, we will have many more examples, and because this misinformation has been popular there are already studies planned to track the pregnancy rate following vaccination.

Third, the number of amino acids in the shared sequence is actually tiny; a segment of 5 amino acids, with only the first two and the last two being shared. Syncytin-1 has a full sequence of 538 amino acids, and the COVID-19 spike protein itself is 1,273 amino acids long. We have an analogy in human disease; one explanation for rheumatic heart disease following streptococcal infection is that certain proteins in the Group A strep bacteria share similar amino acid sequences with myosin, a protein found in heart muscle, allowing antibodies against the bacteria to cross-react with heart tissue. However, in that case there are not only much longer sequences of shared amino acids, but multiple sequences that repeat multiple times each. The section of shared amino acids in the case of Syncytin-1 and COVID-19 antibodies just isn’t significant, and you will find many viruses and bacteria in nature that share such similarities with a great many proteins in humans.

Finally, SARS-CoV-2 is not the only coronavirus in existence; not by a long shot. Coronaviruses are one of the main groups of viruses that cause the common cold, and you and I have both had many coronavirus infections throughout our lives. You still have antibodies to those coronaviruses, as Dr. Yeadon points out in his other videos. Every single coronavirus has spike proteins (that is what gives them their name; they form a halo, or corona, around the virus when you look at it through an electron microscope), and all of those spike proteins share as much or more similarity to Syncytin-1 as the COVID-19 spike protein, because they play similar roles in viral replication to what Syncytin-1 does in placental development (they are fusion proteins). So you have already developed antibodies against coronavirus spike proteins all throughout your life, maybe even every single year, just like everyone around you; and yet this has never been identified as a contributing factor in human infertility. 

So yes, the vaccine will have a lasting impact on your body, assuming you respond well like 95% of clinical trial participants. The lasting effects will be the same as the lasting effects of surviving the virus: immunity to COVID-19, and hopefully long-lasting immunity. The difference is that the vaccine doesn’t carry a risk of serious illness or death to you or transmission to those around you. And thankfully, neither immunity from getting the vaccine nor immunity from getting the virus itself will cause infertility. 


Aren’t the vaccine ingredients toxic?

Updated 12/29/2020

Those whom I interact with regularly who are undecided or hesitant about vaccines are typically patients and parents with sincere, legitimate questions, who deserve the time it takes to hear their concerns, answer their questions completely, and offer reassurance. But unfortunately, there are also people out there who are promoting anti-vaccine propaganda and deliberately creating false narratives. One common strategy to increase unease or paranoia about vaccinating our children is to simply list the scientific sounding ingredients and then ask, “do you really want to put that into their bodies?” Usually this approach will ignore benign sounding ingredients like “sucrose” or “gelatin”, and focus in on lengthy or scientific-sounding ingredients like “nicotinamide adenine dinucleotide” or “cetyltrimethylammonium bromide,” which register emotionally as more intimidating, less safe, and less natural. Of course we know that logically a chemical with a long name would not necessarily be any more or less dangerous than one with a short name; “ricin” has a short name, and it’s the 5th most dangerous chemical in the world (that is just an example; there is NO ricin in your vaccines. I do not want to see a bunch of memes next week claiming they put ricin in vaccines). But fear mongering is not always logical.

DANG IT

They might also home in on a naturally occurring and well known chemical that most people think about in conjunction with another of its uses, counting on that association alone to create fear. A good example is formaldehyde, which most of us think of in the context of embalming, but is also used in applications from color photography to deodorants; and of course, as an anti-bacterial and anti-fungal in certain vaccines. Some vaccines contain about .005 to .01 mg per dose; a 2 month old baby produces up to 200 times more than that every single day as a part of their normal metabolism (for adults, it’s more like 3,000 times more). Yet because our culture so strongly associates formaldehyde with death, merely invoking it’s name is enough to create unease.

Most of the ingredients in vaccines are there to keep the attenuated or killed virus pieces from decaying long before they are injected. Others are there to prevent the growth of bacteria or fungi in the vaccine vials themselves. Still others are used to stimulate the body’s immune cells around the injection site to make them more likely to produce an adequate response that leads to long-term immunity. All chemicals we encounter in our lives are toxic under certain circumstances; none of the ingredients in vaccines are toxic at the doses or in the manner given. I think people often forget that the scientists who design the vaccines, and the doctors and nurses that counsel patients about them and inject them, are human beings who also vaccinate ourselves and our children; we want vaccines to be safe for selfish reasons, too, not just altruistic ones.

That all applies to traditional vaccines; the new mRNA vaccines are made differently, and so they don’t need a lot of the same additional chemicals to ensure they work. In fact, what’s shocking about them is just how few ingredients they actually have. In addition to the messenger RNA molecules themselves, the Pfizer vaccine has just 4 synthetic fats (lipid nanoparticles) meant to deliver the mRNA into the cells that will build the COVID-19 spike protein, 4 salts to make sure the vaccine is at the same acidity and osmolality as the tissue it is being injected into so it can get absorbed (and hurt less), and 1 sugar, sucrose, to protect the vaccine during cold storage. 

Salt, fat, sugar. And that’s it.

Some of the substances can still cause a reaction; the leading theory right now is that the few anaphylactic reactions to the Pfizer vaccine were likely due to polyethylene glycol, a common chemical we give in huge doses for constipation, but which can cause an extremely rare, but serious, allergic reaction. This chemical is used to create the lipid nanoparticles through some Tony Stark level methods I can’t hope to understand. The lipid nanoparticles (very small fat molecules that can protect the mRNA) themselves are indeed new technology; which in science terms means about 30 years old. Over that time period their safety has been studied extensively and found to be safe, non-toxic, and biocompatible/biodegradable. And because the world is crazy, no, they are not tiny robots (but how cool would that be?!).

By contrast, “Nana Lipid Particles” are just the cookies she keeps sneaking your kids when you aren’t looking.
An article in 2016: “After 25 years of research…”
The math checks out.

I can’t claim to be familiar with every anti-vaccine meme and article out there, but I haven’t seen as much about ‘toxic ingredients’ with the COVID-19 vaccine, and I think that’s because even compared to the safe ingredients of traditional vaccines, the ingredients of the COVID-19 mRNA vaccines just sound very unimpressive, and thus feel less intimidating.


If I get the vaccine, can I still transmit/spread the virus?

This is a question I’ve heard frequently, especially from those who themselves work in healthcare or have vulnerable friends and loved ones. It is a question driven by compassion. In this blog we have been trying to address the fears and concerns that arise not only from conspiracy theories and misinformation, but also from the very small but real risk associated with the vaccines; yet I know that many people would brave whatever degree of risk to themselves (again, It’s very small) if it meant protecting their family and community. If they could be guaranteed that their choice to get vaccinated meant they could safely visit an unwell grandparent or have coffee face to face with a friend without any risk of spreading the virus, it would be a no brainer even if there was a considerable risk it might cause significant side effects like Bell’s Palsy (there isn’t). 

And I wish I could give that reassurance today, but while I can say that the chances are very good this vaccine will not only protect you but also protect those around you, we still need much more data to be able to quantify the degree of that protection. 

The point of the vaccines is to provide your systemic adaptive immune system, the part that acts powerfully and rapidly against specific disease, with the information it needs to produce the antibodies you need to keep you from getting very sick. A common misconception is that after you get say the flu shot, you can’t get the flu. It’s not true. The flu shot doesn’t give you a magical forcefield around your body that blocks flu virus, it just helps you fight it much, much more quickly and efficiently when you do get it; often to the point that you never even know you are infected, or at least only have very minor symptoms. Vaccines drastically reduce the chances of you becoming extremely ill from deadly disease like influenza, measles, or COVID-19; that’s their job. 

This is not how you get a cold.
He’s the best he is at what he does; but what he does is not immunology and pathophysiology.

This main function of vaccines is what underpins the epidemiology strategy of giving the COVID-19 vaccine to healthcare workers and the most vulnerable first. The medically vulnerable, because they are the most likely to require high levels of care, to suffer long-term problems from infection, or to die from COVID-19; and healthcare workers because as the pandemic worsens it becomes more and more important to preserve our medical workforce, and vaccinated folks are less likely to need sick time (much less become seriously ill and require hospitalization themselves) for COVID-19. The other reasons for vaccinating healthcare workers go back to courage, trust, and solidarity with our patients in the face of any new treatment. We are prioritizing vaccinating the vulnerable instead of say pathologic extroverts because the effectiveness of the vaccines at preventing significant illness is known (90-95%), but their effectiveness at preventing transmission is still unknown. 

So how do we find out so that Dustin can get his vaccine? Well, the big question mark is IgA antibodies. Most of the research on antibody production from COVID-19 vaccination focuses on IgM and IgG because they predominate in the blood and represent, respectively, our short-term and long-term antibody protection against systemic (whole body) illness. But IgA is the main antibody in the mucous membranes; your mouth and throat, nasal passages, lung surfaces, and digestive track (it’s also the antibody responsible for passive immunity transmitted through breastmilk), and we know that the IgA response to infection is a big, big part of what neutralizes the virus and decreases transmission in those first 10 days of symptoms. If the vaccines “only” cause a significant IgG and IgM response during that post-vaccine exposure to the COVID-19 virus, it will prevent severe infection; and may still prevent enough viral replication to slow transmission. But if it produces a strong IgA response too (or a strong enough mucosal IgG response), it will almost definitely neutralize any live virus in the upper airway as well, making transmission as unlikely as severe illness. In other words, the degree of IgA response is a strong predictor of whether the vaccine protects those around you as well as it protects you.

This is an old graphic; IgD definitely has a function. I just… Don’t understand it. https://pubmed.ncbi.nlm.nih.gov/29733429

Because of this, researchers are already studying the degree of production of mucosal IgA against COVID-19 in vaccine recipients, with some promising results, and at least one intranasal vaccine (which produce a very strong IgA response) is under development. And while the best information we could get would be to see exactly how well someone develops IgA and neutralizes the virus by studying them when they are exposed to COVID-19 after vaccination, it’s sort of hard to catch people in that window. In the end we will probably have to settle for epidemiology data instead; carefully watching to see if clusters of infection occur around exposed, asymptomatic vaccinated people at the same rate that they do around unvaccinated people. That will take time, but if and when it becomes apparent that vaccinated people really aren’t spreading the virus to those around them at all, that will be the point I’ll stop wearing my mask, practicing social distancing, and washing my hands (fine, fine; I’ll keep on washing my hands).

I realize this was a really long-winded way of saying “I have no idea,” but I want to conclude with a few reasons you should get the vaccine even if your main concern is not spreading the virus to others. First, there is already a lot of good data that supports the idea that these vaccines will provide mucosal immunity (and thus decrease transmission), both from studies of the COVID-19 vaccines themselves and from our much more robust knowledge of vaccines in general; it’s hard to say anything with much confidence yet because we’ve had these vaccines for such a short time, but I’m pretty optimist they will. We’ve followed these principles for years; we recommend everyone around a newborn be vaccinated against Pertussis (whooping cough) because the newborn can’t be, and we know that vaccine-derived herd immunity works even for viruses that are primarily spread through respiratory particles. Second, there is no conceivable mechanism by which they would increase transmission. The vaccines cannot make you produce live virus (at all) so they can’t make you contagious, and if you are exposed to COVID-19 later on your body will still respond with a mucosal immune response whether it is augmented by your vaccine or not (and it probably will be); the vaccine won’t stop that. And third, by preventing a severe systemic illness, the vaccine will decrease the amount of time you are shedding virus and prevent transmission in some of the most high-risk settings; aerosol producing procedures like nebulizer treatments or intubation in the hospital. And by preventing symptoms like coughing and sneezing the vaccine will make you less contagious when exposed to the virus, as long as you are still following other transmission control measures like wearing a mask and quarantining after exposure.

IgA response due to ChAdOx1 nCoV-19 vaccine (the tall red columns are good!)

So no, unfortunately being vaccinated against COVID-19 does not give us carte blanche to schedule giant indoor parties, throw away our masks, and treat the pandemic as if it were over; but they are a huge step in that direction, and in addition to protecting ourselves they do have a fair, if yet unproven, chance of protecting those around us too. And besides, if you don’t get vaccinated, how are you going to get your government tracking microchip?

Bad joke, sorry.


Other Vaccine Posts:

No Vaccine Selfie Yet or “Why I am uncomfortable getting vaccinated”

“𝐀 𝐂𝐎𝐕𝐈𝐃-𝟏𝟗 𝐕𝐚𝐜𝐜𝐢𝐧𝐞 𝐰𝐢𝐭𝐡 𝟗𝟓% 𝐄𝐟𝐟𝐞𝐜𝐭𝐢𝐯𝐞𝐧𝐞𝐬𝐬… 𝐓𝐞𝐥𝐥 𝐌𝐞 𝐀𝐧𝐨𝐭𝐡𝐞𝐫 𝐁𝐞𝐝𝐭𝐢𝐦𝐞 𝐒𝐭𝐨𝐫𝐲.”


Dr. Emily Smith, Friendly Neighbor Epidemiologist Vaccine Series

1. Herd immunity and vaccines: Vaccines 101 – https://tinyurl.com/y27txvro
2. Vaccine distribution info and how well do the current vaccines work? – https://tinyurl.com/y2vte5lz
3. Whoa, these were made quick, right? How can we make sure they are safe? https://tinyurl.com/y2awosyn
4. When will I get the vaccine? Who decides who gets a vaccine first? And, a note on solidarity versus individualistic thinking. – https://tinyurl.com/y39cbptv
5. Myth-busters for vaccines (we talk about fertility questions, 5G/micro-chips, fetal cells, and why the mRNA won’t change your DNA) – https://tinyurl.com/y2woz462
6. Explaining the FDA review and talking about the final Pfizer study results. https://tinyurl.com/y22jd32f
7. Should we be worried about the side-effects seen in the UK? – https://tinyurl.com/yxvb36y4
8. Let’s talk about the FDA panel meeting- https://tinyurl.com/y6hzmcgt
9. Reflections on the EUA Pfizer FDA meeting – https://tinyurl.com/y4k2o6kc
10. Pfizer EUA approval, vaccine ingredients, and recommendations – https://tinyurl.com/yyvzeynx
11. Pfizer vaccine Q&A – https://tinyurl.com/y7e3jar8
12. Will I have to get a shot every two months? Should I worry about mutations? https://tinyurl.com/y83wd84k
13. Info on the Moderna vaccine – https://tinyurl.com/y7x2hvn8
14. Let’s compare the Pfizer and Moderna vaccines – https://tinyurl.com/ybzdnqo5

What happened to the Flu?

You all remember what it was like in January and February before the COVID-19 virus had come to the United States, and before we began to treat it like a pandemic. It seemed like everyone was getting the flu, just like any normal year. The flu shot for that flu season only had about a 45% efficacy- not the worst we’ve ever had, but certainly less effective than we’d hoped- and hospitals were busy treating children, adults, and elders for complications of Flu A and Flu B. And then a couple of short months later…. *POOF!* It was like the flu had just disappeared. We didn’t hear about it anymore, nobody was talking about it; everything was COVID-19.

In March and April we began to see memes questioning why the flu had seemingly gone away. And then a few weeks after that… The memes were gone too, like magic! And for 7 whole months nobody mentioned or thought about the flu. Until a couple of weeks ago, when memes like this began to circulate again:

Isn’t is wonderful?

And although it’s only December 15th and the people posting these memes and #whereistheflu conspiracy theories are shooting their shot a bit early, I think now is a great time to answer the question, “Where is the flu?”

Contents:
-What does a normal flu season look like?
-Why doesn’t the ‘where is the flu’ theory work?
-What did happen to all the flu cases?
-What would you have to believe for these memes to be true?


What does a normal flu season look like?

The reality is that there’s really no such thing as a “normal” flu season. While different strains of influenza circulate in our communities each year, they are all unique in their own horrible ways, and we can’t predict ahead of time when we will have a mild flu season, like in 2015-2016, or when we will have a terrible flu season that threatens to overwhelm our healthcare systems like in 2017-2018, the worst I’ve experienced as a physician. But we can draw some generalizations about flu season:

  • It’s going to happen during the Winter.
  • People are going to die.
  • It’s going to suck.

I hate the flu, and even if we as a society have mostly relegated it to sitcom B plots and ‘man cold’ jokes, the reality is that it’s a killer, and I have patients with chronic respiratory diseases, compromised immune systems, or just poor overall health that I worry about every single year as flu season begins to ramp up.

We typically expect flu season to begin in early Winter, usually November, peak between December and March, and typically to be ended by April. A late flu season might last until May, but that’s fairly rare. However, the last flu season we’ve seen peak in December was back in 2014, and for the past 6 years it has been in January, February, or even mid-March.

So while I’d never fault anyone for trying to get work done early, those ‘Where are the Flu?” memes really would make more sense in January or February, when we would be expecting flu season to be peaking. Nobody finds misinformation claiming that doctors are padding the COVID-19 numbers with flu cases convincing in June and July, so I’m sure they wanted to take advantage of the cold weather for as long as possible.

And honestly I hope we are still seeing those “where is the flu?” conspiracies in February and March because the flu cases stay ridiculously low. That would be a lot better than internet memes saying “oh man, remember back in 2020 when we only had one deadly respiratory virus epidemic to deal with?”


Why doesn’t the ‘where is the flu’ theory work?

Let’s go back to that first meme at the beginning of the article, which deserves a bit more of our attention. It comes from the WHO FluNet, and anyone in the world can go to that website and look at reported flu cases for any date range going back to 1995. The first thing you’ll notice about the image is that it is on the order of tens of thousands; each major division of the Y axis is 20,000 cases. The image is supposed to convince you that the WHO just forgot to record flu cases at all as a part of this big hoax, but still published their flu numbers with empty charts for the whole world to see. Pretty incompetent conspiratoring if you ask me. But the truth is, that seemingly empty section of the graph is not empty; the 2nd image below is that same ’empty’ time frame, just with a smaller scale.

This is still an incredibly small number of cases, but it demonstrates the same week-to-week and seasonal variability flu cases normally follow; that part of the graph isn’t empty, and the data checks out.

In this context, the original image is suppose to convey two ideas; either that doctors have stopped checking for the flu altogether, or that they are ‘stealing’ flu cases and filing them under COVID-19.

The first is easy enough to answer; we haven’t stopped checking for the flu. I’ve just logged onto our electronic health record and I have a message from a colleague about a positive Flu case. We are ordering the tests, and some of them are positive. How reliable flu testing is at baseline is a topic for another day; at the very least it can be compared from year to year to help us understand how relatively bad the flu season is. As a physician I rarely order flu tests, but I’m not the one driving this data; and in fact, with COVID-19 causing similar but not identical symptoms to influenza, I’ve personally been testing for flu more in 2020 than in any year before, because differentiating between flu and COVID-19 is now an additional utility of the flu test; I know several clinicians who are doing the same. We can look at the CDC numbers to see if we are outliers here in Waco, or if doctors are in fact still testing for the flu.

So far, labs that participate in CDC influenza monitoring have tested 232,452 Americans for the flu. At the same point last year, the number of tests reported was 265,670, but instead of having only 496 positive results and a 0.2% positivity rate, we had 15,027 positive results and a 5.7% positivity rate. And while this clearly does not include all flu tests that have been ordered since September, it is a representative sample. So we know that doctors at ordering the tests; the tests are just negative.

That leaves us with the flu cases being stolen somehow. One way for this to happen is for the flu analyzers to be calibrated to call flu tests negative so we can count them as COVID-19 instead (and by logical extension, the COVID-19 machines calibrated to detect flu and call it COVID). The problem with that is that every lab has a different strategy for testing these two viruses. Many labs use completely different machines to test for COVID-19 and flu, and their flu machines have been utterly uninvolved with their COVID testing strategy; untouched, with no updates or software downloads that would cause them to stop detecting flu. There are even lots of clinics that don’t test for COVID-19 at all; have they had their rapid flu tests updated to stop detecting flu, and are now just going through the motions of collecting flu swabs to make some other lab’s COVID-19 results more believable? It’s not just far fetched because of the unbelievable extent of involvement such a conspiracy would require, but because so many people would have to be a part of it even when they are far removed from the COVID-19 testing process and apparently have nothing to gain.

A more parsimonious theory is that the tests are being run as normal, but the CDC is changing the numbers. We track flu tests in the US to determine the positivity rate and understand when flu season begins, when it peaks, and when it ends. We use other metrics like excess mortality to really understand the full impact of a flu season and estimate the number of cases. Right now, the laboratory result tracking is telling us that there just isn’t appreciable community transmission; but what if the CDC has moved all of the positives over to COVID-19? By this point last year there had been 15,027 positive flu tests reported to the CDC. In that same time period this year, we’ve had 9,755,813 new COVID-19 cases (including me!). So those flu cases would represent approximately 0.15% of all of the new laboratory confirmed cases of COVID-19 reported in the US since monitoring for the new flu season began at the end of September. Shifting the flu tests we track to COVID-19 wouldn’t just be a dishonest and transparent strategy for inflating the pandemic numbers, it would also be entirely ineffective and unnecessary. If they just reported flu cases like normal, the COVID-19 numbers would be almost exactly the same, and they’d be far less likely to get caught. If you are trying to embezzle millions of dollars from the bank, you don’t cook up a fake set of books and then turn around and stiff your customers a couple of bucks when they come in to cash their checks, too (I am currently in the market for a much better financial analogy. Please send suggestions to tjwebb@tjwebbmd.com).

Claiming that the COVID-19 numbers are being inflated with influenza cases also does absolutely nothing to explain two important facts about the pandemic; the pattern of cases over time, and the number of deaths. If we were ever to see even a fraction of the number of deaths due to seasonal influenza that we are right now from COVID-19, especially this early in flu season, we would be dealing with the worst flu since the Spanish Flu of 1918. If that were the case, the flu itself would be a pandemic exactly as bad as COVID-19… So why all the pretending? The numbers also don’t fit the pattern of seasonal flu at all. Look on the graph below and tell me when ‘they’ would have switched to using the flu to generate COVID-19 numbers. October 10th? That’s when cases really began to climb, and that’s too early for flu season. What about the cases in April, or the nationwide surge in July?

The “What Happened to the Flu?” conspiracy is extremely weak because not only does it have no explanatory power, it also has to be combined with multiple other conspiracy theories (like “the doctors are lying on the death certificates“) to work at all.

I think a lot of people find the apparent absence of the flu convincing, and I think I understand where they are coming from. Most of us aren’t used to thinking like epidemiologists. I’m not. We know people who had COVID and were fine, just like we know people every year who get the flu and are fine. If we know someone who died of COVID, as I do, it’s a tragedy; just like it’s a tragedy if we know someone who died of influenza. But we aren’t actually very good at looking at the world around us and intuitively understanding the scale of a normal flu season versus the scale of a global pandemic. So noticing a decrease in one is enough to allow us- if we really want to be convinced- to dismiss or explain away the other; until we actually look at the real numbers.


What did happen to all the flu cases?

The reality is that the CDC and the WHO are reporting such a small number of positive flu tests because… there are a lot fewer cases of the flu. And although experts have told us to expect a particularly light flu season for months, it begs the question; is it really possible for it to be this light?

The answer is yes, thankfully, and for some very good reasons. First, as we’ve been saying, it’s still very early in flu season; we just don’t know how bad the peak will end up being yet, though these early numbers are a very good sign. Second, flu vaccination rates are actually higher this year than last. With the flu vaccine typically being between 40 and 60 percent effective, even a modest increase in flu shots will result in millions of fewer cases. But more importantly, we can expect a light flu season because every single measure we use to decrease COVID-19 transmission decreases transmission of the flu too. Decreased indoor gatherings, wearing masks that block respiratory particles, a significant portion of the population working from home, doing remote learning, and sheltering in place; all of these are going to decrease transmission of influenza even better than transmission of COVID-19. Why better? Because the flu is less contagious, for one thing; it is less efficient at spreading from person to person and therefore it is easier to mitigate with masks and distancing. But even more important is the fact that some of our strategies that are only modestly effective for COVID-19 are actually very effective for influenza.

Take symptom monitoring for instance. Right now every school, daycare and university, and most businesses, are carefully monitoring their students and employees for infectious symptoms like cough, nausea, and fever, and insisting they miss school or work and see a doctor if they are ill. Because COVID-19 is spread even by people who are asymptomatic or who have not yet developed symptoms, this strategy is only effective for symptomatic COVID-19. There is also a long lead time for COVID-19 during which a pre-symptomatic patient can spread the virus before they are sick enough to screen positive and be told to stay home; the incubation period of the virus is up to 14 days or longer, with most people developing symptoms around day 6-7 on average. Prior to this, they are at work and school and don’t realize they can infect others. That’s why this strategy absolutely has to be paired with excellent contact tracing and quarantine for close contacts. But our contact tracing system in the US failed early on, and between American individualist culture and misinformation and conspiracy theories about the virus, quarantine of close contacts has been the single hardest measure to generate buy-in for.

Contrast this with influenza, which has a 1-4 day (average 2 days) incubation window and is far less transmissible in asymptomatic or pre-symptomatic patients. By the time a person is able to spread the flu, they have symptoms of the flu. In normal years a fever or vomiting might cause them to stay home, but they can continue to work or go to school with mild to moderate flu symptoms like cough and sore throat; but not in 2020, when even the social condemnation attached to coughing in public is enough to keep a lot of us at home when our allergies are acting up. Keeping people who feel well in quarantine because of exposure to the virus was always going to be a hard sale, even when that advice is based on solid epidemiology principles. Fortunately, slowing the flu doesn’t depend on that particular strategy.

Is that enough memes? That feels like more than enough. You get the idea.

It also bears pointing out that the mitigation measures for COVID-19 actually have worked, and are working. Those who want to minimize or deny the realities of this horrible pandemic are fond of pointing to the early models that predicted greater than 1 million deaths in the US and asking, “what happened to all the deaths?” But those were predictions about what would happen without mitigation, and having already reached 307,000 deaths with extensive mitigation efforts, those early numbers now feel like low estimates instead of end-of-the-world scenarios. Because strategies to reduce COVID transmission are being followed or ignored to more or less of a degree not in different states or cities but in different houses on your street (and even by different people in your own house), we will never really know which mitigation measures were most effective or how effective they might have been with higher engagement; but it is clear that even with actual levels of adherence, they are even more effective for the flu than for COVID-19, which makes perfect sense when you compare the characteristics of the two viruses.


What would you have to believe for these memes to be true?

Finally, I want us to really stop and ask ourselves, if these memes and commentaries were true, what would we have to believe? First, let’s reiterate that the people creating these mean one of 3 things:

  1. Where are the flu cases? The flu cases are there, but doctors and the CDC have decided to ignore them altogether.
  2. Where are the flu cases? A lot of the tests for COVID-19 are actually positive tests for the flu, but they aren’t being reported that way.
  3. Where are the flu cases? Oh wow! It’s so wonderful that we aren’t seeing much flu activity right now.

Since we can rule out the 3rd one (even thought it is, actually, the one supported by the facts), it has to be some combination of the first two. And in order to find those ideas convincing, here’s what you have to believe.

Warning: Most of what follows is sarcasm.
(so please don’t quote me on any of this out of context)

– Your local clinic doctors (including me), who hate the flu and COVID-19 and have lost patients to both, are waking up every morning, going into work in full PPE, and seeing patients for cough and fever.
– They are spending 10-15 minutes talking face to face with patients about COVID-19, about the safety precautions and how to do isolation and quarantine, what red-flags to watch out for, and offering heartfelt reassurance and telling their patients not to be afraid, but to stay vigilant in monitoring their symptoms. Sometimes they are even praying with them at the end of those visits.
– This is all a waste of breath and they know it. It’s a big sham, and they are play-acting their part. They know full well that whether their patient has a cold, or seasonal allergies, or the flu, they are going to call it COVID-19 anyway (and go ahead and ignore the fact that we are telling people ‘hey I think this is actually just your allergies’ all the time. If we wanted to inflate COVID-19 numbers we could do it all day long. But we don’t and we aren’t). They’ve spent all these years trying to help people fight disease, and now they are going to spend their time lying to people, leaving them less prepared for and knowledgable about the disease they actually have. And because they don’t give you a new patient panel when you sign up for a global conspiracy, they are actually lying to the same people they’ve spent all of those years trying to help as their primary care doctor.

I realize this is the worst possible gif and the opposite of my point.
I just really like this movie.

– They order a COVID-19 test and the nurse collects a sample and brings it to the lab tech, who places it in a machine to test for COVID-19; maybe they are also running a flu test for that patient. But the flu analyzer has been programmed to call the flu test negative and the COVID-19 analyzer has been programmed to call the flu COVID instead. Why test for anything at all; why not just call a certain percentage positive and have done?
– The clinic doc gets the fake COVID-19 test back and tells you it’s positive, and advises you to isolate for 10 days. This is because they… Hate your job, I guess, and want to make you stay home so you won’t get paid? I mean, I write letters for patients to help them get work accommodations for their medical conditions all week long, and I even call managers, bosses, and HR reps to make sure my patient isn’t at risk of losing their job because of a medical issue. I’ve helped people with their depression and anxiety every day for years, a lot of it because of financial difficulties. I’ve even connected people with legal resources so they could fight to keep working when they were wrongfully terminated because of their health. But sure, I guess it makes sense that I want my patients to face more financial hardships and want their lives to be worse. That’s what really lights the fire under us to make all those sacrifices in medical school and residency.
– The doctor knows you have the flu, but instead of seeing if you are one of the people that might benefit from Tamiflu (it’s not as good of a medicine as you might think), they withhold that medicine because offering it to you would give away the game, and of course their commitment to this fake pandemic is greater than their commitment to helping their patients or their Oath.
– You ask the doctor about your young children; are they going to be ok? Even though they know that children under 5 (including two of my own), and especially under 2 are at high risk for complications from the flu, they go ahead and offer fake reassurances. “I don’t want you to be afraid,” they say, “thankfully, your children are at much lower risk from this virus than even a healthy young adult.” That probably eats at them a bit, lying to you about whether or not your kids are in danger; but they are just really committed to this conspiracy.

– Meanwhile, by the way, their colleagues in the hospital are spending even more hours and making even more personal sacrifices to treat incredibly sick hospitalized patients. Instead of treating them like normal pneumonia, flu, and heart attack patients, they are calling them all ‘COVID-19’ and treating them with steroids, prone positioning, anti-virals, and convalescent plasma; all to maintain the ruse. It wouldn’t look good for the numbers to only be bad in clinic.
– Finally it’s time for the doctor and the nurse and the lab tech to send their fake lab results to the county health department, and then on to the CDC. Here the CDC, rather than reporting fake numbers that perfectly match their false narrative, will carefully tabulate the fake lab results they’ve received from all over the country, throwing in a few positive Flu cases and different flu strains (including some their experts didn’t recommend we vaccinate against) just for good measure. Seems like an awful lot of trouble.

Also, by having an incredibly mild flu season and diverting all of those flu numbers to COVID-19 (even though, again, they aren’t really needed), they allow graphs like the one in this article that make it really obvious to any conspiracy theorist on the internet what’s going on. Such an intricate conspiracy, but so poorly executed.

And why do we do all of this? Well, because fear of the pandemic helps shutdown the economy and hurts your political candidate, according to one theory (I still don’t know how they convinced all of my conservative, Republican doctors to go along with it). You would think there’d be an argument that two contagious killer viruses might convince people to stay home even better than one… Or, according to another theory, to sell COVID-19 vaccines for big pharma. Because everyone knows I get daily instructions from my pharmacy sales rep masters, instead of, you know, barely tolerating being forced to occasionally interact with them so I can get some free insulin samples for my patients. I suppose flu shots just aren’t as profitable.

Not you Gus! I didn’t mean it.

Which brings up another good point. Besides the doctors and nurses and lab techs and of course the CDC, who else would need to be complicit in this scheme? Well, Hoffmann-La Roche Inc. and Gilead Sciences, for one, the manufacturers of Tamiflu. I don’t prescribe it much myself, but during flu season it’s one of the most commonly prescribed medications. That company also makes Remdesivir, one of the medicines used for certain COVID-19 patients; but only in the hospital. Bad work on their accounting department, sacrificing most of their sales from a widely prescribed outpatient medication to focus exclusively on an inpatient medication prescribed only for some patients.

I’m not willing to put anything past drug companies, but it does seem like allowing for a ‘normal’ flu season would at least help them hedge their bets a bit. Then again, Tamiflu is available as a generic now too, so maybe this is a corporate high risk, high reward gamble. Let’s move on.

Who else would have to be complicit in it? These guys:
Sanofi Pasteur, Inc
Seqirus, Inc.
GlaxoSmithKline Biologicals
Protein Sciences Corporation
MedImmune, LLC

Recognize them? Those are the top manufacturers of seasonal flu vaccines, and none of them has a COVID-19 vaccine (at least not one close to being approved). The companies that make the two vaccines currently approved or about to be approved for COVID-19, Moderna and Pfizer, do not have seasonal flu vaccines.

You write the script. Powerful, multi-billion dollar pharmaceutical companies that have lost the race to create a vaccine against a hoax virus (or didn’t even try), and now are missing out on all of that sweet, sweet COVID money. They know it’s a hoax and more than likely have some proof. So what do they do? They expose it for what it is, involving their competitors in scandal and allowing them to grab a greater market share and keep their flu vaccine as the most important vaccine of 2020. Except that’s not what they’ve done; if you go to any of their websites, you are going to see messages saying, basically, “good job on developing those COVID-19 vaccines you guys, we are rooting for you.” Sincere? Who knows. But definitely not the type of corporate warfare you would expect if they knew the virus wasn’t really that dangerous and were missing out on all the fear-monger profits.

Now, I know what you are going to say. ‘Fine, maybe it isn’t the doctors and nurses, maybe it’s just the CDC and the WHO. And hey, thanks for not including me in your global conspiracy. Let’s say that this is a regular flu season, or even a particularly bad flu season. That means that say hundreds of people a day are dying (or 3,000, if you are saying all COVID-19 cases are really the flu), and hundreds of thousands are getting the flu, and the doctors are… What? Too dumb to know the difference? Too lethargic to figure out what’s flu and what’s COVID-19? If we aren’t in on it, then we are either too dumb or too complacent to notice it; you know, the two primary things doctors are known for, being stupid and lazy. Every day at our COVID-19 outdoor clinic I hear the same conversation between doctors that are floating there to help; “have you guys seen much flu yet?” And every day I hear the same answers; “not really” and “I’ve had a couple.” If we were in the midst of a bad flu season right now and it were being covered up, you’d have hundreds of thousands of doctors, nurse practitioners, physician assistants, nurses, and all sorts of healthcare workers blowing the whistle, not just a couple of drug reps posting their text messages on Parler. Instead what those clinicians are saying is, “COVID is really bad right now. Please wear a mask. Our hospitals are overwhelmed; thank God the flu isn’t bad right now too.”

What has two thumbs and COVID-19?

“TJ Webb, nice to meet you”

I’ve actually been thinking about this particular blog post for a while. Ever since I took on the role of being a clinic lead for our system’s very busy outdoor COVID-19 clinic about 6 months ago, I’ve been seeing multiple COVID-19 positive patients, face to face, 3 to 5 (sometimes 6) days a week. Unlike the very high volume, rapid turnover testing-only strategy that is so important from an epidemiology standpoint, these were real medical visits; I heard about my patients’ symptoms and exposure history, we discussed risk factors, we checked vital signs, and I listened to their hearts and lungs. When we needed them, we got blood work or EKG’s, or if the patient was pregnant, listened to the baby’s heartbeat.

COVID-19 is a stressful thing to be seen for, and patients very frequently need more than just a targeted physical exam and a test result. At each visit I provided reassurance, and careful instructions for quarantine or isolation as their clinical situation demanded. I told my patients not to be afraid, and then we discussed what vigilance demanded and a detailed discussion of the signs and symptoms that should lead them to seek further care or go to the emergency department. Sometimes these visits really only lasted 5 or 6 minutes; sometimes they lasted 15-20.

I don’t have an exact count, but I’ve done around 1,500 of these visits since the pandemic started.

Masks are very, very good at preventing COVID-19 transmission, and my N-95 and faceshield are a powerful combination; but they are not perfect. Besides, we know that masks are better at protecting against lower velocity respiratory droplets and work best when worn by both parties. Many times my patients were coughing and sneezing, and some simply couldn’t tolerate wearing their mask for our entire visit because of their shortness of breath or other reasons, so we relied entirely on my own PPE, and the outdoor setting, to mitigate the risk of that face-to-face visit. I knew this would be the case sometimes; it’s the nature of the job.

Because of this, my wife and I have more or less treated my getting COVID-19 as an inevitability (it wasn’t actually inevitable, but it definitely felt that way). So when I recently joked darkly on facebook how nice it was knowing that “if I join the 1,700+ American healthcare workers that have died from the pandemic so far, my $300,000 of med school student loans are non-transferrable to my wife and 4 children,” and then in a blog post on not going home for the holidays said, My PPE game is strong” and I’m really, really good at being cognizant of fomites and at personal transmission control,” anybody with even a small amount of Genre Savviness could have told you what would happen next.

Sure enough, following a night of fever and chills and a morning of coughing, sneezing, sore throat, and headaches, I finally tested positive for COVID-19 yesterday afternoon. As someone who diagnoses and treats COVID-19, who writes about COVID-19, and now who has COVID-19, I thought my perspective might be helpful to others, and today I’d like to write about what I will and won’t be doing over the coming days and weeks (specifically as it relates to my diagnosis; nobody wants to read about my Mandalorian costume 3d printing).

5 things I’m not going to do now that I have COVID-19.

1. I am not going to Panic.

One of the biggest communication challenges I face on a daily basis is helping patients understand that a virus like COVID-19 or seasonal influenza can be extremely deadly and devastating in aggregate, but not necessarily dangerous for a particular individual. There are pitfalls on either side; if my patient erroneously believes that there is a 100% chance the virus is going to make them so ill that they end up in the ICU, they will spend the following days and weeks in fear and anxiety, less capable of navigating their symptoms and more likely to over-utilize an already strained emergency medicine system, and easier prey to those profiteering off of the pandemic by selling unproven pharmaceutical and wholistic ‘cures’ (including, sadly, at least a few doctors out there).

But if my reassurances cause them to believe that the virus isn’t dangerous, as many people do despite a now insurmountable accumulation of evidence to the contrary, not to mention the lived experiences of our friends and neighbors, there is a risk that the rest of my cautions and teaching about transmission control will go unheeded.

We will look at the numbers in a moment, but this is the most dangerous virus in our lifetimes. The risk an illness presents to a community is based both on how dangerous each individual case is and on how many people contract it. So while any particular COVID-19 case is more dangerous than the flu but far less likely to lead to serious disability, life-long suffering, or death than a case of say Ebola, it is much, much more contagious and will therefore make up the ground easily. And we do not share the burden of risk equitably. We know that the risk of a serious illness and death is greater for those above 50 and far greater for those 65 and older. We know it is greater for those with chronic medical problems, especially those affecting the heart and lungs, multiple medical conditions, and compromised immune systems. But these biological factors are not the only ones at play; people are also more vulnerable if they are part of a marginalized community, and have worse access to healthcare, preventative health, and affordable nutrition. We know they are more vulnerable if they are non-English fluent and therefore have a harder time navigating intricate healthcare systems or having their symptoms and questions understood in a busy clinic or emergency room. We know the poor, especially, bear a greater burden of illness in all diseases, and despite talk of COVID-19 being ‘the great equalizer’, equality just isn’t something American healthcare has been setup to deliver.

I am a white male doctor, 35 years old, in pretty good health, with excellent food access, living in a town with a dozen clinics and two hospitals where many staff know me by sight. I have all the advantages in the world when it comes to surviving this. With COVID-19, sometimes all of that isn’t enough, and we can’t predict and don’t really understand why some healthy young people develop incredibly severe symptoms and die despite our best efforts. But it is, relatively speaking, rare. So I’m not really afraid of this infection for my own sake, but I am taking it deadly seriously because among the many people I love and care about are those who have fewer or none of the privileges I do. And even among those few who are actually at lower risk that me- those who are younger, healthier, and whiter I guess- they are still at some risk, and those characteristics and the privilege they represent are not a perfect protection against this pandemic. So for all of those people, I will be staying home for the next 10 days at least.

2. I’m not going to take unproven medications (and I could get them if I wanted to).

One of the main reasons I have chosen to write about being diagnosed with the virus, instead of just quietly continuing to nitpick viral videos, is because this is really my first opportunity to put my money- or my health- where my mouth is. I’ve been writing about the dangers and sheer impracticability of physicians prescribing unproven treatments like hydroxychloroquine and budesonide since May. Now I have to put those reflections into action, and the outcome will affect myself and my family.

There is a tough kernel of suspicion in the minds of many people that when the doctor tells you there isn’t a specific medicine that will treat your illness, it really just means there’s not a medicine we are willing to give to you. Many people really do believe that there are special treatments reserved only for those who are ‘in the club’: doctors and their families, VIP’s, the wealthy, and those with excellent insurance. If you are a person of color in the US, or belong to any other group that has been marginalized and continues to experience systemic discrimination, there are even good historical reasons to struggle with this suspicion and to find it hard to trust the medical field in general; and not just the Tuskegee Syphilis Study, though it remains the most notorious example. For people with this shared cultural narrative, taking a quick look in my medicine cabinet at home, or those of any of the physicians I have treated for COVID-19 during this pandemic, to see that we are taking the exact same medications and treatments we are offering to our patients may be a good start to dispelling this particular myth; but rebuilding broken trust obviously takes a lot more than that.

I know literally hundreds of doctors; I’ve been learning with them, training with them, and working alongside them for the last decade and a half. This creates a great amount of potential for privileged healthcare access, which we have to be cognizant of and intentional not to abuse (and which is not fully cancelled out by the fact that we are, as a profession, notoriously bad at setting aside time for our own physical, mental, and emotional health). Most of those doctors believe exactly as I do about unproven treatments not supported by evidence; but not all. Even if it took a few phone calls, I could probably find a doctor willing to prescribe me budesonide, hydroxychloroquine, systemic steroids, azithromycin; any or all of the ‘silver bullet’ medicines (besides bleach) that have been touted by viral video doctors convinced by confirmation bias, selection bias, conspiracy theories, and negligible sample sizes.

Why am I not? For the same reasons I haven’t prescribed them (except when they are indicated, like my COPD patients who were experiencing an exacerbation and needed a course of prednisone) for those 1,500 or so patients who have entrusted me with their care during this crisis: Because there is no evidence that they work.

Instead I’m going to do three types of treatments, all of which I recommend for my patients.

  • Medications I am already taking.
    • Unless specifically recommended by your doctor, you should not discontinue the medications you need for chronic medical conditions. Although it’s always a good idea to revisit your medicines with your PCP and make sure you still actually need them, especially if you are on many medications per day.
  • Medications to alleviate my symptoms.
    • I take fluticasone and cetirizine for sinus congestion and allergies, and recommend them to my patients when they have similar symptoms. I like guaifenesin for chest congestion, and tylenol and/or ibuprofen for headaches, body aches, and fevers. I may call my doctor’s office and ask for some tessalon perles if this cough get’s any worse, though that medicine doesn’t work for everyone. None of these will cure the virus, but with any luck they will make the next week or two a lot less uncomfortable. Before starting any prescription or OTC medication, check to makes sure it doesn’t interact with your other meds and isn’t contraindicated because of a chronic health condition; your PCP is happy to help you with this.
  • Non-pharmaceutical supportive care treatments.
    • One day I’ll get around to writing a blog post titled “Your Physician is also a naturopath.” Despite claims that doctors want you ‘locked inside your house’ for the entire pandemic, I encourage my patients to get plenty of sunlight and as much exercise as they can tolerate with their symptoms; just not to do it around people they could infect. We have the privilege of a backyard; for those who don’t we talk about how to be outside but safely distanced while you are under isolation or quarantine. We are also going to talk about the need for additional rest and fluids. If you have a sore throat, we touch on judicious use of chloraseptic spray; but I really emphasize hot water or tea with plenty of honey. I might recommend a nasal decongestant, but I also talk with my patients about safely using a Neti Pot or saline rinse, as long as they don’t have contraindications (and don’t use tap water). I take a multi-vitamin daily and eat a balanced diet, but as long as they aren’t taking amounts that could be toxic or being taken advantage of with expensive, high-profit-margin products, I don’t give my patients any pushback on taking additional vitamins or immune supplements. My recommendations regarding alternative health treatments that don’t have solid evidence are these; they should be safe, they should be affordable, they should not interfere with your evidence-based medical care, and if at all possible they should have a plausible mechanism of action that actually relates to your condition or symptoms. That covers an awful lot, and anybody who claims to be helping you but fails those criteria is probably, quite literally, trying to sell you something.

3. I’m not going to get bored of isolation and decide it’s ok for me to stop early.

That first part is a lie; I’m definitely going to get bored of isolation. I’m strongly extroverted and I’ve been terribly bored of socially distancing for months now. I absolutely love being at home with my wife and four children, it’s my favorite place to be in this present world (besides the Bua Thong “Sticky” Waterfall near Chiang Mai, Thailand); but after 10 days I’m going to be dying (Editor: probably a poor choice of words) to spend an afternoon sitting outside at a coffee shop, or go for a trail run in the park instead of doing laps in our small back yard.

Nevertheless, I’ve heard too many stories of people who decided that since they were asymptomatic or minimally symptomatic, or because they had reached day 6 or 7 and felt better, that their COVID-19 infection didn’t count and they were the exception to those pesky CDC guidelines. Who did I hear these stories from? Mostly from the people they had infected. As much as certain people make ‘freedom’ their rallying cry and rail against so-called draconian restrictions meant to decrease transmission of the virus, the truth is we are pretty much free to follow the guidelines given to us by our doctors and by public health experts, or not, to whatever degree we choose. As much as people talk about the specter of government tyranny related to fighting the pandemic, there really isn’t much we can’t do. I got diagnosed with COVID-19 yesterday, and I could have sat inside at a restaurant or a bar last night; nobody would arrest me. I could sit inside at my favorite coffee shop all day today, and publish this blog entry about me having COVID-19 while sitting there, coughing and sweating and with a hoarse voice, and it’s still extremely unlikely that anyone would say anything to me. Why don’t I? Because of this:

Because with all of that freedom comes responsibility, and because the number of family, loved ones, friends, and neighbors, co-workers, and patients we each lose during this pandemic, which is now in it’s darkest hour, depends on how seriously we each take that responsibility; how deeply we feel the true gravity of our own actions. We are living right now in the failures of our society to do just that. I don’t claim to have been perfect over the past 9 months; but every single one of us needs to stop and honestly consider if there is any area of our lives where we can make different choices in the coming weeks and months to try to prevent even more loss of life.

Deadliest days in US history from a single cause or event.
(This list omits individual days from the Spanish Flu Pandemic of 1918-1920, which killed on average 1,000 Americans a day but came in several very bad waves)
This meme is less than 48 hours old and is already out of date.
Today it would look like this:
1. Galveston Hurricane – 8,000
2. The Battle of Antietam – 3,600
3. Yesterday- 3,055
4. San Francisco Earthquake – 3,000
5. September 11th – 2,977
6. Last Thursday – 2,861
7. Last Wednesday – 2,762
8. The Day Before Yesterday – 2,630
9. Last Tuesday – 2,461
10. Last Friday – 2,439
(11. Pearl Harbor – 2,403)
With hospitals getting overwhelmed, by the end of the month it’s possible
that only the top 1 or 2 will still be on this list.

4. I’m not going to Church.

Our church, Mosaic Waco, has done an amazing job of meeting safely throughout the pandemic. We have “Drive-In Church” in-person but outside and socially distanced every other week, and staff members, volunteers, and congregants consistently wear masks. Our pastors and other leaders have sought out and listened to the wisdom of epidemiologists, physicians, and other experts, especially those who are brothers and sisters in Christ, and understand acutely the difficult balance of goods in deciding how best to gather as believers. They have rightly considered responsible transmission control measures as an essential part of our responsibility to love our neighbors during a pandemic.

All that said, I skipped last week. We were having Drive-In Church and I had signed up to serve, but we were beginning to see signs of illness in our family, and our policy has been to exercise an abundance of caution when it comes to the health of those around us. I’m skipping this week too, obviously, though we are going to continue to attend online. The worship band probably can’t manage without me running the slides, poor things, but the pandemic demands sacrifices of us all.

I bring it up because there has been a popular and persistent narrative that has invaded the Church in America that choosing not to meet in person, or humbly following expert and even pastoral advice for social distancing and masking, is somehow a betrayal of Christian values; even when failing to do so is potentially dangerous for those we name as brothers and sisters and claim to love. We are commanded in Matthew 10:16 to be as wise as serpents and as harmless as doves, and seldom has the interrelationship between these two concepts been as obvious as during a viral pandemic, when our ability to be do no harm to those around us is predicated so strongly on the amount of wisdom we practice, and the amount of wisdom we are willing to receive from experts. Attending your local church in-person, and particularly indoors, when you are ill, under quarantine, or have other reasons to believe you might be at risk of transmitting the virus is as unwise and harmful as it is unloving.

5. I’m not going to make my experience normative.

We’ve talked already about all of the privileges I personally have facing this illness. Except for my age and a minor medical problem or two, it would be hard for me to be at lower risk from this virus. And even though I can’t perfectly predict what will happen, statistically I’m probably going to be fine.

And that’s great, but it does leave me open to a big temptation that I have seen so many people fall into; taking the anecdotal experience of one or a handful of people and using it to dismiss the suffering of millions, including 290,000 of our neighbors who have died in the last 10 months. After each warning, each exhortation to take action now to prevent more disease and death, you will inevitably see someone comment “I had COVID and I was fine.” And we are glad for that, but me or you feeling well and having a mild course of illness says absolutely nothing about the experiences of others. Even deeper than the flawed logic at play here and the willful disbelief and disregard of physicians, nurses, EMS workers, respiratory therapists, and all the others who have shared their own and their patients’ experiences with this crisis, this view betrays a deeply seated arrogance; believing that our own personal experiences are somehow more real than the suffering of our fellow human beings, or the grief of their loved ones.


5 things I am going to do.

1. I am going to take precautions in my own home.

The very first question I get from almost every parent when they are diagnosed with or even tested for COVID-19 is, “what about my children.” I’ve had the opportunity to talk with hundreds of patients about what is an extremely personal and complex decision; how much to isolate and distance from their own children if they have the virus. Thankfully, this conversation gets to start off with one piece of very reassuring data; while children have become very ill and died from this virus, it has been rare, and children and adolescents seem to be the people in our society least likely to experience a severe course of COVID-19.

Nevertheless, the risk is not negligible and it should not be ignored. The degree of caution each of us needs to follow in our own homes when diagnosed with COVID-19 depends on many factors; the ages and developmental ages of our children, how much they depend on us for their daily needs, their individual personalities and the ways they experience love and closeness, the available space in our homes, and the amount of support we have, among others. I have a lot of privilege in a lot of these areas, particularly in having a spouse who takes care of everything with the kids by herself for 50+ hours a week at baseline. If we chose to go the route of many doctors and other healthcare workers early in the pandemic and I moved out for 2 weeks, she would make sure that they didn’t lack for anything except actual time spent with their father.

We have decided not to go this route. Instead, we’ve taken these precautions:

  • I am wearing a mask when I’m in close proximity to my family.
  • I am washing my hands obsessively.
  • I am not letting anyone drink after me (if you have kids, you know exactly how difficult that can be).
  • I am not kissing anybody (if you have kids, you know exactly how difficult that can be).
  • I am not preparing food (much to everyone’s relief).
  • They are strictly quarantining; groceries delivered, no visitors, no birthday parties, no trips to the store or quick stops for coffee.

These decisions become even more challenging when you are caring not for a healthy child, but for an aged parent or a chronically ill or immunocompromised loved one. Again, these are difficult decisions, and we each have to decide for our own families what is the right balance between the need to protect them from the virus and their need to be near us and receive our love, affection, and care in person.

2. I am going to keep fighting for my patients.

Most (though not all) of the misinformation I write about here on the blog contains at least a nugget of truth. Those who have said for the past 10 months that the measures we have adopted to fight the virus are worse than the virus itself couldn’t be more wrong; but they are right about the added dangers of interruptions to care, decreased access, and postponing medical visits, which have all been secondary effects of the pandemic. We’ve been working hard for months (and in the early days of the pandemic were literally working around the clock) to make sure our patients could still get the access to care they need. Even so, it continues to be a struggle.

Having your primary care physician out for 10 days, isolating due to COVID-19, is a huge barrier to care; and it would be even if we had primary care doctors to spare, which we definitely don’t. There are some services or interventions I provide that only a handful of our doctors are trained to, and there are patients whose situations and histories I know all the details of, and even with good medical documentation it would take another clinician a lot of additional work to be brought up to speed with them. There are also patients who simply prefer their doctor and are slow to seek help or accept guidance from any other, which says very little about me personally as a physician but an awful lot about the inestimable value of carefully built, mutual trust and respect at the core of the doctor-patient relationship.

So I’m doing what every other doctor I know does when they are sick: in between naps and bowls of chicken noodle soup, I’m making myself a nice hot cup of tea and logging onto our computer system remotely, responding to telephone calls, refilling medications, and following up on lab results, all trying to make sure my patients have access to equitable care and that the interruptions in that care because of my illness are as few, and as mitigated, as possible. I realize that sounds super braggy, but that’s not my point at all. My efforts are hardly heroic (I once watched a pregnant 2nd year resident in charge of the OB unit receive IV fluids for her hyperemesis gravidarum in between helping other women deliver their babies. I’ve got nothing on that); but I think it’s important that anyone reading this knows how deeply their doctor cares about them and how hard they are working on your behalf, even when you can’t see it.

3. I am going to notify my close contacts.

Done. Unless those close contacts don’t read this blog, of course, in which case they are on their own.

Actually, I’m incredibly thankful that I don’t have anyone to notify. I’ve alerted my teams both at my usual clinic and at our COVID-19 outdoor clinic, since we work together every day. We wear our PPE continuously in clinic, are seldom within 6 feet of each other and never for prolonged periods, and if we have lunch it’s outdoors and very physically distanced; I actually don’t count as a close contact for anyone I work with. We are watching my children and wife for symptoms, and have notified a few people that she has been around out of an abundance of caution even though they also don’t count as ‘close contacts’ by the CDC guidelines. Other than that we don’t have any phone calls to make. It’s a good feeling and I highly recommend it.

4. I am going to finally replace the HVAC ductwork under the house.

Not COVID-19 related, but I’ve been promising to get it done for weeks. Check back with me after isolation and I’ll let you know how it went. #fakenews #misinformation

Sexist. Passive Agressive. Accurate.

5. I am going to makes plans in case things go bad, and go to the hospital if my symptoms get severe.

I know this is a two parter, but it’s short and I really wanted to keep the symmetry of ‘5 things I won’t do/5 things I will do’. Back in March when videos began to circulate from overwhelmed hospitals in Italy and France and Katie and I first began to grasp the gravity of the situation, we made a few arrangements. We knew I would be on the front lines one way or another. I made sure she had all of the account numbers for retirement accounts (she handles most of our finances anyway, so bank accounts weren’t an issue), the password to access my life insurance policy, etc. We talked carefully about those non-transferable medical school loans that would be discharged in the event of my death, and about being on guard against predatory offers to “refinance” loans which should, in fact, simply disappear. We talked about burial arrangements and funeral wishes, and how we would want to be remembered to our four young children if we passed. I gave her my list of top 10 guys she was allowed to marry after an appropriate mourning period. We finally got around to making a will.

My wife’s search history shortly after this sobering conversation.
(this joke included over strenuous objection and my own better judgement)

I also made e-mail addresses for each of our kids for when they are older, and began to send them the occasional note or letter, letting them know just how much I love them and delight in seeing who they are now and the wonderful people they are becoming.

Now that I actually have the virus, we are revisiting these items, I am writing to my kids again, and we are making sure everything legal and financial is hammered out just in case.

The fact is that we expect me to be fine, but we’d be extremely foolish not to take this illness seriously; many younger and healthier people than me have died from it already. I’ve been giving people guidance about what to watch for at home for almost a year now; chest pain, significant shortness of breath, confusion or altered mental status, severe fatigue and malaise, low oxygen levels (we’ve reclaimed my pulse oximeter from our 3 year old’s Doc McStuffins doctor bag), or any acute worsening in overall status. For once in my life as a doctor I’m going to follow my own advice and treat my health seriously, and I’ll be heading in to the ER for further evaluation if I experience any of these symptoms.


Final Thoughts

Doctors and nurses know they are going to get sick; it’s practically in the job description. We have the incredible privilege of taking care of people on some of their best and some of their worst days, but that also means continuously getting coughed or sneezed on, being exposed to contagious illnesses, and occasionally, despite our best efforts, being exposed to a blood-borne pathogen. When it’s a known entity we are familiar with and have been fighting for years, the uncertainty following those experiences is less hard to bear; and honestly after 10 months of this pandemic, having COVID-19 doesn’t feel much different than any of those other old enemies, even if the ‘what if’ factor is a little higher.

I know this post will be met with sympathy, and I truly appreciate everyone’s thoughts and prayers; but I hope the main take away for anyone who reads this rather long-winded announcement of my illness is that what we are doing to care for our patients and asking of each and every person we diagnose with this terrible virus are the very same things we ask for, and demand of, ourselves. If you or a loved one gets diagnosed, I hope you will have symptoms as mild as the ones I am currently having- a little fatigue, a little cough and sore throat, a few chills- hopefully even milder, or none at all. But I also hope you will be just as cautious as we are trying to be; taking the risk of transmission very seriously, communicating with those whom you might have unintentionally exposed, and respecting isolation for you and quarantine for your close contacts as a measure that can absolutely save many, many lives. I hope you are not afraid, and I hope you have all the information and support you need from friends, neighbors, and especially your local doctor.

And to the 300,000 people in this country who have died of this awful virus, the tens or hundreds of millions who have lost loved ones, family, and friends to it, and the 15 million others who have suffered from it physically to one degree or another, I am incredibly grateful to have had the chance to fight it with you and to walk through it alongside so many of you, and wouldn’t change any of that just because of this admittedly mild illness I have now; whether it gets worse in the coming days or not. I’m looking forward to doing it again, as soon as I meet the CDC criteria to do so.

-TJ Webb, Patient

“Why Don’t Doctors…?”

A friend re-posted this meme and the list of questions below recently, and I want to clarify at the outset that they were interested in a response from their friends in the medical field, not trying to perpetuate the misinformation, nonsense, and deliberate misrepresentations the original author is promoting. While it takes only a sentence or two to ask a nonsensical or disingenuous question or blast some ridiculous health misinformation, a careful and satisfactory answer will probably take a bit longer. Because of this, I’ve decided to tackle these one question at a time over the next few weeks, and will update this blog post with my responses as I go.


One last preliminary; we should recognize two things about the comic above, besides the fact that it’s pretty standard COVID-19 misinformation (“ooh they want you to wear a mask but nobody will tell you to be healthy! No medical expert has ever recommended people exercise before!”). First, it has pretty much nothing to do with the rest of the post. Second, it’s a riff off of the comic below from Mike Baldwin, author of the Cornered single-panel newspaper comic.

Mr. Baldwin is an apolitical cartoonist, and I can’t find anything in his writings that would give me the impression he would endorse this list of complaints about doctors; but of course I can’t find anything to disprove it either. There is one comic where a doctor had removed someone’s entire intestine because his “stomach was all tied up in knots,” so take from that what you will. Still, if the original author is going to start this whole thing off with a stolen and poorly revised comic strip, best to give some credit to the actual cartoonist (whose original comic was more poignant anyway).


We Have Questions”


12/6/2020: Why don’t doctors tell you to take magnesium instead of stool softeners (which dehydrates the bowel)?

Before I even dive into these, I have the definite sense that the number of “Wait, What?!” moments I encounter in responding to this post is going to be extremely high. In fact, with just a cursory glance at this long list of “questions,” I’m really not sure whether the “Wait, What?!’s” are going to outnumber the “Um… We Do’s”. I think I’ll keep score. 

This post is a good example of both. 

Um… We Do
First, let’s be clear what they mean when they say ‘why don’t doctors tell you to take magnesium?’ Surely they mean a laxative compound like Magnesium Citrate or Magnesium Oxide, the active ingredient in Milk of Magnesia. These are commonly used over-the-counter laxatives, and I think we can give the benefit of the doubt that the original author is not here advocating for anything like high doses of magnesium salts like Mag Gluconate or Mag Chloride, typically used to treat magnesium deficiency, as a first line treatment for constipation. Your kidneys will thank you if you don’t overdose on magnesium supplements.

And assuming that this is indeed the form of magnesium they are discussing for constipation, of course we recommend this to patients- when it is indicated. When a patient comes to me with complaints of constipation, the first thing I do is listen to the history of their constipation, including what they’ve already tried for it and whether it was helpful. This helps me both to diagnose whether their constipation is actually due to an underlying medical condition that will need additional work-up, and to make sure that I am not recommending treatment options that they have already tried and found to be ineffective. In general, here are my recommendations for constipation, and usually in this order:

  • Increased water intake, increased exercise and walking, dietary changes. 
  • Increased dietary fiber, including either food sources or fiber supplementation. 
  • Stool softeners including colace, which are more gentle than laxatives but generally less effective.
  • Laxatives, ranging from dietary options that include sorbitol (prunes and prune juices) to polyethylene glycol and milk of magnesia or mag citrate. 
  • Combination stool-softener/pro-motility agents like sennosides.
  • Finally rectal suppositories and enemas, not because they are a worse option than the others but because the patient will pretty much only try these if they have already tried everything else and are now truly desperate. 

Because my patients’ time is valuable and I trust them to make good healthcare choices with appropriate advice, we usually briefly discuss the risks and benefits, potential side effects, and stepwise strategy for all of these types of agents; I don’t tell them to drink more water and do some lunges and see me in two weeks if they still haven’t pooped. So it’s fair to say that while Milk of Magnesia or Mag Citrate are not by any means my go-to medications for constipation, I do talk about it as an option with patients very regularly (ha, ‘regularly’. Get it?) If these medications are both readily available OTC medications that you can buy at your local pharmacy and are commonly discussed with patients, why did the OP decide to focus in on it as the one hidden, secret treatment for constipation that doctors won’t tell you about? I don’t really know, but probably because it sounds more natural to invoke an element like ‘magnesium’ than “Sodium 1,4-bis(2-ethylhexoxy)-1,4-dioxobutane-2-sulfonate”… Though I usually shorten this to ‘docusate’ and in fact (in the spirit of full disclosure) had to google that chemical formula (obviously). And in the alternative health world, unfortunately, sounding natural and crunchy is too often more important than the actual efficacy, side effect profile, and safety of the treatments being recommended. One should ask, why didn’t the author complain that doctors recommend magnesium laxatives and stool softeners instead of increased water intake and yoga, both of which have been proven to help with constipation?

Wait, What?!
Before we move on, we should also address this “dehydrates the bowel” aspect of the post. Because of the beautiful and very intricate fluid homeostasis the body maintains, there’s really no such thing as ‘gut dehydration’ outside of two situations; total body dehydration, which is of course associated with constipation but also a whole host of temporary and potentially chronic problems resulting from poor blood flow and oxygen delivery to vital organs; and medical conditions that result in dysfunction of the normal transport of fluid and ions into the intestinal lumen, such as in Cystic Fibrosis where deficiency and dysfunction of the cystic fibrosis transmembrane conductance regulator (CFTR) protein results in decreased free fluid (and bicarbonate) in the gut and thus accumulation and alteration of intestinal mucous and eventual obstruction. So what are they talking about here?

As best I can tell, they must be referring to the fact that some medications commonly used for constipation work by drawing free fluid into the lumen of the gut from the intracellular space by changing the osmotic gradient of the intestines. While it’s true that this could lead to total body dehydration if the fluid is not replaced with oral hydration, most people who are taking medications for constipation (and all that are following their doctor’s advice and don’t have contraindications) will be increasing their fluid intake as well. The more likely risk is diarrhea, abdominal cramping, and bloating. Which medications do this? The ones that contain magnesium, among others. But not all agents work that way; some actually work by increasing the peristalsis of the intestines (similar to how exercise helps constipation), while others help the thickened, firm stool mix better with the free fluid and fats that are already in the intestinal lumen, which is exactly what that fluid is there for in the first place. Here’s a handy chart so you can see how each of these agents works:

So if you are going to complain that anything that mixes stool and fluid together in order to ease bowel movements “dehydrates the guts,” you are going to be complaining about some of the gentlest, safest, and most natural approaches to constipation, including things like upping your fiber intake and cooking with olive oil. If you wanted to go the pulling-fluid-into-the-intestinal-lumen-through-osmotic-changes route, you could definitely go with the magnesium citrate or the magnesium hydroxide the original author is talking about; but let’s not pretend like they are the crunchiest or most natural options available when you had to walk past all of those sorbitol rich prunes, pears, and apricots in the produce section on your way to the pharmacy to buy them.

Um… We Do: 1
Wait, What?!: 1


Why don’t doctors tell you to change your diet when you have heart burn and indigestion instead of you taking Prilosec (which causes more heartburn, colon cancer, osteoporosis and leaves food fermenting in your body)?


Why don’t doctors tell you that HERBS heal? That FOOD heals? 


Why don’t doctors teach you how to lower toxic chemicals in your home when you have constant headaches and allergies? Fragrances and chemicals cause toxic buildup in our cells and can cause more allergies and headaches!


Why aren’t you informed by your doctor that if you eat a grapefruit everyday, it will lower your blood pressure naturally and you don’t need (pills)(this is why a person can’t eat it while on blood pressure meds)?


Why doesn’t your doctor tell you to take activated charcoal for headaches, bloating/gas, skin issues, colds, the flu, food poisoning (activated charcoal bonds waste and toxins and safely removes them from the body)?


Why don’t doctors tell you about herbs and herbal teas to support immune and digestive functions (different herbs help different organs do their jobs to keep the body healthy)?


Why isn’t your doctor suggesting that you take a probiotic daily (this boosts immune function, helps clean and balance the bowel, helps regulate absorption and elimination, and keeps colds and allergies at bay)?


Why don’t doctors teach the value of breastfeeding instead of telling you to use formula instead? Breastmilk is a baby’s very first defense in health outside of the womb! It adapts to what a child needs at each individual feeding, and is THE MOST powerful thing that builds and supports an immune system in a baby. 


Why doesn’t your doctor provide you with any in depth information or package inserts for your vaccines before injecting yourself or your child (they don’t disclose that there are aborted fetal cells, cow cells, African monkey cells and dog cells, along with many other adjuvants like mercury and aluminum and formaldehyde…. none of which are beneficial to the body)?


Why don’t doctors teach you that you store negative emotions in your physical body which can cause you physical pain and sickness, instead of saying you need a (pill) 

(emotions play a very significant roll in our total health, without tools to help navigate our emotions, we can easily become ill)? 


Why don’t doctors tell you when they take a whole organ from your body, that you’re still going to suffer, you just will suffer in a new way (organs are all useful, we need them for many reasons, and most organs can be healed completely without removing anything)?


Why do they set up protocols for prescriptions that most of them wouldn’t even take themselves? 


Why don’t doctors take a real role in helping people live better lives?


So do I need to Quarantine for 7 days, 10 days, or 14 days?

This is a short post because, frankly, I don’t have time to write it (clinic all day, D&D with the kids tonight). Those of you hoping for another 7,000 word in-depth discussion (read: nobody) will have to settle for just 3,000 or so today. Nevertheless, I want to start with a digression and show you this chart I use in my clinic:

This chart is for my diabetic patients who have a very particular treatment regimen; they are taking both a long-acting basal insulin once or twice daily, and they are taking a short or rapid acting insulin before each meal. Because of this, we need some blood sugar numbers; we need to know their fasting blood sugar in the morning so we can adjust their basal insulin, and we need to know their numbers 2 hours after breakfast, lunch, and dinner so we can adjust their meal coverage with the short acting insulin. They are not taking insulin on a sliding scale; those patients will need to check before meals in order to take the appropriate dose.

Now, I work extremely hard to empower my patients to adjust their insulin on their own, and a lot of our visit time is focused on teaching them about the various insulin length of action times, the logic behind basal/bolus insulin dosing, and especially what numbers to look for that should trigger them to increase or decrease their dose. But it’s challenging, and as much as I love it when a patient is on ‘auto-pilot’ with their insulin, we still do a lot of adjusting in clinic, which is where these charts come in. Fasting blood sugar high? We’ll go up on your long-acting Lantus insulin. Taking 5 units of novolog before every meal but the after-lunch numbers are still super-high? We can go up on your pre-lunch and keep the pre-breakfast and pre-dinner numbers the same. You get the idea.

So that’s the glucose log I print for my patients. Now let me show the one I actually hand to them:

You see, like all doctors my approach to any medical problem represents a balance between what my medical training tells me is the best possible treatment plan and the actual, lived experiences of my patients. Some of my patients will check their blood sugar 4 times a day, every day (some of them even if they don’t strictly need to; they just really, really like to know). But I don’t think I could manage to do that, and so I don’t ‘demand’ it of my patients. The reality is, we could get almost all the information that the patient and I need by checking their blood sugar half that much; fasting every day, then checking after a different meal each day. And most of my patients are much, much more likely to follow through with checking twice a day than four times a day (as I certainly would be).

What does this have to do with the quarantine recommendations for COVID-19? Everything, because both the CDC’s new guidelines and my approach to blood sugar logging for my diabetic patients are based on an essential mediator of medical outcomes: Health Behavior.


Where did the original 14 day guidelines come from?

The CDC began to recommend a 14-day quarantine for international travelers coming to the US as early as February, and the same for any household and close contacts of COVID-19 positive persons shortly thereafter. This was based on the incubation period of the virus; the range of time it typically takes an exposed person who becomes infected to develop symptoms. Initially this relied on the already known incubation periods of similar novel Coronaviruses, SARS and MERS, from epidemiology studies that were done following those epidemics in 2003 and 2012. As the COVID-19 pandemic progressed, studies began to emerge which showed similar incubation periods for the SARS-CoV-2 virus as well. A study from The Netherlands in February found the incubation period to be between 2 to 11 days based on a small number of patients in Wuhan, China; very similar to SARS and especially MERS. This was supported by multiple other studies that all showed an apparent incubation period somewhere in the range of 2-12 days.

This begs the question, “if most studies showed the incubation period to end at 10 to 12 days, why were we all told to quarantine for 14 days?” And this is where health behavior comes in. The first (and least important) reason, I think, is because 14 days is just a lot easier to remember. “Your last exposure was last Wednesday, so you can be done with Quarantine after next Wednesday” is easier to remember than 11 days or 12 days because we naturally think in weeks anyway. But much more importantly, the novel Coronavirus was novel and recommendations needed to be made based on very limited evidence. The two studies above had sample sizes of 88 and 158 respectively; enough to be going on with, but not nearly enough to be really confident. Those studies consistently showed that though we thought the average incubation period would be 5-6 days, there was still a possibility that once we had more data it would end up being much longer; and there was a very good chance that even if the average incubation period stayed less than a week, some people would still be contagious for much longer, maybe even greater than 2 weeks. With a virus this contagious, ignoring that uncertainty could be very, very dangerous.

Hence the recommendation to be released from quarantine only once you have been asymptomatic for 14 days since your last exposure; it was easy to remember, it was very likely, based on early evidence, to cover the vast majority of cases (although it does absolutely nothing for fully asymptomatic cases, of course), and it was unlikely to be expanded based on new evidence.

That last bit is really important, because even though epidemiologists, physicians, and other scientists know that it’s exactly how science is supposed to work, we’ve all seen how suspiciously our society looks on any changes in recommendations based on new evidence. If the CDC started with 14 days of quarantine and later decreased it to 12, some people would be a bit irritated and probably lose some confidence in them (we’ve seen this time and time again; the undeserved “they keep changing the guidelines!” and “They don’t know what they’re doing!”), but overall it would be a welcomed change. But if they had started with say 9 days and then, based on new evidence, expanded it to 16 days, how would that have gone down? It would have been pandemonium.

So they picked a timeframe that was 1. Supported by the data available and 2. Unlikely to be expanded later based on new data. But there was still a problem, and it was this: Health Behavior.

14 days of quarantine is hard. It’s hard psychologically, it’s hard physically, and it’s hard economically. I see COVID-19 positive and COVID-19 exposed patients every day and I have to tell you, I feel terrible every single time I have to recommend a 14 day quarantine to someone. I see the irritation or frustration or even despair as they try to figure out what plans they have to cancel, what friends and family they will have to miss, and how they are possibly going to make ends meet if they can’t work for that long. The results of quarantine so often touted by the anti-quarantine, COVID-19 is a hoax folks, like increased depression and anxiety, are real. No one ever denied this, it’s just that the pandemic is not a hoax and has, as of today, killed 1.5 million people worldwide and 271,000 in the US.

And because it’s hard, every single one of us knows somebody who didn’t quarantine when they were supposed to. Unsurprisingly, that’s one of the main factors I see at play in my outdoor COVID-19 clinic visits; people were exposed to friends or family who had not reached the end of their quarantine period but decided that enough time had passed that they wouldn’t be at risk of spreading the virus. Based on what? Gut feeling, mostly; and also reaching the point where their desire for experiences or people or options precluded by quarantine was simply greater than their will to continue quarantine. For most of us, that point will probably come sometime before those 14 days are up. I even know of doctors who couldn’t make it to 14 days, and drawing on exactly none of there clinical training or basic sciences knowledge decided that they must have ‘dodged a bullet’ when they remained asymptomatic less than a week from their exposure, and resumed life as normal. Who am I to judge. I’m a strong extrovert and even general social distancing has been hard enough on me; there but by the grace of God go I.

And sometimes the guidelines, while valid, seem nearly impossible to comply with. For instance, I have friends who diligently completed their ongoing household contact quarantine guidelines, which begin on the day the COVID-19 positive patient is diagnosed and end 14 days after that person’s 10-day isolation period. That’s 24 days total for their household contacts.

This is no small problem; studies from previous epidemics requiring self-quarantine measures have found incredibly variable rates of adherence, and often south of 50%. In many ways America was a set-up for poor compliance to these guidelines; highly individualistic culture, a pandemic occurring in the most contentious election year in recent memory, massive campaigns (organized and unorganized) of misinformation about the virus, and with no clear messaging or leadership on a national level. Those last two points are crucial, because the strongest predictor for adherence is not cultural or socio-economic factors, or even fear of the virus; it’s how knowledgeable people are about the virus and the way it spreads, and how well they understand the quarantine guidelines. Which is, uh, why folks like me are doing this sort of thing.


12/2/20: The CDC will update quarantine guidelines.

Which brings us to today, and the new quarantine options from the CDC, which are these:

Following close contact or exposure to COVID-19, an individual may self-quarantine for:

  • 10 days, as long as they remain asymptomatic,
    or
  • 7 days, as long as they remain asymptomatic and have a negative COVID-19 test.

Why were these changes made? Because they were wrong back in February? Because the election is over (finally)? Not at all. There are two possible reasons: either because enough new evidence has emerged to convince the epidemiologists at the CDC that these timeframes are as safe and effective as the original 14-day recommendations, or because they are convinced that enough people will actually follow through with these less extreme guidelines that there will still be a net decrease in transmission.

Let’s look at the first one. There have been nearly 14 million cases in the US since February and over 64 million world wide; even without access to complete information of each of these individuals and their exposures to COVID-19, we should be able to muster more than the 88 cases that first study was based on. Have all of the newer, more robust analyses of this data changed the picture of COVID-19 incubation so drastically that the CDC was forced to update their guidelines?

Answer: Not really.
It’s important to note that when the CDC did finally release the updated guidelines late in the night, they clarified that the new guidelines were alternative options to the 14-day quarantine, which was still their strongest recommendation. I believe this is supported by the evidence.

Just like there was nothing magical about day 14 that caused the virus to go, “all righty I guess we’re done here, pack ‘er up boys!” back in March, there’s nothing magical about day 10 or day 7 now. A systematic review and meta-analysis of all the then available estimates of the COVID-19 incubation period, first published in The British Journal of Medicine in August, found an average (mean) incubation period of 5 to 7 days, and 95th percentile estimate between 10 and 14 days…. Remarkably similar to the earlier estimates. The figure below is from that paper and reflects the distribution in all of the studies they could get their hands on. Notice how there isn’t a steep drop off at day 10; in fact, the range of the possible incubation period stretches all the way out to about 3 weeks. Unlike the early observational studies, this meta-analysis involved multiple studies with hundreds of cases each, though that original data was still from early on in the pandemic.

Another meta-analysis from later in the year, first published in October in the online journal Current Therapeutic Research, included 18 studies representing 22,595 participants. That’s a lot more than 88. What did they find? The average incubation period was about 6 days. This paper was advocating for a much shorter quarantine, along with testing, similar to the new ‘7 days with a negative test’ recommendation from the CDC; tellingly, however, it only included analysis of the mean incubation period, not the range of incubation from those studies; it doesn’t address the impact of all of those cases that would cease quarantine on day 7 but become symptomatic within the next few days.

Finally, a relatively small but thoroughly analyzed study from Singapore including 164 cases from January to April and published in the journal Epidemiology and Infection in September shows some cases with an incubation period definitively longer than the 10 day mark set by the CDC, though they were relatively small in number. It also found that the incubation period does seem to be positively correlated with age, with the longest incubation periods among those in their 70’s and older.

To summarize, unless there is some big study that the CDC has access to and I can’t seem to find (and please send it to me if there is, so I can take this post down and not look like an idiot), the current evidence has not revised the known incubation period of COVID-19.

You can still develop COVID-19 symptoms
more than 10 days after your exposure.


Q: So why the change?
A: Health Behavior

So if the CDC isn’t changing the quarantine guidelines because of some scientific breakthrough that has utterly overturned our understanding of the virus’s incubation period or the way it is transmitted, why make the change at all? Because the 14-day quarantine guidelines aren’t working; not because quarantine doesn’t work, but because people won’t do it. They are banking on the idea that enough people will be willing to comply with a less aggressive quarantine period that still covers the vast majority of cases (compared to a longer quarantine that very few people were willing to follow) to make up for the relatively few cases whose incubation period would have been longer.

I don’t know if they are right or not. Something’s gotta give, so I really hope they are. But overall I actually kind of like this new recommendation because it has the potential to change the behavior of one group of people that has probably been contributing to the pandemic numbers as much as anyone else; asymptomatic COVID-19 carriers who aren’t following quarantine at all. The biggest weakness with the 14-day quarantine was that there was no fail-safe built in for the people who just weren’t willing to quarantine. They might stay home from work or school for 14 days because they had to, but would use some of that time to shop, have parties, or engage in other activities that had a high likelihood of transmitting the virus. I don’t mean to imply it was all from selfish motivations; some people with much less natural laziness than myself probably just couldn’t cope with 14-days off, and have probably been using their quarantine to help others and do good deeds around the neighborhood, or volunteer more at their local church or community center. Good things in themselves, but still very, very dangerous when you have been exposed to a deadly and highly contagious virus. And like I said before, many others very understandably don’t have the margin to be out of work for that amount of time. The new guidelines are helpful because for people very motivated to stop quarantine after day 7, a test for COVID-19 now greatly increases the chances that we’ll catch their infection and modify behaviors that lead to transmission. Even if they weren’t following quarantine before that day 7 test, they might follow isolation guidelines if it’s positive.

We know that asymptomatic and pre-symptomatic people can still spread COVID-19, but asymptomatic testing has always been a double-edged sword. Very wide scale asymptomatic testing would be one of the best possible ways to catch and isolate cases early and really modify the course of the pandemic, and asymptomatic testing targeting people in essential services, like nursing home nurses and doctors, is the best way to prevent pre-symptomatic transmission among some of our most vulnerable populations. But in both of these situations, the test result always leads to either a neutral or a safer set of decisions; if asymptomatic people test positive, they isolate, while negative people continue their standard level of caution. If a nurse or doctor tests positive, she calls in; if negative, she continues to work.

But testing of asymptomatic people who have been exposed and are still under quarantine is completely different, because the test result now has two drastically diverging branches; not safer and neutral, but safer and less safe. If an exposed person does test positive, it is much easier for them to feel the weight of their responsibility to keep those around them safe from it; I’m sure anybody reading this who has tested positive remembers the moment they received that news, and remembers how real the need to isolate suddenly felt. But since they are already under quarantine, there is a very real chance that a negative test will give many people a false sense of security without actually guaranteeing that they won’t become contagious, and instead of continuing with the same degree of caution they are most likely to exercise far less. There are a hundred different cartoons online right now demonstrating this concept. I like this one because it feels like the person who wrote it really has a vendetta against somebody named Casey.

This is the reason my COVID-19 clinic has shied away from broadly testing asymptomatic close contacts; the value of that test can be a big positive or a big negative, and it entirely depends on what the person plans to do with that information. If they plan to quarantine well regardless of a negative and only want to know so they can alert their close contacts, that’s terrific; but I’ve talked with lots of people, patients of mine and otherwise, and even some healthcare workers, who were under quarantine due to close contact and planned to get tested so that they could go ahead and travel, throw a party, or go back to work early. A negative test, within the incubation period, cannot definitively make these actions safe, and depending on when in the incubation period, might be no help at all. That’s why I carefully counsel every patient about what to do with their test results, symptomatic or not, based on their clinical history. I’m not opposed to asymptomatic testing for exposed individuals; it just has to be accompanied by a very careful discussion of what the test can and can’t be used for.

With all of that in mind, if you are going to do asymptomatic testing for exposed close contacts, 7 days seems like a fair point to test. Again, it’s easy to remember; ‘1 week of quarantine and then get tested’. But more importantly, it’s past the mean incubation period; a test on day 7 covers the incubation period for most people who remain asymptomatic, and has a good chance of catching any pre-symptomatic patients with an incubation period up to day 8 or 9. Between that and of course testing the folks that do have symptoms as soon as they get them, that covers most people. And if that negative test does give a little false sense of security, it’s at a point in the timeline of their exposure where lots of folks are feeling ready to throw caution to the wind anyway.

It’s not perfect, but I wouldn’t call the new quarantine guidelines ‘misinformation’ either. It’s a calculated risk based on the expected health behavior of a population who is absolutely exhausted with this pandemic. I hope it pays off.


So… What do I do then?

Adherence to quarantine is highest when people really have a firm understanding of the quarantine guidelines and the rationale behind them. The rationale behind this decision is that more people will comply with less extreme quarantine guidelines that are still, for the most part, safe. But it doesn’t mean I’ll be counseling my patients differently; I still want them to know that they could become contagious for a few days after that day 10, and that the negative test on day 7 is not a 100% guarantee. I want them to understand the incubation period of the virus and the extra caution they still need to take for those several days after their quarantine is technically over. When I’m writing school and work notes, if their quarantine period under the new guidelines has them going back on a Friday, we are going to push that back (with the patient’s permission) to Monday. When they test negative on day 7, I want them to know that they should still come back and get re-tested if they develop symptoms on day 11 or 12.

And that’s the advice I’m offering to you now. If you have a close contact and need to quarantine, try to make it to at least day 12, if not day 14, before releasing yourself if at all possible; or get tested on day 8 or 9 instead of day 7 if you can. Advocate for those around you by fighting for your right to ere on the side of caution, recognizing that the current guidelines are a compromise with the expected health behaviors of our society. A timely and hopefully effective compromise, but a compromise nonetheless. And just as you wouldn’t act like Casey and use a negative test on day 5 as an excuse to cast aside all precautions, so a negative test on day 7 should be treated as reassuring, but not foolproof.

But as for me and my house, we will quarantine for 14 days.

Nobody wants to ruin your Holidays

As the pandemic has escalated over the past several months and almost all of us who had been previously unaffected have now had friends, family members, or other people we care deeply about either pass away or at least become very, very ill from the virus, I’ve noticed a trend in the misinformation that we accept, share, and believe. The nature of a global pandemic is that it robs us of our delusions, and we are now many months out from being able to believe what was commonly said in March and April, that the pandemic is not coming, and that even if it does come it is not deadly. The landscape has shifted, and until more conspiracy theories crop up about vaccines or possible outpatient treatments in the coming weeks and months, the misinformation has settled back into the realm where it is most resilient; into the question of motives. It doesn’t matter what actually happens with medications, vaccines, case numbers, and death rates; believing that the people trying to help you are actually trying to control you is always fair game.

Hmm… Gandalf is pretty sus.

In about a week we are going to see the merger of COVID-19 misinformation and the ever-popular “War on Christmas” conspiracy which annually reminds us that dark forces are at work in the world to destroy my favorite holiday and everything it stands for. But until then, Thanksgiving is the target apparent of the powers that be.

Full disclosure, I’ve waged a small private war against Thanksgiving for years, and it has nothing to do with how many people are gathered. My concern is with the way we celebrate and especially teach children about the history of Thanksgiving and the way we sterilize the history of Native America-European settler relations. I also have some concerns, as the doctor to many patients with diabetes and CHF, about the lack of nuance in our culture’s understanding of feasting, and typically resolve this by telling my patients not to check their fasting blood sugar on Black Friday (unless they take correction dose sliding-scale insulin, of course). For me, it’s the most hypocritical holiday of all, because while I caution moderation to my patients I know I will probably fail to practice it myself. Because you see, despite all of my concerns about Thanksgiving as a holiday, I also love turkey and dressing, pumpkin pie, and most importantly (as any true Southerner will tell you) green bean casserole, macaroni and cheese, mashed potatoes and brown gravy (I’ll lose readers over that), and a sweet potato and marshmallow dessert we have hilariously convinced ourselves is a side dish instead of a hedonistic excess and probable harbinger of the end times.

(I also like seeing my family and stuff.)

So the togetherness and joy of the thanksgiving holiday is something I’m loath to give up for any reason, and I would be lying if I told you that I knew all along that we would opt for a small family Thanksgiving day in our own home, or that I immediately made that decision after reviewing the trends in COVID-19 numbers or even after reading Dr. Emily Smith’s excellent, excellent review of the relevant epidemiology facts. We earnestly struggled with it. And as we weighed the medical risks of our extended family members against my daily interaction to COVID-19 positive patients and my wife’s recent exposure to the virus, I could taste the potato casserole fading from my future as we made the difficult call and informed very disappointed (but understanding and supportive) family.

Fine, but when I say “Cancel Columbus Day” I definitely mean it.

And I’ve been counseling my patients to do likewise, just like many physicians, epidemiologists, and other health scientists around the country. And despite the suspicion and mistrust that a doctoral degree elicits these days, it has nothing to do with wanting to control my patients lives, training them for future subservience to the government, my crusade against the idea that our relationship with Native Americans was ever truly mutually respectful and supportive, or even the principle that misery loves company and if I don’t get to eat my grandma’s turkey dressing recipe on Thursday they shouldn’t either.

Instead, it’s because we are living today in the most dangerous window of the pandemic so far, and because there are characteristics of Holidays in general, and Thanksgiving in particular, that makes this week an incredibly dangerous one for our country.


3 Reasons that Thanksgiving is Dangerous.

1. Certain holidays are more dangerous than others.
Even allowing for difference of culture and family tradition, the innate characteristics of certain holidays make them more or less dangerous in terms of transmission of a respiratory virus. January 2nd, World Introvert Day, will probably be just fine; but the indoor concert you are planning for National Kazoo Day three weeks later on January 28th should be cancelled because that is a lot of aerosolized spittle in an enclosed space (it should be cancelled anyway regardless of COVID-19, but that’s not my point).

If we are going to discuss the characteristics of Thanksgiving, it would help to compare it to another widely celebrated holiday we’ve experienced during COVID-19, the 4th of July. As a reminder, here is a look at the numbers.

The two weeks after the 4th of July saw the largest spike in cases of COVID-19 we’ve experienced during the entire pandemic (except for the one we are in now). There’s a strong enough case to be made that the trajectory of that wave was already increasing prior to the holiday; but the public gatherings, parties, and beach trips dramatically contributed to the rise in cases, heightened the severity of that late-July peak, and appreciably altered the curve for the worse in places like Florida and California. In a moment we’ll compare some of the characteristics of these holidays, but that’s really splitting hairs; the biggest reason that Thanksgiving is dangerous is because COVID-19 transmission follows the principles of exponential growth; the more cases you start with going into a time of decreased caution like a holiday, the greater the impact it will have on the curve. We are already close to or above capacity in many hospitals around the country; even another 4th of July, with the numbers we have right now, would absolutely drown us. And there’s plenty of reasons innate to the holiday that make Thanksgiving much, much worse.

It’s true that the 4th of July has some characteristics that could make it more likely to result in spread of COVID-19 than Thanksgiving; mainly that it involved very large events that brought together people from very different spheres of contact. A few cases of COVID-19 could spread easily to multiple social circles and families from one big 4th of July party. But Thanksgiving has some characteristics that make it more dangerous too. First, unlike the 4th of July, most people celebrate Thanksgiving indoors; transmission is more likely indoors than outdoors, all things being equal. Second, contact tends to be prolonged; you aren’t just passing various people for a moment on the way to the beach or grabbing a beer, you are sitting face-to-face for hours while eating and visiting and (unless you are a good-for-nothing-in-the-kitchen family freeloader like me) cooking. If a contact at a 4th of July party has COVID-19, you may or may not have been exposed. If someone at Thanksgiving Dinner has COVID-19, everyone there is definitely an exposed close contact.

This is literally a picture of our Thanksgiving. Except for the 2nd one (I grew up Baptist).

Third, that issue of bringing people together from different spheres of contact is true for Thanksgiving just as much as for the 4th of July. Traveling for the holiday is one of the major things that public health experts are warning against, and even if you aren’t flying or driving across state lines, not everyone’s social circles really overlap much with their cousins’ or grandparents’. One family member who has had an exposure or hasn’t taken precautions in the weeks leading up to Thanksgiving runs the risk of infecting their entire family, and those family members bring their exposure back to the other members of their community. Finally, Thanksgiving brings people together who are not likely to socially distance from one another. It’s all well and good to say ‘we will eat outside and stay 6 feet apart’, but how many times has that actually happened when getting together with family you have been longing to see? There will be hugs, there will be boardgames, there will be long heartfelt conversations- or yelling matches about politics. Not to mention the decision of whether or not to finish off somebody else’s half eaten piece of pumpkin pie if nobody is looking, which is a difficult enough choice even under normal circumstances.

But we don’t have to just take my word for it or guess whether Thanksgiving will be as bad (or worse) as the 4th of July, because Canada has a Thanksgiving too, which they hold (ridiculously) on October 8th.

The Canadian numbers show a miniature warning of exactly what we would expect after a national holiday during a national uptick in cases; a steepening of the curve and a much larger number of new cases over the next month. The difference is that Canada has nowhere near the number of active cases or the amount of community transmission that we have; our increase is going to be much, much more dramatic.

2. Holidays bring together those who are at greatest risk with those who spread the virus best. 
We talked about the total lack of social distancing between relatives when they finally get together, and nobody is better at not socially distancing than children. If you think about the emotional value we all place on the holidays, probably one of the first images that comes to mind is the sight of your children running to their grandparents and covering them in hugs and kisses. It’s honestly one of my favorite moments each and every time it happens. It’s also a very, very dangerous situation if there’s any possibility those children have COVID-19. Children spread COVID-19 very easily; some studies have shown that children spread it even longer and more efficiently than even the sickest ICU patients. They spread it even when asymptomatic, and are asymptomatic at a higher rate than adults. They are also in school, and schools are full of other small gross people that spread COVID-19 efficiently, and those schools will not be closed for the holidays for any significant period of time prior to Thanksgiving.

And who are they hugging on? Almost certainly the people in your family who are at the highest risk if they do get exposed. We have been discussing the risk factors for severe COVID-19 infection, COVID-19 pneumonia and respiratory distress syndrome, and death on this blog since April and a lot of those factors haven’t changed; age, chronic lung disease, diabetes, heart disease, other chronic medical problems. But age is the first one, and the risk of someone dying from COVID-19 increases dramatically after age 50.

By bringing together the people in your family most likely to have been exposed to COVID-19 over the past few weeks (because of school) and most likely to spread it even when asymptomatic, and the people most likely to get seriously ill if they are indeed exposed to COVID-19, holiday gatherings with extended family really do present a dangerous situation for the most vulnerable members of our families.

I’ve had patients ask my advice on what to do about visiting grandparents and great-grandparents for Thanksgiving over the past few weeks. I hear their anguish, their indecision, their desire to celebrate with family fighting against their fear of spreading the virus to someone they love, and the deeper fear and guilt that they are making the wrong decision by choosing to miss out on those beautiful moments together. My recommendation? If you think that, barring some tragedy, the person you love has some good years of holiday celebrations left, it seems wise to sacrifice this one in order to safeguard all of the others. This pandemic won’t last forever.

3. It isn’t just COVID.
I’ve been reflecting on my very first efforts at writing about COVID-19 back in March, before I even started this blog. At that time the US had 23,604 deaths from COVID-19 and healthcare workers and public health experts were urging caution, which people were generally willing to follow… for a little while. Today it is 260,000 and instead of seeing this as validation of the concern we have had since March about how bad this virus can be, many people have long since thrown caution to the wind for really no other reason than that we are all incredibly, unbelievably fatigued. I’ll write about that sometime soon; but what I’ve really been thinking about from those first posts is these two short paragraphs, which are just as true today as they were then.

Guess what? We are there.

As I’ve said before, most people don’t understand what an overwhelmed healthcare system looks like because we’ve never experienced it. It means not having access to doctors and nurses when you are in DKA or have a skull fracture. It means your kid can’t get treatment for his seizures or his infected spider bite. It means that every single medical condition is more dangerous (many are more dangerous during the holidays anyway) because medical professionals don’t have the time, the mental energy, the tools and equipment, or even the staffing to deal with them properly. It means not being able to get an ambulance to get you to the hospital or a bed when you get there. At a time when tent hospitals are being put up around the country, we need to decrease COVID-19 transmission right now to prevent permanent injury and death from everything from high-risk pregnancy to Congestive Heart Failure to snow-skiing accidents.

And of course, as we saw in New York, an overwhelmed healthcare system makes the virus itself incredibly more dangerous as well. “I can always go to the hospital if I have a bad case” has never been a good argument against exercising caution; but it is simply not true if you can’t go to the hospital or if they can’t take care of you well once you get there. The death rate has held more or less steady since it started to decline because of our increased understanding of how to fight the virus with targeted, COVID-19 specific ventilator techniques and successful use of medicines like dexamethasone for hospitalized patients. But the biggest factor that will cause it to go up again is doctors who are too tired to think and nurses who are too busy and fatigued to catch their mistakes.


But how can I celebrate Thanksgiving with family safely?

I never want to be accused of being an alarmist, and if we are talking about reliable epidemiology principles and the solid medical realities of how the virus is transmitted, I would say of course there are safe ways to do Thanksgiving together. In theory. We could talk about things like only meeting outside, everyone distancing from people not in their immediate family, no sick people at all being allowed, and everyone strictly quarantining for a full 14 days prior to the Holiday. The problem is, those are things that are hard for anyone to do, let-alone a large group of people, and the chances that every member of your family can or will strictly adhere to those guidelines is very low; and it gets lower with every person you add. If people are working anywhere other than home, or they are traveling at all prior to the holiday, or if you’ve got just one family member that believes the pandemic is a government sponsored hoax meant to force you to wear a mask and will therefore gleefully shirk every precaution the family has agreed upon when the time comes, your gathering has gone from perfectly safe to not perfectly safe; and not perfectly safe is, in aggregate, really really dangerous right now.

Whoever made this meme and then watched it go viral: “Yeah, take that Casey! Hahahaha, hahahaha!”

Or let me put it another way. I’ve seen more patients with COVID-19 than any doctor in my clinic system; maybe more than any doctor in town, though there are those whose exposure risk I would rate as being higher than mine (our pulmonologists and ICU docs, for example, or the young medical residents who are seeing patients with COVID-19 in both the outpatient and inpatient setting and the ICU… and of course our nurses, who typically have more time face-to-face with our patients in the hospital, and in clinic perform procedures like nasopharyngeal swabs that are higher risk for aerosolizing respiratory droplets). I’ve been tested for COVID-19 12 times; half because of symptoms and half because of our internal exposure protocols. I’ve been negative 12 times; my 13th test is tomorrow (and if it’s positive I’m coming back to delete this paragraph). I would never disparage the degree of caution that has been taken by my medical brothers and sisters who have contracted COVID-19 in the line of duty, or imply that I’ve done anything they haven’t; but I’ve been seeing COVID-19 positive patients almost daily since April and have utterly failed to contract the virus. My PPE game is strong. I’m really, really good at being cognizant of fomites and at personal transmission control. I’m confident that if I can design and implement clinic protocols that protect patients and staff 40 hours a week, I could do the same for a 3 hour meal… But I’m staying home for Thanksgiving.

Why? Because it isn’t worth the risk. Because the virus is very, very real and I really care about my relatives and neighbors. I’m not afraid of COVID-19, and I’m not letting it control my life. I’ve heard all of that hyperbolic nonsense and rejected it; prudent action on behalf of those you love is not “living in fear,” and giving up one meal with extended family for one year is not letting it “control your life.” I’ve also heard the rejoinder, “but where do we draw the line?” Somewhere else, obviously. And even though I’ll probably be back here in three weeks encouraging you to have a small family Christmas this year, if you want the best possible chance at a safe Christmas with extended family (after strictly quarantining for 2 weeks and carefully laying out ground rules for everyone attending, and not flying to get there…), the best thing we can do is take wise, collective action to stem the tide now. Turkey and dressing will taste just as good in May or June.

Pretty heavy-handed, I know… But it feels like we are at that point of the pandemic.

COVID-19 Vaccine Misinformation (minute-by-minute analysis)

After weeks of COVID-19 misinformation being a secondary or minor issue- to me because we have been so busy actually diagnosing and treating the virus, and to the country in general because election misinformation was much more interesting- I suddenly find myself with more pieces of misinformation to write about than I could possibly make time for. There is this meme that probably needs some attention as people who haven’t complied with mitigation measures since March threaten non-compliance with any future mitigation measures because the mitigation measures they already didn’t comply with didn’t work (because they didn’t comply with them). If I get time I’d love to explore that a little further (and, I should hope, a bit more graciously than I did in that last snarky sentence).

This reminds me of the great Chesterton quote; “Christianity has not been tried and found wanting. It has been found difficult; and left untried.” Could we say the same thing about self-quarantine, shelter in place measures, and especially lockdown efforts? And what then shall we say about wearing masks? “It has been found slightly inconvenient and inexplicably controversial, and tried only begrudgingly and inconsistently?”

There’s also a discussion that we need to have, as a nation, about how this pandemic didn’t go away on November 4th and isn’t going to go away when we have a new president in the White House. This virus is pitilessly apolitical. It doesn’t care about Republicans and Democrats, the electoral college, lawsuits in Pennsylvania, or any of the other big problems facing our democracy (did I just include Republicans and Democrats in the list of problems facing our country? Yes, yes I did). In an election year, and particularly one this contentious, there was never any chance that information and understanding about the pandemic would fail to fall out along party lines. Now that the election is over, is it possible for us to drop our politicized misinformation and as a countrymen find some common ground on which to fight this deadly virus together? Probably not. But it doesn’t mean I can’t rant about it for five or six thousand words.

But I think the most pressing is the video I’ll share a little way below, which was sent to me by a Facebook friend. It’s a short misinformation video about the COVID-19 vaccines that are being developed and, like most misinformation, is an amalgam of half-truths, deliberate misrepresentations, and outright lies. It’s very short and I’ve posted it here in it’s entirety with the hope that you will read the accompanying discussion and not just watch the video.


Will I get the COVID-19 Vaccine?

Let me start with a statement that might be a bit controversial; while I’m obviously strongly leaning that way, and hope I have the decision put before me as soon as possible, I haven’t absolutely decided whether or not I will get the COVID-19 vaccine once it is available. That might sound like heresy coming from a doctor, particularly when we are currently in midst of the worst wave of the deadliest pandemic of our lifetimes.

But let me explain what I mean. While it’s encouraging to hear that the new vaccine from Pfizer is 95% effective against this very, very deadly virus, and while a safe and effective and widely accepted vaccine is the best and quickest route we have to beating the COVID-19 pandemic without even more massive loss of life, I remain at heart and by training a scientist, not a science fan; I default to skepticism of any new discoveries or developments until I have reviewed the evidence for myself. With regards to the COVID-19 vaccines that have been in development over the past year, I am like most physicians cautiously optimistic. Before deciding to have the vaccine administered to myself and my four children, however, I plan to review all the data that I can in order to ensure my choice is as informed and sound as possible, just like I would for any medication, surgery, or any other intervention my doctor recommends (or, for that matter, any treatment or medication that I recommend to my patients).

“But Dr. Webb, this is exactly what anti-vax parents are doing when they refuse vaccines.”

Yeah, except that it isn’t. At least, not generally. You see, when I say I plan to review the data I mean the actual data from the clinical trials and independent studies, not misinformation and propaganda. If you are like me and have the privilege of scientific training that allows you to independently parse the information contained in published clinical trials, you probably have no desire whatsoever to outsource this type of academic work to people who do not have that training and who are approaching the information with blatant and unabashed bias. But if you do not have the background to do that work yourself, you still deserve the same degree of reassurance and comfort before choosing to accept a vaccine or have it given to your children; it is just less likely that you have access to the resources you need. The anti-vaccine movement knows this and it is in this gap- the gap between the confidence you need for such an important decision and the degree of explanation, information, and reassurance that you are generally given– that they do their best (or most effective) work.

Who is to blame? Well, obviously, I am. Your local doctor, your pediatrician, your PCP; we carry the burden not of fighting propaganda, the blame for which rightly rests on those creating and spreading it, but of helping you become resilient against propaganda and misinformation through patient-centered health education.

So I am begging you, if you are at all wary of or uncertain about a COVID-19 vaccine, and if you do not have the technical background or family/community resources you need to review the source data independently, ask your primary care doctor. Maybe even give them a heads up when you schedule an appointment so they can look into it beforehand (they probably already will have). If they are active on social media, ask them if they would be willing to write about it and share it openly. Some primary care physicians, like Dr. Ben Brashear here in Texas, believe so strongly in this type of work that they have devoted a large amount of their time and energy to helping their patients and other readers navigate these issues through their clinic websites and social media pages. I think this is the single most effective way to combat Social Media Misinformation; with a hundred or a thousand or ten thousand doctors and scientists in small towns like mine or Dr. Brashear’s helping patients whom they have already built a trusting doctor-patient relationship with navigate what information is reliable and what isn’t.

And of course, on the off-chance that over the past 6 months of my writing these blog posts you have somehow decided you actually trust me, I’ll plan to write a short post about my decision on the vaccine as soon as I’ve decided, for certain, what to do for myself and my family.

I should also point out, while we are dispensing with preliminaries, that this post is not designed to be an overview of the research and development of the various COVID-19 vaccines. For that I will point you to my hero, Baylor Friendly Neighbor Epidemiologist Dr. Emily Smith.


“The ChAd Vaccine” Video Minute-By-Minute Discussion


0:12 Share this everywhere!

I’ve been doing this sort of misinformation debunking work as a hobby for about 8 months now and I’ve come to recognize some of the language or verbiage that ought to make us extremely suspicious that the information we are about to be given is not necessarily reliable. The speaker hits several right out of the gate:

  • This is a fact.”
    • In my experience, things that are facts don’t need the disclaimer “this is a fact.” Both for people spreading misinformation and those of us fighting it, the goal has to be to lay out such a clear and compelling case for the facts that the rhetorical sledgehammer of “I’m telling you the truth, I wouldn’t lie to you” is as unnecessary as it is hollow. If someone finds this verbiage convincing, it is likely because they are anxious to be convinced; and it should put you on your guard. “Let your ‘Yes’ be ‘Yes,’ and your ‘No,’ ‘No.’ For whatever is more than these is from the evil one.” -Matthew 5:37
  • Share this everywhere.”
    • Similar to the last point, I believe that most people giving reliable, expert advice or guidance will never ask you to “share” something they have written. Why? Because the burden of demonstrating that an issue is so important and pressing that it should be shared broadly lies again with the author, and lies in the substance and veracity of the arguments, not with the mere desire of seeing their assertions disseminated broadly. Nevertheless, I do recognize that “share this now” is a part of our vernacular now and used by almost everyone of a certain generation on back; but I think it is most suspicious as a herald of misinformation when it is accompanied by….
  • They will take this down.”
    • I sure that at some point something I write, either here or just on just on social media, will be taken down or marked as inaccurate; and when that happens I will probably throw a fit like I’ve seen others do. Until then, I will hold onto the sanctimonious belief that only those intending to spread misinformation feel that it is necessary to preface each video, meme, and essay with “this will be removed” or “they don’t want you to know this.” Who, exactly? The expansiveness, complexity, absolute loyalty, and conflicting goals and values of all of these conspiracies you believe are striving to prevent you from seeing some silly video are really beyond belief. The reality is that most scientists don’t mind at all if you watch the Plandemic documentary or Dr. Stella Immanuel’s speech on capitol hill; what matters is that you know going into it that this misinformation has already been disproven, and that you are armed with the understanding and data you need to work through and decode it. This presents an easy enough decision for me; my goal of helping you sort through this misinformation is best served when it is accompanied by the source material, and posting the video alongside the discussion is a no-brainer. But I think it’s a much more difficult decision for Facebook, Youtube, and Twitter, because they have to worry about the viral nature of this misinformation and the real potential for harm, and can’t accompany every repost or upload with a detailed analysis. Allowing lies to circulate without any disclaimer or precautions to protect those that are easily deceived is irresponsible and cruel; it submits to the whims of anyone with any lie to tell or anything to sell. But the very act of censoring or cautioning about misinformation also serves to reinforce the narrative of oppression; the last redoubt for conspiracy theorists is to use the very censure called down onto themselves for the unreliability of their assertions as proof of their veracity. It is a poor sort of fortress to be sure; yet there are far, far too many who see it as the last citadel of truth.
  • And, saddest of all, “Share to all of your Bible groups.”
    • We will talk about the specifics of what misinformation or misrepresentations in this video specifically might appeal to certain streams or factions within Christianity, but for the time being all I can do is grieve, as a follower of Christ, that a video or meme about the pandemic being spread primarily or at a higher velocity within Christian circles is so often a sure sign that it contains little truth and much that is meant to deceive and disrupt efforts of self-sacrifice and self-denial on behalf of our neighbors and community. I have written about how I believe the Church ought to respond to misinformation and why, but it really does feel as though we are behind the World in this area, both in our discernment and in our charity. Lord Jesus, please teach us to be as wise as serpents so that we might be as harmless as doves!

0:26 “Share with… Anybody that doesn’t want aborted fetal tissue fragments put into them.”

This is actually a major claim of the video and the most compelling topic of discussion of the three the speaker introduces, and we will cover it more extensively in just a couple of minutes. For now, let me just say that it is a fact that the COVID-19 vaccine, or any vaccine for that matter, does not contain any aborted fetal tissue fragments! Share with your Bible group, they will take this down!

It also won’t change your DNA, but we’ll get to that too.


0:40 This is the packaging of the AstraZeneca COVID-19 vaccine.

I have not seen the packaging of the AstraZeneca vaccine or any others for COVID-19 and have no reason to believe this individual photoshopped this package (and compelling reasons to believe they are not capable of doing so, as we shall see).


0:59 “It’s called Chad”

ChAdOx1 stands for Chimpanzee derived Adenovirus-vectored vaccine developed by Oxford University. The 1 means it’s the first of multiple Chimpanzee derived Adenovirus-vectored vaccines for COVID-19 that Oxford is working on.

It does not stand for “Chad- whatever that is, zero, or whatever it is- times one.”


1:19 Go to ResearchSquare.com

Research Square is a fine website, just be aware anything you read there is in pre-print; it hasn’t been finalized or peer reviewed yet. That’s the whole point of the website, for people to get feedback before they publish.


1:21 “I want you to learn to do your own research.”

The speaker claims that she wants her viewers to “do their own research” and begins well enough by directing them to Research Square, a reputable website where you can find original sources. But within about 10 seconds she has transformed “doing your own research” into something about as academic and reliable as a Wikipedia binge (or exactly as academic and reliable, since a Wikipedia binge is exactly what it is); googling random words you don’t understand and reading about them, then deciding what you think they mean without any background or context. It’s hard to tell whether she is being intentionally deceptive here, or if she really believes that she has attained a solid grasp of these concepts through the methods she is espousing.

That’s not what research is. In the context she is using it, ‘doing your own research’ at minimum means using the amazing, abundant resources of the internet to learn more about the concepts being discussed, and then using that new knowledge to get yourself over that first hump in the Dunning-Kruger effect and figure out 1. what you need to learn next and 2. what the limits are on how much you can actually learn about this on your own. The good news is, as long as you are humble in your assessment of your own understanding, you can also use that knowledge to 3. verify the reliability of whomever you go to to learn more.

We’ve all done this before, haven’t we? When I wanted to talk to an HVAC specialist about a problem with the air supply plenum in my crawlspace, I studied the anatomy of different HVAC systems, read some discussions on HVAC forums, and watched several videos that addressed similar problems. When this didn’t fully solve my issue, I called the specialist; and I used that research, mixed with a healthy appreciation of my own general ignorance on the topic, to both improve my understanding of his recommendations and to inform my gut decision on whether to trust his expert advice or get a second opinion (for anybody who is curious, he said the squirrels shouldn’t be living in there and he’s coming out to take a look on Monday. Based on my independent research, I’ve decided I believe him… though the squirrels have been waging a fierce misinformation campaign).

I’ve written (though not yet published) about this before; I want my patients to use Google. Really. And then I want them to come and talk with me about what they’ve read so I can help them get further beyond the point they could by themselves. Like I said in the article I’ve written that nobody else has access to:

“Most of all we went to school to become very, very good at parsing information about the human body and its diseases, and when it comes to the research you’ve brought in that is the primary way I can help; by helping you sort out which information is actually going to affect you and which isn’t, which you should worry about and which you shouldn’t, and what the underlying motivations might be for the people that published it. I’ve spent countless hours looking at research and studies and clinical trials and have become very good at determining when a study design is too flawed or data is too skewed to be reliable, when there is a strong bias that makes the data suspect, or when a conclusion is not supported by the evidence as it claims. If you are a scientist or a researcher or have training in those areas you may be able to do the same, maybe just as well or better; but for most people that isn’t the case, and it would be a little silly to trust your doctor when they offer one of the services they are highly trained for, such as looking at your child’s ear and determining if there is a bacterial infection requiring antibiotics, and not trust them when they offer another service they have been highly trained for, such as telling whether the research you’ve brought in about the human body is reliable or not.”


1:28 “Don’t rely on us or anyone else, do it yourself!”

This is so subtle and clever that I just wanted to point it out briefly. “Don’t rely on us or anyone else” when doing your research is an attempt to level the playing field between the different sources you might listen to, and it seems so reasonable on the surface.. Don’t listen to me, or your doctor, or a scientist, or an epidemiologist or researcher, only listen to yourself. The problem is that, at least in the viral version of this video, we have no idea who this lady even is. Telling you not to take her word for it or your doctor’s implies those two sources of information are equally educated, informed, and reliable; this from a lady who just called it the “CHAD Zero Times One Vaccine.”


1:49 “Google every single word on here.”

Again, that’s not “research.” If you need to google some of these words to know what they mean then by all means do so; but that is the pre-research prep work, not the research itself. Thinking you understand a concept because you looked up the definition of a word is unmitigated folly, as she demonstrates in a few moments.


1:58 Recombinant DNA doesn’t mean they are reprogramming your DNA. At all.

The speaker and her assistant begin their “research” by looking up the term “Recombinant DNA” on Wikipedia. Wikipedia is great, and one of my favorite things about it is that most articles are written at a level that most lay people can understand (except the math ones. Yikes). So I think if you want to follow the speaker’s advice here and read that wikipedia article, you should. I’ll wait.

https://en.wikipedia.org/wiki/Recombinant_DNA

But the thing is, she doesn’t actually read it in this video, does she? She only reads the first sentence and then, despite her prior warnings, asks you to take her word on what that sentence means. But listen to the way she says it! The emphasis, the alarm, the righteous anger as she enunciates “molecular cloning” and “genome”! She spits the words out as though it were self-apparent how evil they are, without seeking (or asking you to seek) any additional understanding of what they actually mean. Just one googled word in, and she has entirely abandoned her ‘method’ of research; don’t google every single word in this article that you don’t understand, just take it on her authority that this is bad, bad stuff. She tells you earlier not to be intimidated by scientific terms; but here she actually wants you to be frightened by them.

If you actually read that article, you will quickly realize that the idea she implies here (and stated explicitly earlier on), that recombinant DNA reprograms your genetic code, is actually complete nonsense. In fact, it’s exactly the type of nonsense you would expect if someone’s entire understanding of the science involved was gained through googling random words and reading the first sentence only of wikipedia articles.

The Recombinant DNA got him!

Recombinant DNA describes how the vaccines or medications were developed, not what they do once they are inside of you. Just look at the ‘applications’ section of that same wikipedia article; rDNA technology has been used to develop insulin, accurate testing for HIV, and safe growth hormone for patients with pituitary failure, not to mention interferon therapy for cancer, treatments for cystic fibrosis, and TPA, a life saving treatment for strokes and heart attacks. None of these therapies change your DNA. Saying recombinant DNA therapies change your DNA is like saying that Mashed Potatoes mash you if you eat them. No, the potatoes were mashed during the preparation phase so that they would be delicious for you later on; you don’t get mashed, they do. DNA of fungal or bacterial or animal cells was changed in order to develop these treatments, so that they would be safe and effective for the people who need them.

Since I’m waxing eloquent here, I’ll give one more analogy. It’s like my first and only experience in debate club back during Freshman year of college. The topic was “is preemptive war justified.” The first team to debate, the “for” team, got to define the terms of the debate and chose to argue that preemptive war was justified because nations have the right to defend themselves if they are the victims of a preemptive attack; so preemptive war, “war initiated by a preemptive attack,” was 100% justified… on the part of the nation that was attacked first.

They changed the very definition of the term to suit the argument that was easiest to defend; they were arguing for retaliatory or defensive action instead of preemptive, because it was a much simpler position to defend. And the only problem with that is that words have meanings, Keith!

Sorry, I may still have some baggage to work through there. But that’s exactly what this speaker is doing too; changing the meaning of the term ‘recombinant DNA’ and just hoping you won’t notice or indeed read the very article she has pointed you to herself.

There is one more part of this discussion, and it doesn’t have anything to do with what she’s mentioned here, but intersects with this idea of “reprogramming DNA,” even if I don’t think she has the science background to realize it. Here she’s focused on rDNA, but you’ll also hear discussion about mRNA; messenger RNA, the genetic sequences that organisms use to instruct cellular machinery to build proteins. The two vaccines that have recently shown such promise, from Pfizer and Moderna, both use mRNA technology. Traditional vaccines provoke an immune response, teaching your body to produce it’s own antibodies to fight the infection, by presenting your immune cells with non-dangerous particles of the virus that it can recognize and then build antibodies against. Each of these viral particles has to be produced in a lab and enough of them have to be preserved and injected to ensure some are picked up by your macrophages or dendritic cells and then presented to your lymphocytes (T and B cells) to make sure that you really do develop the ability to mount a robust immune response when you exposed to the virus for real later on.

The mRNA vaccines do the exact same thing, only instead of injecting the deactivated viral proteins directly into your body, they only inject a code for them; a code that teaches the machinery in a few of your own cells to build and release the proteins needed to produce the desired immunity. This outside mRNA hijacks the cellular machinery to produce the proteins needed for immunity without any of the proteins that cause illness; and the rest functions just like a normal vaccine. This is the same naturally occurring ‘technology’ that mRNA viruses use themselves. This is great news for people who want to acquire natural immunity; by mimicking the action that the viruses themselves use, which in turn produces our immune response to them, these vaccines have become the closest you can possibly get to acquiring immunity naturally without actually running the risk of getting sick and infecting others. Instead of getting a deadly mRNA virus from a cough or sneeze, you get a safe mRNA ‘virus’ from a vaccine, and from it your body’s own immune system learns how to kill the deadly virus.

This video below explains these concepts really well, starting at the 1:53 mark.

Again, this mRNA technology doesn’t change your DNA. It just sends a message to some of your cells with a set of instructions, just like any common cold would. Your chromosomes, your genetic code, are unaffected; the vaccine doesn’t even interact with them. If an analogy would help, imagine someone ‘hacked’ your network printer at the office. Normally you are the only person who prints to this printer; you write the document on Word or Notepad (judging you) on your computer and then hit “print,” and the signal goes to the printer, which prints the document. But one day you walk in to find that someone else has been printing things to your network printer. That doesn’t mean that they’ve hacked your computer, it just means they have used your paper and ink (and toner! those monsters).

And what did they choose to print? A detailed set of instructions on how to protect your networked printer from hackers. Big Cybersecurity, at it again.


3:00 “We used direct RNA sequencing to analyse transcript expression from the ChAdOx1 nCoV-19 genome in human MRC-5 and A549 cell lines.”

Here is where we enter what is, I think, the heart of what has drawn most people to this video. I think we can quickly dispense with one piece of false information before entering a more important discussion. The ChAdOx1 nCoV-19 vaccine does not use the MRC-5 cell line. This is an inherent problem with both the ignorance of the speaker (and here I do not mean to be insulting, but merely mean the lack of actual education and experience in the field in which she puts herself forward as an expert) and the deep flaw in her ‘method’ of research. This article is not from the vaccine manufacturer at all; it’s from an independent lab that used these human cell lines to study the vaccine after it was produced. You can find the full text here and read it for yourself. The manufacturers did not use those cell lines. In telling you all about the MRC-5 cell line and warning you that;

One thing [the ChAdOx1 vaccine] definitely has is the lung tissue of a 14-week-old aborted caucasian male fetus.”

Narrator: “It doesn’t.”

the author is stating an absolute untruth based in her own haphazard and unreliable method of trying to find scientific information and uncover medical conspiracies. If her “research” methodology has left her unable to even grasp the basics of who is doing the study and why they are doing the study, or the difference between making a vaccine and studying a vaccine that has already been made, why would you possibly trust her method of research? For that matter, why trust her at all, when she has proven herself so unreliable? Even her assistant, the enigmatic Claire, tries to offer some clarification that the cell line used in the study has been replicated over and over again since the 60’s; that the researchers did not actually abort a child and then collect its cells to study the vaccine (or make the vaccine, as she mistakenly believes); but that attempt is ignored by the main speaker.


What about fetal cell lines in medical research?

Despite the speaker’s severe misunderstanding, and regardless of the tired horror tactic of trying to get you to visualize fetal parts being injected into your children in order to illicit a visceral reaction (there are no aborted fetal parts or fetal cells in vaccines, even the vaccines developed using human cell lines), this is an important question and I think we should spend some time on an actual discussion of it, instead of the sensationalized and inaccurate rage that characterizes its treatment in the video.

I am a pro-life doctor. Like most physicians my views on abortion are nuanced, deeply felt, and strongly based in the lived experiences of my patients. Since this video was designed to spark a visceral reaction among pro-life people in order to make them more susceptible to vaccine misinformation, I think the issue of abortion and fetal cell lines in research warrants discussion on this blog post. I have helped prevent countless abortions, both through providing high quality women’s health services, often to women who otherwise would not have good healthcare access, and by providing compassionate listening, patient-centered care, and judgement free counsel during the most tumultuous times of an unintended pregnancy. There are those that will argue that doctors shouldn’t be pro-life, that my moral opposition to abortion means I can never truly provide unbiased guidance and information to a woman facing this most difficult and painful decision of her life, or that I am somehow unable to respect my patients’ autonomous decision making in this area and help them leave my office more empowered than when they came in. I don’t believe that matches the experience of my patients. I might argue that informed consent, a core principle of medical ethics, is impossible without a robust patient-focused discussion of the medical realities and practical alternatives surrounding the decision to terminate a pregnancy, and that there is reason to believe that these conversations are too often sacrificed or short-circuited once the specter of abortion first arises. It is a debate for another day, to be sure, and with many of the physicians who hold the opposite view I nonetheless share a strong mutual respect, born of proven care for and dedication to our patients, that overrides even our deeply held reservations on this issue. Even on the question of abortion and consent itself, we both believe, based on all of our medical training and the high degree of altruistic concern we bring to our jobs, that we are striving to do what is best for our patients; to help them in the way that is best for them and most consistent with their own stated goals and deepest felt wishes.

Many medications and vaccines use fetal cell lines. The reason is simple; human cells typically work best for studying and developing treatment for human diseases, and fetal cells have unique characteristics that allow cells to achieve, or nearly achieve, cellular immortality; allowing the same cells to be replicated over and over again without any need for additional cell lines to be collected. There is no question that this is a challenging ethical and moral area for pro-life scientists like myself, and strongly pro-life physician and multidisciplinary healthcare organizations, like the Christian Medical and Dental Alliance (CMDA), have discussed and written extensively about it. Here are a few articles CMDA has published, written by conscientious physicians of deep, theologically sound Christian conviction. I hope you will weigh their words and reflections with at least as much gravity as a random person on the internet telling you to “pray big” and share her video with as many “christian-loving” people as possible.

Christian Medical and Dental Alliance:
Am I My Brother’s Keeper?
By Dr.
Amy Givler, MD, FAAFP

Christian Medical and Dental Alliance:
Is Vaccination Complicit with Abortion?
By Dr. Gene Rudd, MD

There are a few salient facts you should know about this area of medicine.

  1. No children are aborted or have been aborted for the purpose of developing medicines or vaccines. The sensationalism that some forces in the anti-vaccine movement are willing to engage in knows no bounds, and it is not uncommon to hear the propaganda that these unborn babies were actually aborted for the purpose of being used in medical research. This is simply wrong. The few unborn children whose cells (or accurately, copies of copies of their cells) are regularly used in medical research and development were likely aborted for the same reasons that most abortions occur; the unbelievably difficult balance of perceived goods and anticipated challenges faced by a woman who had not intended to become pregnant. These mostly occurred in the 60’s and 70’s, and cell lines (copies of cells) derived from those same aborted fetuses have continued to be used ever since without the ‘need’ to derive new cell lines from abortions occurring today. For instance, HEK 293, the actual cell line used in the development of the ChAdOx1 vaccine, was derived from an abortion in The Netherlands in 1973; we simply do not know the story of the woman who chose to have this abortion, or the reasons behind her choice.
  2. There are no fetal cells in vaccines; not even in vaccines developed using fetal cell lines. Vaccines are not a ‘mix’ of fetal cells and viral particles, not by any stretch of the imagination. When fetal cell lines are used to grow viruses that infect humans in the vaccine development process, it is distant to the final product of the vaccine, which has also been through multiple rounds of purification. The human cell lines are used to grow the virus and deactivate it; they are not included in the actual material injected through a syringe to produce an immune response in our bodies.
  3. Not all vaccines use human cell lines. There are vaccines for almost every vaccine preventable illness that are designed using methods that even the most rigorous pro-life groups consider ethical. When the anti-vaccine movement tries to convince you that all vaccines are suspect from a pro-life perspective, they are rather co-opting a pro-life position for their own aims rather than being a legitimate part of the pro-life movement.

Like the CMDA doctors above and most pro-life physicians and scientists, and even the Vatican, I believe that using vaccines and medications not developed using fetal cell lines from aborted human beings is strongly preferable whenever possible, and that this is an area where continued economic and moral pressure can encourage pharmaceutical companies and research institutes to pursue alternative means of developing novel treatments to human disease. However, the principles of whole-life pro-life ethics also dictate that a treatment or preventative measure developed in part through material derived from a past harm through abortion, with no potential to cause further harm in this same way but massive potential to prevent loss of life (including unborn human life) is still, clearly, a moral good; a position even Popes have affirmed. In saving the lives of a great many people from a single death that would not have been prevented regardless, we derive the greatest possible moral good from what was an undeniably tragic situation for all involved.

For pro-life persons, accepting a vaccine that was developed from fetal cells collected 50 or 60 years ago makes them neither complicit with nor promoting of a depreciation of human life. But seeking treatments developed using alternative means may send a message to pharmaceutical companies that these issues are indeed dear to their hearts and that their collective will is that these methods in research would become a thing of the past.

And the great news for staunchly Pro-Life people is that not even all effective COVID-19 vaccines use fetal cell lines. Neither the Moderna vaccine nor the Pfizer vaccine, the two that have been recently publicized as 95% effective against COVID-19, used fetal cell lines in development or production. The question of fetal cell lines in medical research and development is an important one; but it is not likely to be an issue when getting vaccinated for COVID-19, assuming you have some degree of freedom in which vaccine you choose.


4:23 “This is what they want… They KNOW this vaccine is going to hurt people or kill people so badly.”

A few things here.

  1. If there is a way to kill people not so badly, please let me know. We could be on the brink of a medical breakthrough here.
  2. Who is “they” anyway?

She jumps around so much in this video that the viewer is left to assume, just like with the MRC-5 discussion, that this last bit is screenshot from the original papers from the vaccine manufacturer; that the people making the vaccine have, in their published study, asked the universe at large to supply them with some sort of computer program or something to help them sort through all the people they intend to maim or kill. We’ve talked before how conspiracy theories rely on this weird paradox where shadowy conspirators are both incredibly clever, subtle, and nigh-invulnerable but also so clumsy as to announce their real plans in such a way that some random person on the internet can piece it all together with a 5 minute video. Pfizer or Moderna publishing “please help us, our excel spreadsheets aren’t robust enough to keep track of all the victims we are after” at the bottom of their research would certainly fall under this phenomenon.

But this isn’t from the vaccine manufacturers. It’s from the Medicines and Healthcare products Regulatory Agency (MHRA), the British counterpart of the FDA. And it isn’t from a research paper, it’s from their contracts division, announcing the technology services they are hoping to contract with as they anticipate the release of these vaccines.

Why would the MHRA or FDA want to track possible adverse reactions to a new vaccine?
Because it’s literally their job.

And why would they anticipate a “high volume” of reported adverse reactions?
Because we are in the middle of a highly politicized, deeply contentious global pandemic; billions of people are going to get these vaccines, and some of them are going to have very mixed feelings about it. Adverse reactions to vaccines range from the common but mild to the serious and extremely rare, but reported or perceived reactions are all over the place. I saw a patient yesterday who believed that his flu shot had caused him to feel fatigued and sore the next day (it had), and also to have six days of diarrhea and loss of taste and smell two weeks later (it hadn’t). He tested positive for COVID-19, the true source of his symptoms. I’ve also had patients who believed their flu shot gave them COVID-19, which is utterly impossible.

Vaccines feel scary; they are sciency and mysterious and they are going into your body, and you are taking someone’s word for it that they are safe and a wise decision. I get that. A new vaccine is even scarier, and a new vaccine for a virus that is deadly, has changed our entire lives over the past year, and is surrounded by a thick haze of misinformation and conspiracy theories is even scarier. Some of the folks getting that vaccine are going to do so, probably to keep those around them safe, only after warring within themselves over it (even I told you I’ve still got some research to do before I’m fully satisfied with the decision). For some of those folks, anything medical that happens to them in the next few months might potentially feel like the negative fallout of that one difficult decision. The point of the MHRA using an AI tool to augment their ability to analyze that data is so that they don’t miss any real adverse reactions hidden in all of that noise; to make sure that if the vaccine is dangerous after all, despite the safety demonstrated in clinical trials, they discover it as quickly as possible. Again, because that’s their job. This is evidence that the people tasked with making sure the vaccines are safe really do take that role seriously; not evidence that someone is planning to hurt you and wasn’t sneaky enough in hiding their intentions.


5:01 “I don’t know how you do it, I’m not technical.”

After watching the same 5 minutes of these folks pointing a shaky phone camera at their computer screen and pulling up various image preview programs and web browsers over and over again while writing this blog post, I can now verify that this is the single most true and reliable statement in the entire video.

It looks like I’m just being cheeky at this point, so I guess it’s time to stop there.

30 Days on Doctoring: Reflections on Death and Eternity

As doctors, we carry our dead with us no more or less than anyone else; it is only that we generally have many more to carry.

I can still bring to mind the faces of every patient I’ve lost. Some of them I remember only as faces and stories, or mainly stories, the names long since faded. The older or very ill men and women for whom I led resuscitation attempts for no other reason than that I was the closest doctor to their hospital room when their heart stopped beating, the children and infants I continued efforts for in the emergency room, who had died in the field but compassion dictated we exhaust every possible option for, and talk with the parents carefully and in person, before discontinuing our final attempts to bring them back. These people, created in the Image of God and bearing their own unique identity and personality I never knew, stay with me as memories of the last desperate battle against death, difficult decisions made rapidly, and finally small, quiet prayers offered in the unofficial office of priest I unknowingly accepted when I enrolled in medical school all those years ago. The memory of who they were in life is left in the safe keeping of others.

Others I had a greater privilege of really knowing; I was there not merely in their last moments but for their last weeks or days, saw them battle with and often come to peace with the drawing near of their time on this planet; saw them experience and then cease experiencing pain, anxiety, worry, doubt. Like anyone who has lost somebody, I have been struck by the strangeness of spending those days with them in conversation, earnestly offering what comfort I could, only to be in the room with them bodily again sometime later, but now utterly alone. I hold these images together, the person living and the person dead; but am thankful the former is by far the stronger impression. I have been thankful, when medical circumstances have allowed, when those last days have resulted in choices that led a person to die in relative peace and comfort at home or otherwise surrounded by loved ones, and my role of final comforter in life and companion on the very brink of death has been taken by others infinitely more qualified. In those cases, I have the privilege of keeping only the living person in my memory.

Still others I remember in three dimensions; their face and voice in life, their sense of humor, their struggles and triumphs. Those whom I have been physician to over many months and years and, like the patient I called ‘mi abuela’ and who used to slap me on the arm for being such a bad grandson, only learned of their deaths after the fact. Often those relationships went far deeper than the mere clinical as over time a very human fellowship came to define our patient-doctor relationship as much as any exchange of medical information, advice, or prescriptive guidance. These patients especially kindle in me the hope of Heaven, and I find unspeakable comfort and joy in the not unreasonable hope of a continuance of the friendship and brotherhood between two souls we began on this Earth, then unalloyed by any thought of medical knowledge or clinical skill needed or offered.

We cannot recall all of these many losses with complete satisfaction. Often times we do reflect on our role in informing and preparing a patient for death with some degree of contentment, with the assurance that we had the needed foresight and skill for the moment and can take comfort, at least in our small part, in a job well done. In contrast, there are for each and every one of us mistakes we know we made, and hopefully have apologized for, that accurately place on us some small or large degree of responsibility for a person’s death. I am grateful that these experiences have been rare, and am deeply grateful to have found compassion, understanding, and forgiveness at the close of each of those stories.

But most often, neither of these is the case; neither perfect complacency nor right and accurate self denouncement, and we are left with less closure, less complete understanding than we would have wished. For every tragedy where a family and friends are left to wonder “what could anyone have done?” there is a physician who is left to question, earnestly drawing on all their clinical reasoning and accumulated knowledge, “What could I have done?”

People think that as a profession, as a field of study, we engage in post-mortem examinations, case reviews, and mortality and morbidity conferences either because we long for greater academic knowledge or because we wish to find someone to blame for the tragedy of death. These are both true, though decidedly not in the way that most people think. The longing for knowledge is not sterile or disconnected from the human story or from grief, and the desire to assign responsibility is not adversarial or blaming, but rather both seek to view tragedy as an opportunity to grow and provide still better care in the future. In our anatomy classes our dead were our first teachers; ever after they remain our best teachers, because the lessons they provide are the most powerful. But there is a third motivation that I think is equally as powerful as the others. As physicians we carry our dead, and when a loss is unexpected or tragic, or holds any possibility of error (as almost all do), we carry the weight of the burden of that death all our lives. In seeking to understand the role we might have played we are attempting to define the dimensions of that burden; to know exactly how much of the weight we are, personally, to carry.

The Hope of Heaven is what remains. Similar to (I am certain) lawyers and social workers, physicians long for a day when our particular skills, abilities, and expertise are utterly and permanently irrelevant. The farmer or craftsman may contemplate eternity with an expectation of some continuation of a form of his earthly work, and hope to see it brought to completion by an increase and perfection of skill or else a diminution of toil; the doctor believes his work will be perfected only in eternal uselessness, when in the presence of the Great Physician we can have nothing at all to contribute. The most skilled physician on earth longs to be only a poor apprentice pruner or assistant herdsman in eternity, when pain, illness, and all forms of human, Earthly suffering are at a final and unequivocal end. It is with this hope that we walk into every exam room, approach every hospital bed, and delve into every instance of physical, emotional, and spiritual pain. It is this hope alone that makes them bearable as a physician.

And it is this hope that we, implicitly or explicitly, hope to impart to our patients who are undeniably bearing the greatest part by far of those burdens, which with all our training we can only strive to lessen but know we can never truly undo or perfectly prevent.

Lord, hasten the day.

Don’t Be Afraid of COVID-19.

The following is a short repost from social media.


Well, call me triggered.

I’m a Family Medicine Physician, and every day for the past 3 months I’ve seen patients for COVID-19. Every day for 3 months, I’ve told every patient I’ve diagnosed with COVID-19, with the exception of the few I’ve sent directly to the hospital because of the severity of their symptoms, the same three things:

1. Don’t be afraid of COVID-19.

I say this to my patients for a few reasons. First, because I am mostly seeing patients in the outpatient setting, my patients and I have the privilege of emphasizing this point. Second, for many patients who have a mild to moderate severity course of COVID-19, anxiety is a very real issue, and I want to make sure that while they are recovering they are not sitting at home wondering when the virus is going to get them. Most people who get COVID-19 don’t end up in the hospital (as we have been saying since the beginning of the pandemic), even fewer end up in the ICU or die from the virus (as we have been saying since the beginning of the pandemic). The virus is very, very dangerous, but our brains are bad at statistics; just because this is the most dangerous viral pandemic since the Spanish Flu of 1918 doesn’t me that your individual chances of dying are high or that getting deathly ill is a foregone conclusion. If I were mainly seeing very sick patients in the hospital or ICU I wouldn’t be saying this as much; we would be talking more about treatment and response than about the patient’s anxiety about getting sicker, though the latter certainly deserves our time and attention in any clinical setting. When a patient is struggling to breathe, “don’t be afraid” is a theological statement rather than a clinically valid reassurance, and it typically gives way to “I am with you; I am here and I am going to do my absolute best for you.” But in the outpatient setting, talking with patients who are worried about how COVID-19 will affect them and their children and their friends, “don’t be afraid” is an extremely important part of the conversation.

2. If you have the following symptoms, go to the hospital.

As important as “don’t be afraid” is, it is equally as important to talk about what we call emergency and return precautions. Yes, for most people COVID-19 is not deadly; but it is for some, for many in fact, and we do not have any perfect way of predicting who will have a more severe course. For my healthy patients in their 20’s and 30’s, the chances of ending up severely ill are extremely low; yet people who are medically just like them- same age, same paucity of risk factors- have died from the virus. The same for parents who are worried about their children; children are at extremely low risk from COVID-19, yet some children have died from the virus. I can look my young, healthy patient in the eye and honestly tell them I expect them to be fine; but I cannot promise them that they will be, and that’s a vital distinction. So with each and every patient, in addition to reassurance, we talk about what to look out for. Shortness of breath. Chest pain. Severe malaise and fatigue, even syncope; passing out or almost passing out from the toll the virus is taking on your body. We talk about oxygen levels if they happen to have a pulse oximeter at home, and signs of hypoxia if they don’t. We discuss both the reasons they would come back to see me in clinic and the reasons they would skip my clinic and go directly to the Emergency Department instead. With my older patients or patients who have known risk factors (most Americans, in fact, including myself, considering that risk factors for a more severe course of COVID-19 include hypertension, diabetes, obesity, chronic lung disease and other very common ailments), this discussion is even more important, because even though the odds are still in their favor, their ending up in the hospital or dying from COVID-19 is not nearly as unlikely. I want my patients to be free from fear; but I also want them to be equipped with the knowledge they need to make sound choices if their symptoms do worsen.

3. Please keep the virus from spreading to others.

This piece of guidance is no less important than the previous two. If you are healthy and young and your chances of dying from COVID-19 are very low, that’s really wonderful; but self-isolation during your illness is still the responsible, kind, and charitable decision because not everyone is as lucky as you. The case fatality rate of COVID-19 is much higher than even very deadly illnesses like the flu, and it is very, very contagious. With each and every patient I discuss the precautions they can take to keep the virus from spreading to their own family, and of course the responsible social decisions like sheltering at home during their contagious window and alerting their close contacts so they can self quarantine. It’s one thing to tell yourself that you’ve only exposed other people at similarly low risk to yourself, but once you have spread the virus to someone else you have no control of whose grandmother, whose father in poor health, or whose immunocompromised child it spreads to from there. I said before that we are bad at intuitively comprehending statistics; the COVID-19 virus, like most illnesses, is unlikely to cause death to any given individual regardless of risk factors, but is extremely deadly in aggregate; containment is still our best strategy for keeping the 210,000 deaths in our country from doubling or tripling by the end of this pandemic. The reality is that most people get this; most people I talk to understand the need and are concerned about keeping their families and communities safe. But there is a counter-narrative being promoted by some that rejoices in defying all calls for caution, sober mindedness, or charity when it comes to COVID-19, and so the reminder from me, the doctor actually seeing the patient face to face in clinic, becomes that much more important in case my patient has been lured by these cruel and irresponsible ideas.

These are the three pieces of advice, the three categories of discussion that I have with each and every patient. It is time consuming; it appropriately turns what might be a 5-8 minute visit into a 10 or 15 minute visit. It requires careful explanation of statistical and clinical concepts that might be challenging. It is worth it, because the proper way to approach a diagnosis of COVID-19 is with caution on behalf of others and preparedness rather than fear for yourself and your family, and it’s my job as a Physician to equip my patients with the knowledge and tools they need to approach the virus this way, even in the face of anxiety and rampant misinformation.

So when I see someone with a platform like President Trump’s endorse the first point of not being afraid of the virus, follow the second point of going to the hospital when his symptoms escalated and he experienced hypoxia and shortness of breath, and finally utterly disregard and contradict the third point of taking precautions on behalf of others, I am, I think very understandably, upset. Because when a doctor or a nurse survives COVID-19 (and many haven’t), contracted by putting themselves in harm’s way every day and despite taking maximum precautions to keep themselves and those around them safe, they rejoice that they are now able to dive back into the fray, fighting the virus with no less caution but somewhat less stress and anxiety for their own health, knowing that reinfection is very likely a rare occurrence. But when the president contracts COVID-19 by ignoring all precautions and survives it with the help of state of the art high-level hospital care, expensive and experimental treatments, and a private team of doctors and nurses, his first statement after leaving the hospital is one that builds upon his long-standing guidance and example of not taking precautions or acting to protect those around you, despite neither you nor your family and community having anything like the medical access that helped him.

Please keep yourself and others safe. Don’t be afraid of the virus, but please act in charity to those around you by taking reasonable and proven precautions like wearing a mask, maintaining physical distancing, and engaging in sound epidemiological principles like getting tested if you are ill, self-quarantining if you are exposed, and honestly and proactively participating in contact tracing if you are diagnosed.


Edit #1:
I will go ahead and anticipate a couple of objections to this post. First, some people are going to claim that the facts I’ve shared here are inaccurate; that the ‘CDC admitted’ that only 6% of the deaths were actually from COVID-19, or that the fatality rate is actually lower than the flu, or some such nonsense. For people who still believe these pieces of COVID-19 misinformation, there is no shortage of good explanations and rebuttals available on the internet and I suggest finding and reading one. For people who don’t mind a long and mediocre rebuttal over a good one, I’ve written a few myself over at tjwebbmd.com.

Second, some people are going to look at this tweet from the president and say, “but TJ, he isn’t discouraging caution or telling people to take COVID-19 less seriously! He just said don’t let it dominate your life, that could mean lots of things!” To those people I will say, along with Doctor Archibald from Veggie Tales, “Stop being so silly!”

When I tell my patient “don’t be afraid” after reviewing their vital signs, asking about their symptoms, carefully examining them and listening to their heart and lungs, and carefully talking through emergency precautions and transmission control measures, they are absolutely not confused about what I mean. And nobody in America is confused about what the president means when, after months of promoting misinformation, minimizing the pandemic, shirking transmission control guidelines even to the point of endangering his secret service and staff during his own illness, refusing to wear a mask (and then only wearing one intermittently and with a wink at mask truthers when he does), he then says to ‘not let it dominate your life’. And nobody will be surprised when the ongoing unwillingness of our national leadership to take the pandemic seriously, and encouraging others to do likewise, results in more cases, more severe illnesses (and associated suffering and medical debt), and more deaths.


Edit #2:
On the same day that I posted a short essay titled “Don’t Be Afraid of COVID-19”, Dr. Emily Smith, Your Friendly Neighborhood Epidemiologist, posted a short essay saying that Yes, We Should Be Afraid of It. Now, Dr. Smith is so much smarter than me that this would normally be enough to make me immediately delete my post; but thankfully, it turns out we are saying essentially the same thing, despite the seemingly contradictory essay titles. To understand what Dr. Smith and I mean when we say you should/shouldn’t be afraid of COVID-19, go and read her essay where she discusses the difference between unhealthy fear and wisdom, the latter being something our national response to this very deadly and dangerous virus has been sorely lacking.

𝐒𝐨, 𝐰𝐡𝐲 𝐬𝐡𝐨𝐮𝐥𝐝 𝐰𝐞 𝐛𝐞 𝐚𝐟𝐫𝐚𝐢𝐝 𝐨𝐟 𝐂𝐎𝐕𝐈𝐃? 𝐁𝐞𝐜𝐚𝐮𝐬𝐞 𝐭𝐡𝐞 𝐬𝐜𝐢𝐞𝐧𝐜𝐞 𝐭𝐞𝐥𝐥𝐬 𝐮𝐬 𝐰𝐞 𝐬𝐡𝐨𝐮𝐥𝐝. 𝐋𝐞𝐭’𝐬 𝐝𝐞𝐟𝐢𝐧𝐞 𝐰𝐡𝐚𝐭 𝐭𝐡𝐚𝐭 𝐢𝐬 𝐟𝐢𝐫𝐬𝐭 𝐭𝐡𝐨𝐮𝐠𝐡. 𝐓𝐡𝐞𝐫𝐞 𝐢𝐬 𝐚 𝐝𝐢𝐟𝐟𝐞𝐫𝐞𝐧𝐜𝐞 𝐢𝐧 𝐰𝐢𝐬𝐞, 𝐡𝐞𝐚𝐥𝐭𝐡𝐲 𝐟𝐞𝐚𝐫 𝐚𝐧𝐝 𝐮𝐧𝐡𝐞𝐚𝐥𝐭𝐡𝐲, 𝐝𝐞𝐛𝐢𝐥𝐢𝐭𝐚𝐭𝐢𝐧𝐠 𝐟𝐞𝐚𝐫. 𝐓𝐡𝐞𝐫𝐞 𝐢𝐬 𝐚 𝐝𝐢𝐟𝐟𝐞𝐫𝐞𝐧𝐜𝐞 𝐢𝐧 𝐫𝐞𝐜𝐤𝐥𝐞𝐬𝐬 𝐛𝐞𝐡𝐚𝐯𝐢𝐨𝐫 𝐚𝐧𝐝 𝐜𝐚𝐮𝐭𝐢𝐨𝐮𝐬 𝐰𝐢𝐬𝐝𝐨𝐦. 𝐈𝐭’𝐬 𝐭𝐡𝐞 𝐫𝐞𝐚𝐬𝐨𝐧 𝐰𝐡𝐲 𝐰𝐞 𝐭𝐞𝐥𝐥 𝐨𝐮𝐫 𝐜𝐡𝐢𝐥𝐝𝐫𝐞𝐧 𝐧𝐨𝐭 𝐭𝐨 𝐭𝐨𝐮𝐜𝐡 𝐚 𝐡𝐨𝐭 𝐬𝐭𝐨𝐯𝐞 – 𝐭𝐡𝐚𝐭’𝐬 𝐧𝐨𝐭 𝐮𝐧𝐡𝐞𝐚𝐥𝐭𝐡𝐲 𝐟𝐞𝐚𝐫, 𝐢𝐭 𝐢𝐬 𝐰𝐢𝐬𝐝𝐨𝐦.

Dr. Emily Smith, PhD, MSPH