“Non-Lethal” Weapons: A Doctor’s Perspective.

Disclaimer #1: While the opinions expressed in this essay are correct, they are mine alone and do not necessarily express the views or opinions of my employer. Probably some of these opinions do also reflect the views of my employer or at least the other people I work with, but I couldn’t specifically say which views or which people, so I’ll just leave it at “these opinions are mine alone.”

Disclaimer #2: I’m not great at writing disclaimers.


When Violence Intersects Medical Misinformation.

As the past weeks have been marked by nationwide protests against excessive force and police brutality in general and the disproportionate killing of unarmed black men and women in particular, I have remained fairly silent on this blog, which has a specific and limited scope, and have expressed my views elsewhere. Last week when George Floyd’s autopsy report was released, I had hoped to write about the medical realities of his death and expose the fallacies of claiming that it was the result of natural causes or elicit substances rather than the lethal and prolonged physical assault we all witnessed with our own eyes. Unfortunately I was utterly unable to create time to do that discussion justice, and thankfully nobody seemed to be buying that nonsense anyway. Dr. Judy Melinek, a Forensic Pathologist, offers a detailed and careful explanation of George Floyd’s death and autopsy findings in an article on MedPage Today. Her evaluation includes the following statements:

“EMS and police are sometimes trained that anyone who says “I can’t breathe” is lying — because if you can speak, you can breathe. This is not true, and there are many reasons why people might say “I can’t breathe” and still be in medical distress. These reasons include increasing fatigue of respiratory muscles; blockage of pulmonary blood flow; incomplete airway obstruction; and acidosis, a buildup of acid in the blood which triggers an increased breathing rate and causes the sensation of shortness of breath.”

In her conclusion, Dr. Melinek also explains why the autopsy performed by the County Medical Examiner actually supports his death being due to his prolonged assault, as opposed to various interpretations that sought to use the term “cardiopulmonary arrest” to argue that his death would have somehow occurred even in the absence of that fatal action.

“Floyd stopped breathing and his heart stopped beating (cardiopulmonary arrest) because of the injury caused by his restraint in the custody of law enforcement officers, to include asphyxia from neck compression. Asphyxia means that there is a lack of oxygen going to the brain. It can happen from obstruction of the airway, restriction of breathing from compression of the neck or chest, or the prevention of blood flow to the brain by collapsing the blood vessels in the neck.”

So during a busy week that offered no time to write, I was glad that this work was already being done by those whose professional credentials and experience in this area greatly surpassed my own. Otherwise, except for calls to protest with proper transmission reduction measures (masks, hand sanitizer, as much physical distancing as possible given the circumstances) since we are still in the middle of a pandemic, I have seen very little intersection between this particular blog and the protests.

However, as I have watched video after video and read account after account of police forces using “non-lethal” weaponry for crowd control purposes, as I have seen people fleeing from rubber bullets, black college students being tased and dragged from their vehicles without even being accused of a crime, and white elderly men being shoved to the ground and bleeding from their ears, I have realized that there is quite a lot happening here that involves medicine; and in fact, medical misinformation. I would argue (and ought to argue, for the sake of justifying this post in the first place) that the very way we conceptualize these methods of force is a form of misinformation in itself.


“Some of my best friends are cops.”

I’d like to start with two important caveats. They may weaken the overall message of this post, but they are true and so they ought to be included. First, I live in a city where I am frequently genuinely thankful for our law enforcement. Our police and Sheriff’s departments are active in combatting human trafficking and working with local non-profits to ensure that survivors receive support services and counseling instead of prosecution and further abuse. I have been told of police brutality and excessive violence in my community from patients who have experienced it directly, and as a white man in a position of perceived authority as their doctor, it is likely I have not been told as much of it as my patients have to tell. I believe these stories, as I believe that tolerance of any racist practices or police brutality implicates an entire department, and have offered to help those patients seek legal services in addition to helping them cope with the physical and psychological consequences of those experiences. Still, if there is widespread police corruption and brutality here in town, I at least have been blissfully unaware of it (and if it does exist, that ignorance is probably my own fault). If our police department is hyper-militarized like so many seem to be, we have at least seen no signs of it at the many recent protests and demonstrations.

Second, there are in fact men and women I care about and respect who are in law enforcement, and some I love as brothers. At least one even works in evaluating and policing the police themselves. It is hard for me to imagine them acting in the ways I have seen officers act in these videos. Yet we cannot be naive to the internal loyalty and in-group mentality that is deliberately cultivated in police departments around the country (a phenomenon that medicine is not immune to, and has to work hard to fight against). When I pray for these friends, I pray not only for their safety but also for the courage to refuse unlawful and immoral orders and to intervene and report if and when fellow officers commit acts of discrimination or excessive force and violence. As I’ve said for years, being against police brutality does not make you anti-police any more than being against child abuse makes you anti-parent. Just as the best doctors are vehemently anti-malpractice, so the best officers are anti-brutality, discrimination, and excessive force.


We only hope it’s non-lethal force.

What follows is a review of the medical facts and literature regarding the “non-lethal” methods and tools we have seen police using around the country. The main point I would like to establish is that any force, any act of assault with any tool of violence, is only “non-lethal” after the fact. We are fearfully and wonderfully made, and I have seen people recovere from shocking injuries; but we are also frail in so many ways. Often these devices only cause injury or pain instead of actual morbidity and mortality because they fail to impact in one of several particularly dangerous locations, or because their intended targets have the benefits of relative youth and relative good health. Other times, it is the heroic efforts of EMS and ER doctors and nurses that keeps the induced injuries from being fatal. The idea of something being non dangerous because the patient was afterward rescued by hospitals and healthcare professionals is obviously a contradiction in itself; if they needed rescuing, it clearly was dangerous. It is outside the scope of this discussion, but this is the same false use of statistics that certain para-health industries use to argue that they are safer than actual medical care, when really they are counting on the medical field to bail them out when things frequently do go wrong. When we look at lethality, we have to remember that many who are saved might have died; and we have to remember too the extensive suffering and lifelong injuries that also do not show up within mortality statistics alone.

The term ‘less lethal’ is far more apt, and even justifiable; but almost every weapon is ‘less lethal’ compared to firearms. The rate of death from intentional stabbing is very small compared to intentional shooting, but we would never call a knife a non-lethal weapon. As we will see, ‘less lethal’ still means potentially lethal, and many of the weapons and techniques being used still possess the potential to kill. They are not crowd control devices or nuisance stimuli, but weapons. The question we need to be asking ourselves is whether the use of weapons, including weapons with potential to maim and kill, has been justified. If police officers in these videos had no justification to discharge a firearm, did they have any justification to discharge a taser or rubber projectiles?


TASER

I want to begin with the TASER, or Thomas A. Swift’s Electric Rifle, because it is both the most commonly used less-lethal weapon employed by police and also our cultural prototype for what a non-lethal weapon is like. The fact that TASER is an acronym, and that the name is an homage to a racist science fiction novel, is something I only learned today and is outside the scope of this essay; but perhaps not irrelevant to the greater discussion of race as a factor in police brutality and use of force, or the recent use of these weapons against protesters.

Tasers are designed to be truly non-lethal. They deliver a high voltage but low current of electricity through clothing or directly into skin, incapacitating a target but causing no lasting harm. Typically this is in a 5 second burst, but the burst can be repeated or prolonged by the controller. When initially reviewing literature on Taser related injuries, most injuries seemed to be from the sudden incapacitation and not the electricity; bruising and lacerations from falling suddenly or striking an obstacle after the shock occurs. However, some of these injuries are very serious, such as concussions, testicular torsion, and even fractures at the base of the skull and around the eyes; they are still weapons, after all, designed to cause real pain. Still, under controlled conditions, at least, they seem very safe compared to traditional weapons, and it is even common for police officers to have the devices tested on themselves when they receive their training. Our shared mental image of someone being tased and their hearts stopping suddenly, based no doubt on a merely superficial relationship to cardiac defibrillators, just wasn’t readily apparent in the literature.

Or at least, that’s how it felt at first, until I came across this line from a Canadian Medical Association Journal editorial entitled Tasers in medicine: an irreverent call for proposals:

“Tasers are perfectly safe and have never, ever killed anyone. We know this because TASER International, manufacturer of the market-leading device, says so, claiming “the TASER ECD (electric control device) cannot stop the heart”. And TASER International is an honourable, and for most of its existence very profitable, company. So honourable, in fact, that they have sponsored research to prove the taser’s safety. Just about all the research, as it turns out.”

This might be that ‘sarcasm’ thing I’ve heard so much about.

The editorial cites the 2007 death of a man in the Vancouver airport following multiple taser bursts, and goes on to cite instances of TASER International actually suing researchers for publishing evidence that their products can be fatal, and even suing medical examiners for listing taser related injury as a cause of death on a death certificate (and here I am hoping this blog never becomes popular enough to catch their attention). To this the author replies, “Obviously, no one is better suited to instruct a qualified physician, coroner or specialist in forensic pathology on how to determine the cause of death than advisors to a corporation with a vested interest in the device being critiqued.” This criticism piqued my interest and led to a renewed literature search, which muddied the waters a bit more on taser safety.

Animal models of ventricular arrhythmia following taser use. Zipes, 2014.

An extensive review by Dr. Douglas Zipes published in the journal of the American Heart Association found multiple cases of cardiac arrest following taser use. Dr. Zipes, professor at the University of Indiana School of Medicine, states “the published body of evidence now makes it perfectly clear that a TASER X26 ECD shock can induce VF (ventricular fibrillation; a pulseless heart rhythm, i.e. cardiac arrest) in humans, transforming the argument from if it can happen to how often it happens.” He reviews both human cases of taser shots fired to the chest resulting in cardiac arrest, many of whom died, and animal models that support the anecdotal evidence offered by these cases. Finally he concludes,

“Educational material should stress avoiding chest shots if possible and should warn against repeated or long trigger pulls. However, it is clear that a single 5-second shock can induce VF. A user should be judicious with ECD deployment and treat it with the same level of respect as a firearm, suspect cardiac arrest in any individual who becomes unresponsive after a shock, quickly call for medical support, and be prepared to resuscitate, including using an automated external defibrillator if needed.”


While Dr. Zipes does conclude that death due to taser discharge is rare, it is not impossible. Treating these weapons as a safe and excellent way to make peaceful persons exercising their 1st amendment rights do as you say is clearly an unacceptable abuse of these devices.


Rubber Bullets

I think we tend to conceptualize rubber bullets and other high-velocity projectile weapons as a painful reminder that you are breaking the law; a non-lethal but extremely uncomfortable option to enforce compliance with police orders and halt a violent criminal in their tracks. Per my understanding, these projectiles are intended to be aimed at the legs (not aimed at the ground, which can cause bullet to ricochet) and at worst would cause soft tissue injury and bruising. Even in this scenario it turns out that more severe injuries are possible; but the bigger problem is that this isn’t the way these weapons are being used.

As we have witnessed in video after video, these weapons are instead being fired into crowds of protesters, often those who are peacefully assembled, without particular regard for where on the body they land. They are indeed ricocheting off of walls and barricades and are striking people in every part of the body. An article published in the British Medical Journal in 2017 found that the greatest risk from these weapons is when they are used at close range and the projectile strikes the face, head, or neck. These weapons have sufficient velocity to cause skull fractures and intracranial hemorrhage, causing permanent brain damage, or tear through the fragile arteries of the neck leading to rapid blood loss. When these projectiles impact the eye they can cause permanent blindness, or can penetrate through the fragile orbit of the eye and cause orbital fractures which can result in extensive brain injury and death. And while intentional targeting of the head and neck at close range is the most dangerous use of these weapons, firing at longer ranges is dangerous as well; while it decreases the velocity it also greatly decreases the accuracy, increasing the chances that even an appropriately aimed lower extremity shot will veer or ricochet and strike someone in a more vulnerable part of the body.

“These articles included injury data on 1984 people, 53 of whom died as a result of their injuries. 300 people suffered permanent disability. Deaths and permanent disability often resulted from strikes to the head and neck (49.1% of deaths and 82.6% of permanent disabilities).”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736036

Though I have chosen not to include extensive images of these types of injuries on this blog post, they can be found easily enough online. One article from The Internet Journal of Surgery does include images of rubber bullets being retrieved from the neck, where they have lacerated the carotid artery, and from the abdominal cavity; but they aren’t for the faint of heart.

The head and neck are not the only locations that are vulnerable to these types of projectiles. Multiple research articles and case studies report serious injury and death resulting from rubber bullet injuries to the torso. I have quote just a handful below:

“The post-mortem examination revealed that death had been due to gunshot wounds in the chest which had caused heart and lung damage with subsequent massive internal haemorrhaging.”

https://pubmed.ncbi.nlm.nih.gov/18514453

“An autopsy examination of a man who was shot with improved rubber bullets revealed that the bullet caused pulmonary contusion (not the cause of death). The case raised a question as to how severe an injury is necessary to deter a person without causing death.” 

https://pubmed.ncbi.nlm.nih.gov/19696582

“Four projectiles penetrated the right chest lodging in the right lung and injuring the right pulmonary artery, causing death. The mechanism of death in this case is rapid massive pulmonary haemorrhage.”

https://pubmed.ncbi.nlm.nih.gov/16167715
Physicians for Human Rights

The article I quoted at the beginning of this section from the BMJ concludes:

“We find that these projectiles have caused significant morbidity and mortality during the past 27 years, much of it from penetrative injuries and head, neck and torso trauma. Given their inherent inaccuracy, potential for misuse and associated health consequences of severe injury, disability and death, KIPs do not appear to be appropriate weapons for use in crowd-control settings.” 

Yet this is exactly the way these projectiles have been used in the past several weeks. And they have not even been reserved for riot response, they are literally being used for crowd control; to move back crowds of peaceful protesters, to assault those engaged in peaceful civil disobedience, and to clear clergy and lay persons working at a scheduled ministry event on private church property so that the president could use their church for a photo op.


Blunt Weapons and Physical Assault

One of the most understated shocking moments during the episode in Washington D.C. when military and police forces forcefully removed peaceful protesters, clergy, and lay persons from the premises of St. John’s church and the surrounding environs, was the one above when an officer in full riot gear rounded the corner and immediately hit a cameraman in the abdomen with the edge of his polycarbonate shield. Compared to the other methods that police can be seen using in videos of the attack, from flash-bang grenades and tear gas to rubber bullets, this may seem mean spirited but fairly minor; but as a physician, I was pretty shocked.

The abdomen is fragile. There are a lot of organs with a lot of blood flow in that area of the body, and unlike the thorax it doesn’t have a cage of hard ribs offering an additional layer of protection; just some skin, muscle, sub-cutaneous and intra-abdominal fat, and various organs. Of these organs, the liver and spleen are particularly concerning in abdominal trauma, and laceration or rupture of either can result in rapid intra-abdominal bleeding that can quickly lead to death without, and even with, proper medical attention. These injuries can sometimes occur even in healthy patients under seemingly innocuous circumstances. In the 4th season of Scrubs, a patient has a splenic rupture after wrestling with his 10 year son; and it isn’t a ridiculous plot line, medically speaking. Shields are shields; they are meant for defense, and we should be very concerned when police officers use them to play “U.S. Agent” (a more violent and aggressive version of Captain America) and assault peaceful civilians and members of the press. Other weapons, such as batons and clubs, are unlike shields actually intended to cause blunt force trauma and internal injuries, and do it well. When used against violent criminals they are far less lethal than firearms; but again, we are seeing them used against peaceful protesters, members of the press, the elderly, and even medics.

But by far the most shocking image of the week came from Buffalo, where two officers shoved 75-year-old Martin Gugino backward and then left him to lay there bleeding from either his ear or the back of his head, either of which is terrifying (this is the same man whom the president later tweeted might have been an “ANTIFA provocateur”). This is the type of injury that can indeed kill or paralyze, and these two officers could probably just have easily picked him up and moved him out of the way instead of shoving him over. As a doctor in a country with an aging population, I shouldn’t have to explain how obscene this is. Any child or grandchild who has received the call that an elderly relative has fallen knows the sinking realization that life is about to change drastically. Often it is a single fall that heralds the onset of a person’s decline. For instance, the risk of dying within the first year after a hip fracture is 21%, and that doesn’t even begin to paint the full picture of loss of independence and alteration in quality of life that often occurs after a major fall. Fall risk screening is a major component of geriatric care because of how devastating any fall can be in that population, but our screening questions are apparently incomplete; we never ask whether our elder patients plan to attend peaceful protests in the proximity of men who have sworn to serve and protect them.

Sensitive images below.


Tear Gas

There are quite a few more “non-lethal weapons” we could review, such as flash bang grenades, water cannons, and long range acoustic devices, which can cause a number of severe short-term and long-term injuries. But in the interest of time I want to focus on one last topic; tear gas.

Tear gas and pepper spray cause irritation of various receptors to produce tearing and crying, coughing, sneezing, intense physical discomfort, temporary (hopefully) blindness or blurred vision, disorientation, and pain in the throat, mouth, eyes, and lungs. Of course we could conceptualize how using this on a large crowd could cause sufficient chaos to result in more serious injuries, but in general the affects of the agents themselves are very short lived and resolve with washing away the chemicals and exposure to fresh air. There seems to be two major situations where these agents would be more dangerous.

The first is when they are used against individuals with preexisting respiratory conditions such as asthma and COPD, or other medical vulnerabilities, or in situations where proper ventilation and detoxification is not provided. An in-depth 2016 review of the epidemiology of tear gas exposure in the Annals of the New York Academy of Sciences provides the elucidative paragraph below. Of course, when you are firing into a crowd, you are by the nature of that act targeting people indiscriminately, without regard to their personal risk factors or able to offer individual aftercare to those who have suffered more severe injury.

But the second situation where these weapons are extremely dangerous is, as you might have guessed, during a global pandemic caused by a deadly respiratory virus. My most recent blog post discussed the difficulties of gauging the degree of asymptomatic transmission; we know it happens, but we don’t know how often. Part of the difficulty is that the virus is spread primarily through respiratory droplets, so while the viral load is sufficiently high in asymptomatic carriers, the mode of transmission is less well understood. When tear gas and pepper spray are used against peaceful protesters at the height of the COVID-19 pandemic, symptoms that spread respiratory droplets, like coughing and sneezing, are induced and the asymptomatic and presymptomatic among them are themselves weaponized. And the injuries caused by this weaponization, unlike the use of rubber bullets and tasers and police batons that injure or maim or kill only the intended target or bystanders, has the potential to spread to the family members, children, parents, and grandparents of those affected.

As I write this, our city has had the highest number of new positive COVID-19 cases in one day that we have had at any point in this pandemic. We seem to be entering the first true surge we have experienced here in Texas, and this is mirrored in various cities and states around the country. And while individual protesters and organizations continue to be faced with the very difficult decision of how to balance safety during a medical crisis with their desire to advocate for systemic changes that will lead to long term justice, the police departments in those various cities, with their personal respirators and canisters of tear gas, seem to have decided that using the terror of the pandemic is not outside the scope of measures that they are comfortable with.


But aren’t they at least better than guns?

This is the question I am really wrestling with today. The mortality rate for an assault with a firearm dwarfs all of the above agents and tools, and so it seems very reasonable, on the surface, to be thankful that the law enforcement agencies and officers engaged in these actions were armed with these not-as-lethal-as-guns weapons instead of with guns alone. It is conceivable that instead of hundreds of minor and dozens of major injuries from over a week of police using these various devices against protesting crowds, we might see dozens of deaths and hundreds of major injuries after just a single attack with firearms. One of the core questions we have to ask ourselves is whether the use of these weapons, as part of arming police forces as though for war and sending them en masse to confront groups of non-violent protesters, contributes to a sense of anonymity and freedom from culpability that lowers an officer’s threshold for escalating such encounters. We have seen video after video where police officers dressed in full body armor take sudden and aggressive actions against crowds ranging from the fairly unruly to the utterly non-violent to medics and priests. Perhaps if they had been armed only with firearms, the realization that every life they fired upon would be forfeit, every citizen they attacked a casualty, would be enough to give greater pause before lashing out at non-violent protesters or using their weapons as tools to enforce obedience to the wills of their superiors.

Or perhaps that is a naive and privileged hope, built upon a lifetime of not even being able to imagine a police officer ever shooting me.

Regardless, it is clear from medical research that these weapons are weapons indeed. They cannot be merely dismissed with a wave of the hand as though the damage they caused were transient or their potential to kill negligible. When used in a situation where the only other choice is a deadly weapon, it is likely enough that they represent the most merciful option. But when law enforcement officers use them against those who have committed no crime, have offered no violent resistance, have in fact merely expressed their right to assembly to protest the murder of yet another unarmed black man through excessive and particular police brutality, they represent an unacceptable risk to the public that those officers have sworn to serve and protect, and demonstrate the very calloused disregard for human life that have triggered such protests in the first place.

Apparent medical misinformation from an unlikely source: Asymptomatic, Presymptomatic, and Minimally Symptomatic.

On Monday, during a World Health Organization virtual press briefing, Dr Maria Van Kerkhove issued a statement that seemingly shook our entire understanding of the COVID-19 pandemic. Dr. Van Kerkhove is an Epidemiologist specializing in emerging infectious diseases and has been the technical lead for the WHO COVID-19 response team. The statement, which was immediately picked up by multiple news outlets, was this one:

It still appears to be rare that an asymptomatic individual actually transmits onward.

Dr Maria Van Kerkhove, World Health Organization

Needless to say, the response was immediate, and massive. For months we have been treating every person we interact with, including and especially ourselves, as though we were potential sources of COVID-19, in order to flatten the curve and prevent both a surge of cases and the possibility of our healthcare systems being overwhelmed. We were told, early and often, and with increasing levels of scientific certainty, that it was not enough to simply stay home if you were coughing or had a fever; that we could spread the virus even before we had developed symptoms, or if our symptoms were only very mild, and that the person we spread it to might not be so fortunate. Suddenly, the WHO seemed to be making an about-face.

For those that are exhausted of the caution made necessary by the pandemic, and the associated anxiety (read: all of us) it was welcome, if somewhat annoying, news. For those who have consistently proclaimed the pandemic to be something between an overblown flu being used for political purposes to an actual hoax or planned conspiracy, it was a triumph; even the WHO was saying it wasn’t anything to worry about. But for many of us who have been following emerging evidence, testing methods, contact tracing techniques, and COVID-19 data from around the world since March, it sounded too good to be true.


What we all wanted it to mean.

The idea of asymptomatic transmission, the virus actually being transmitted from a person who does not feel ill, who may not even know they have been exposed, is pretty terrifying. It means that you could, without ever knowing it, be the agent of delivering a deadly pathogen to a loved one; and that you may not ever know you were the one that gave it to them even after the fact. The idea of someone who has never had the virus losing a family member to it, and then finding out months later that they are antibody positive and have thus been a carrier at some point, is heart breaking. For me, it conjures epidemiology computer simulations of faceless grey figures gradually turning red, as the world slowly but surely is overcome.

This is the stuff of nightmares.

If Dr. Van Kerkhove’s statement meant that only those with symptoms could possibly pass along the virus, it would make all the difference in the world. For one thing, it would drastically change our isolation and transmission control strategies, shifting our focus from social (physical) distancing and treating all contacts as possible COVID-19 contacts, to simply monitoring very well for cough and fever and other viral symptoms, like we already do for influenza and other respiratory illnesses. Although it wouldn’t mean the virus was less dangerous, it would mean that exposure to it was somewhat predictable; if we were careful, our biggest risk would be those few bad actors who had symptoms but denied them, and persisted in exposing others.

And yes, it would also mean that many of the experts, epidemiologists, and physicians (including myself) (that’s an oxford comma folks, and I’m definitely only including myself in that last group) had been wrong about both the degree and the nature of risk to our society. But here’s the thing; we would be fine with that. It would be a big hit to the ego, for sure, and I’d of course have to delete this blog before I applied for my next job, but overall eating crow is an incredibly small price to pay for the assurance of safety for my family and my patients, and for the assurance of a sound strategic path forward in defeating this virus once and for all. As we’ve said all along; every doctor who sounds like an alarmist about COVID-19 also hopes they are wrong. We are the exact people who would be the happiest if it somehow turned out it wasn’t that big of a deal.

It would also mean that somebody had a lot of work to do to figure out how COVID-19 had overwhelmed so many healthcare systems and decimated entire cities and nations. We would need to account for those 404,000 deaths worldwide, a quarter of which have occurred in the United States. If those people were all exposed by individuals with definite and likely identifiable symptoms, we would need to figure out why we had failed so badly at fighting such a straightforward viral disease.


Always go to the source.

When I first read the headlines and articles, I was cautiously optimistic; but very cautiously. This defied what we had believed all along, and it defied most of what we know about the way that respiratory viruses spread. It didn’t make sense with the transmission patterns we have seen and the reported K value of the virus for it to only spread through fully symptomatic patients. It also conflicted with two recent studies from China and Singapore that seemed to indicate that transmission does in fact occur, and at a high rate, from patients without any respiratory or viral symptoms. These studies reached similar conclusions despite very different methodologies, which is always more convincing than reaching the same conclusion with the same method or data set. The Singapore study concluded,

“The evidence of presymptomatic transmission in Singapore, in combination with evidence from other studies, supports the likelihood that viral shedding can occur in the absence of symptoms and before symptom onset. “

https://www.cdc.gov/mmwr/volumes/69/wr/mm6914e1.htm

Still, I was hopeful. When I reviewed those studies there had been some assumptions and a few minor (and one major) methodological issues I wasn’t exactly comfortable with, and at any rate those studies were published back in April and we have learned an awful lot about SARS-CoV-2 since that time. I assumed that Dr. Van Kerkhove and the WHO were working from the most up-to-date data, so I did what I always advise people to do when evaluating emerging medical information; I went directly to the source. It’s a bit long but it’s worth reading Dr. Van Kerkhove’s entire answer and not just the excerpts that have been used in the various articles above.

Now, I know what you are asking; if these statements were confusing, why didn’t I ask her to clarify? Well, actually… that was a different TJ altogether.


Asymptomatic vs. Presymptomatic vs. Minimally Symptomatic.

There is one major component of Dr. Van Kerkhove’s answer that has been lost from most of the majors news stories and social media posts. Medicine and public health are subtle and detail heavy sciences, and it is unfortunate but perhaps unsurprising that the nuances of the above statement were lost, and that major news outlets reported “WHO says no asymptomatic spread,” when the real answer is much more restrained.

Dr. Van Kerkhove spends a considerable part of her answer specifically delineating between asymptomatic, presymptomatic, and minimally symptomatic cases, and it’s hard to put too fine a point on this distinction.

  • Asymptomatic cases are people who have been exposed to the virus, and it has reproduced itself within their bodies at a high enough rate that it becomes detectable by our testing methods; either it is present in their blood stream at a detectable rate at some point in time (they have a positive PCR test) or they have developed an immune response that can be detected after the fact (they have a positive antibody test). They have had the virus. However, they have never at any point had any symptoms they can identify; no day of fever, no fatigue, no cough, no ‘I thought I caught something but it got better’; they are fully non-symptomatic.
  • Presymptomatic cases are people who meet all of the above criteria at a certain point in time, but will eventually develop symptoms from the virus. Unless they are followed very closely, it is impossible to distinguish them from asymptomatic cases.
  • Minimally Symptomatic cases are people who have the virus but develop only very mild symptoms, or symptoms not as commonly associated with the COVID-19 syndrome. This is very, very challenging from both a diagnostic and an epidemiological standpoint. Many people have chronic cough, allergy symptoms, or shortness of breath related to chronic medical issues. Figuring out whether these symptoms worsened at a certain time that coincides with their SARS-CoV-2 infection, and that the infection was actually the cause, is nearly impossible, yet the way these cases are treated has huge implications in the way we understand data on asymptomatic transmission.

If you are reading this and thinking that these distinctions seem a little murky and difficult to unravel, you aren’t wrong. I don’t do contact tracing directly, but the idea of clearly delineating, over the phone and after the fact, between these three situations seems like a nightmare. Yet our understanding of the spread of this virus, and thus our risk to one another, hinges strongly on public health workers involved in contact tracing categorizing people into these groups with a high degree of fidelity. It is sound epidemiological work and is necessary and important, but realizing how much subtlety and difficulty is involved should make us wary of any overly optimistic (and yes, overly pessimistic as well) statements about risk based on such data. This is why it is so important that this data is compared to research on modes of transmission, viral shedding, and viral load in asymptomatic patients, and that all of those types of evidence be weighed together very carefully.


When misspeaking and misunderstanding becomes medical misinformation.

So the substance of Dr. Van Kerkhove’s answer is that unpublished data from an unknown number of countries, relying on methodology that is hardly foolproof (but may be the best we have available), seems to show that transmission of SARS-CoV-2, from the subset of people who will never develop even very mild symptoms, is rare. It is good news, but it is an incredibly measured response when properly understood, and the phrasing left it alarmingly ripe for misunderstanding. As soon as media outlets picked up this story it was clear that the original intent had not been understood, and that widespread confusion, vexation, and misinformation would result. On Tuesday, Dr. Van Kerkhove and the WHO attempted to clarify the statement.

“The majority of transmission that we know about is that people who have symptoms transmit the virus to other people through infectious droplets. But there are a subset of people who don’t develop symptoms, and to truly understand how many people don’t have symptoms, we don’t actually have that answer yet.”

Dr. Maria Van Kerkhove

But as you might have suspected, the damage was done. One of the most alarming things about misinformation in general, and medical misinformation in particular, is how those who share it are seemingly impervious to correction. They will choose to continue to believe information that has been demonstrated to be impossible, videos that have been proven to be a hoax, and now even statements that have been immediately retracted and clarified by those who uttered them. When confronted with the retraction, I have seen people essentially say, “well I believe it anyway.” Even today we are seeing people spread the original articles and double-down on the claim that asymptomatic spread (meaning, in their vernacular, ‘anyone without cough and fever’) is not possible, and that the WHO has finally confessed their complicity in this global conspiracy.


So… Is asymptomatic transmission still a thing?

I had hoped that we would be presented with the data Dr. Van Kerkhove had reviewed indicating the rarity of asymptomatic transmission. We have not seen that information yet, but other studies have reviewed available contact tracing data and arrived at a very different conclusion. Two recent studies were published on asymptomatic and minimally symptomatic spread within the last two weeks, one on May 28th in the journal of the Infectious Disease Society of America, and one on June 3rd in Annals of Internal Medicine. They offered similar conclusions:

“This review summarizes evidence that SARS-CoV-2 transmission is not only possible but likely highest during pre-symptomatic and asymptomatic phases.”

https://doi.org/10.1093/cid/ciaa654

“The early data that we have assembled on the prevalence of asymptomatic SARS-CoV-2 infection suggest that this is a significant factor in the rapid progression of the COVID-19 pandemic. Medical practice and public health measures should be modified to address this challenge.”

https://www.acpjournals.org/doi/10.7326/M20-3012

Both studies supported the high viral load and infectivity of presymptomatic individuals who would later go on to develop symptoms, which had been found in the China and Singapore studies in April. Both established, firmly, that transmission from asymptomatic individuals who would not go on to develop symptoms does in fact occur. They both analyzed the limitations of their methodologies and data sets, and explored the difficulties in distinguishing between asymptomatic, presymptomatic, and minimally symptomatic patients. Hence they both appropriately shied away from assigning any firm degree of risk or responsibility for transmission to asymptomatic spread of the virus. Unfortunately, we do not have reliable numbers for how many people are getting the virus from someone who will never know they have it. More studies are needed, but it seems clear that asymptomatic transmission is here to stay, at least as long as COVID-19 is.

COVID-19 as a Mass Casualty Event; my response to a letter signed by 600 doctors.

Over the weekend I had several viral medical misinformation videos sent to me, but I chose not to focus an entire essay on any of them for various reasons. One was a nurse speaking at a re-opening rally in Raleigh, North Carolina about empty hospital rooms and postponed surgeries. We’ve talked about healthcare systems being slower in pre-surge areas due to mitigation efforts a good bit in prior blog posts, and since the actual content of her comments were relatively straightforward and could be as easily interpreted as praise for social distancing measures as criticism, I decided it didn’t necessitate and entire post. Another was an interview with Dr. Jeffrey Barke, a concierge medicine doctor in Orange County, California who had recently spoken at a re-opening rally there. While there were a few medical issues he raised that deserved some response (bringing up hydroxychloroquine again, failing to distinguish between the medical realities in pre-surge areas vs. those more heavily effected), his comments were primarily politically rather than medically oriented. Finally, there was an immediately debunked video of Bill Gates briefing the CIA on his plan to release a respiratory virus, and then give a vaccine for it that would actually modify people’s brains to make them hate religion. Which, I mean, come on America. Really?


Instead, what caught my interest is the following letter to President Trump, signed by 600 doctors.

Page 1
Page 2

The remaining 8 pages are a collection of signatures from, presumably, over 600 other doctors. The letter itself was written by Dr. Simone Gold, MD, an ER trained Physician in California who now does concierge medicine as well. It is part of her A Doctor A Day campaign and has been featured on Forbes, Fox News, Breitbart, etc. and circulated widely on the internet. Today I would like to focus on the parts of this letter I agree with, for there is much to agree with, and then explain the one great error I believe Dr. Simone is making. But first, we should address a few preliminaries. 


Signed by 600 Doctors

When reading a letter like this, the temptation is to get dragged into those last 8 pages and try to address the motivations, credentials, and biases of the doctors signing. Certainly, with 600 signatures this becomes an investigatory nightmare, but I believe it would be a profitless endeavor even with a more manageable list of names. When a doctor shares blatantly erroneous data, like Dr. Erickson and Dr. Massihi, or a scientist promotes false claims and conspiracy theories like Dr. Mikovits, a closer examination of motives is warranted. But unlike those viral videos, there is as far as I can tell no false medical information contained in this letter. This is a position statement, and while some individual co-signers may have their own political or financial motivations, I earnestly believe it is best to take the stated motivation of advocacy for individual patients and our population as a whole at face value. 

That said, I believe we can make some general observations, and to do so I will bring you thought my own process when confronted with this list of names.

First, I checked to make sure my own name wasn’t listed. I don’t remember signing anything like this and don’t believe I would have, but arguing against the letter and then finding out my name was on it would be the most embarrassing (and funniest) complication to my opposition that I could think of.

Whew, close one.

Second, I googled a few of the names. Now nearly 3 months into fighting against medical misinformation in a more formal and deliberate way, I have learned to be surprised by less. I didn’t think anyone would make up 600 doctors to support their letter, but wanted to make sure. I only chose a handful at random, but they were all real life people. 

Third, I read about a few of them. The first doctor I looked up had his medical license revoked 20 years ago. Oomph, rough start. But the next practices Family Medicine in California, another is an Ophthalmologist who does LASIK eye surgery, and the one after that is an Emergency Medicine doctor in Connecticut. As I googled a dozen or so names I did not find anybody practicing Emergency or Critical Care medicine in New York, and didn’t really expect to (though maybe there are a handful on this list); but that first doctor who isn’t allowed to practice medicine anymore seems to have been a funny coincidence, and overall it seems that these are, by and large, real practicing Physicians in various specialties around the country. I can in no way vouch for or against their personal experiences with COVID-19, their level of experience or skill as clinicians, or their political views.

Finally, I looked over the list itself and reflected on the numbers. A few Dentists and PhD’s, a few people listed without any credentials, but mainly MD’s and DO’s; Doctors of Medicine. I made a quick scan to make sure there wasn’t anybody I knew, which could get awkward. There are over a million doctors in the United States, as Dr. Gold’s website points out, and here we have 600 names. No doubt there are many, many more who would sign such a letter. If you are trying to google individual names or even just scrolling through, it seems overwhelming; but it’s actually a relatively small group. I am part of one COVID-19 Physician and NP/PA group on Facebook with 150 thousand members, and a Critical Care COVID-19 group with 33 thousand members. The discussions there are focused on treating and preventing the illness, the most recent studies, transmission control strategies, and review of treatment protocols. While many of us are also very concerned about the secondary effects of the virus, such as the complications of isolation and distancing, I have seen no posts and very few comments saying that the whole thing has been overblown. I could not say how many in those groups would or would not sign the letter above, but the idea I am trying to get across is that 600 doctors in a country the size of the US is a fairly small sample. When taken as a whole this letter really does seem to represent a minority opinion, as the website itself alludes to.


A Doctor A Day

Dr. Gold’s personal website, drsimonegold.com (can you believe she used her name as her website url? The arrogance), currently redirects to A Doctor A Day, which almost -but not quite- admits to it’s goal of offering a minority, dissenting opinion of the importance of mitigation strategies in fighting COVID-19. It begins with the following text:

The numbers here send a bit of a mixed message, don’t they? On the one hand, they clearly would like to contrast “ONE opinion” with both the million licensed physicians and the thousands of physicians who have something to tell you. But a straightforward reading is maybe too honest by half; there are nearly a million physicians who seem to be expressing one opinion, that COVID-19 is very dangerous (that’s called a consensus); but thousands of doctors want to give a second opinion, that it isn’t dangerous enough to justify the steps we’ve taken. I’m being quite facetious here, of course, but I do think that they are trying to have their cake and eat it to by implying both that the views of doctors are varied and nuanced, and that the doctors who agree with them are thinking independently while the rest of us are towing the party line and sharing “just one opinion.”

That’s why the second opinion part is what really gets to me, because it so clearly implies that the views expressed by A Doctor A Day are not also being expressed by other physicians who nonetheless support mitigation measures. And that simply isn’t the case. I’ve yet to meet a doctor who isn’t aware of, concerned about, and talking about the potential for secondary harms due to social distancing and quarantine strategies, and the ones I know are working very hard to mitigate those harms. I’ve personally been talking and writing about it since early March. In fact, recognizing how much more vulnerable our patients are in the midst of a pandemic has been a core reason for the mitigation and social distancing measures since day one, because an overwhelmed healthcare system has even less ability to care for patients with chronic illnesses and mental health conditions than a reduced capacity healthcare system.

March 16th
March 14th

The A Doctor A Day campaign is promoting a narrative that says the many, many physicians and other healthcare workers encouraging ongoing social distancing and quarantine measures and extreme caution with reopening have simply not thought of, or have refused to acknowledge, the difficulties that those measures create for our patients and our communities. But their second opinion is already contained in the first; it has been weighed carefully, it has been felt deeply, and in the face of a hundred thousand lives lost and who knows how many million in the balance, most of us have found the danger still too great to abandon our fight against the virus. The opposite cannot be said; the doctors vocally forwarding this alternative perspective have been strangely reticent to acknowledge how bad the virus really is, sometimes even leaning on ‘inflated death numbers’ and other misinformation to lessen the reality of what we are facing.


The Videos
Dr. Scott Barbour M.D. you have GOT to turn your camera to landscape…

Besides the homepage and the letter, the main content is a series of videos featuring interviews with Physicians who talk about the damage and potential damage being done by shelter-in-place orders and social distancing. They run about 5-10 minutes long each and so far there are four, though the link for one seems to be broken. Interestingly, some of the interviews are conducted by Dr. Jeff Barke, who seems to be a partner on the project. There are some problematic moments, mostly in the form of leading questions such as when Dr. Gold asks one Physician how he kept his office open when ‘we have heard from around the country that most patients can’t come see their doctor’, without offering any evidence that this is the case, or when Dr. Barke asks a Cardiologist about caring for Congestive Heart Failure patients when ‘they can’t get Echocardiograms’, which also doesn’t seem to be the case. But these doctors being interviewed sort of hedge on those questions, and mostly they spend their time expressing their concern about the potential negative health effects of mitigation strategies on their patients, like most of us would, and the things their clinics are doing to compensate. I think a video series like this invites comparison. Consider this video from Dr. Mike, who does a handsomer and more successful YouTube version of what I am trying to do on this blog.

The most striking thing to me about these videos is that the doctors from both sides of this discussion seem to be genuinely and primarily concerned about the well-being of their patients. Which shouldn’t be a surprise if you know many physicians. The second thing I notice is that it doesn’t seem hard to get doctors to tell you about their experiences during the COVID-19 pandemic; a contest of who can make the most videos or recruit the most signatures isn’t likely to be helpful, which is why it’s important we look closely at the arguments themselves.


The Letter: What I Agree With

I wrote about treating COVID-19 like a nation-wide mass casualty event back in March, and in many ways I agree with Dr. Gold’s concerns. Faced with such an overwhelming medical reality, one of our first goals has to be to ensure that our vulnerable patients “do not deteriorate a level.” As a primary care physician caring for patients who often have limited access to specialists and treatments at baseline, I and my patients have had to be especially deliberate and strategic about caring for their conditions during COVID-19 while the medical system is even more challenging to navigate. Many of my patients lived pre-COVID-19 in what Dr. Gold describes as ‘triage level red’; poor or no access to cancer screening, unable to afford dental care, not having access to Psychiatry for ongoing and often overwhelming mental health issues. The list could go on; patients with seizures who can’t see a neurologist, those with CHF who can’t get an Echo, not because they aren’t being scheduled right now, but because they cost $2,000. Diabetics whose control has worsened because their insulin prices suddenly skyrocketed in the name of profits. If these doctors are going to advocate for patients who could normally have these services done but might not now because of COVID-19, they should also be advocating for the patients who have never had access to these services and thus live and die in triage level red. Maybe some of them are advocating for those patients; but they all should be, and if they are willing to sign this letter to the president out of that concern then all 600 of their signatures should be on the next petition to improve healthcare access for all.

But COVID-19 is the reality right now, and regardless of the individual examples (it is a hard sell to prove, for instance, that a hip surgery would have reduced someone’s risk of a pulmonary embolism), I have seen many situations similar to the ones they mention in the letter, and some have indeed been made worse by COVID-19; both by fear of the very dangerous virus itself and by the disruptions to ‘normal’ life rhythms and support structures, financial difficulties, and loss of community. I do not have to imagine those stories from the initials and brief vignettes in their letter; I have the names and faces of all of my own.

We all do. Every physician and clinic I know is involved in combatting this, not to mention ministers and priests, social workers, mental health workers, and teachers. I feel like a broken record when over and over again I have to share the changes my own clinic has made to create safe access for patients; seeing patients outside in their vehicles to decrease transmission risk, rapidly building and implementing telephone and video visits without any precedent or prior infrastructure for using those tools, designating COVID-19 testing and treatment sites to keep sick patients and vulnerable patients from putting one another at risk, and all of the individual and corporate work and stress that goes into examining and upending every single protocol and procedure you have used for years. We do all of this because as hard as we worked to ‘flatten the curve’ in March and April, and as loud as are being about preventing a second surge now, we are also worried about that third surge, and are working hard now to flatten that curve, too. The balance of each of those threats has to be weighed in deciding when and how to return to our ‘normal’ routines, if such a thing can even exist again.


Mass Casualty Event

Finally, I want to return to Dr. Gold’s central analogy of COVID-19 as a Mass Casualty Event. A mass casualty event is a situation where so many are injured that the available resources could not possibly care for everyone who needs care. This is the Oklahoma City Bombing, or 9/11. Dr. Gold is right, that in a ‘mass cas’ the most important first step in caring for the injured (besides safety, of course), is an effective triage system. She talks about the color-coding system we use for these types of events, and I think it’s worth studying for a few moments. I’ve provided a couple of different representations, because I want you to understand just how different a mass casualty event is from the normal way we practice medicine.

To the untrained eye, it looks like these diagrams are used to train doctors and other medical professionals to triage patients. But they aren’t. Triaging patients is not a difficult concept, but it does take some time to master. Sorting out those that need immediate attention from those who can safely wait is a skill that is taught early and honed daily. You do this in every context of medicine almost all day long. It is most obvious in the hospital and the ER, when your visit with a sweet older lady recovering from pneumonia is suddenly cut short by sudden shouts from down the hall or a Code Blue over the speaker. But it also happens in clinic, when you hear the crash of a walker in the waiting room or notice that your 2:45 PM “Arthritis recheck” is now listed as having a chief complaint of “Chest Pain,” or your 9:15 didn’t come to clinic even though you know he’s been severely depressed. We triage in our minds constantly, and Mass Casualty is a specialized enough field that our training in it typically comes after we have already been triaging in our minds constantly for years.

These tables are not for training us how to Triage. They are for re-training us how to Triage in a way we are very, very uncomfortable with. They are, in a way, un-training us.

Think about those categories, and what they mean. Green means that person gets none of my time or attention; even with injuries, even having suffered trauma. People I might otherwise spend an hour with talking through their experience and tending their wounds, I deliberately re-route and ignore to get to sicker patients. Yellow is someone who has urgent needs, who probably needs care within the hour. In the ED this would be considered a very ill patient, and someone who is going to get immediate attention; in a mass cas event, they are set to the side because the sicker, red patients need attention now, and the resources are simply too limited. Finally, think about my examples from the hospital, and look back at those tables one more time. Notice black: “Obvious death,” “Non-survivable injury,” “Cardiac Arrest.” Normally if you are running through your continuous mental triage and suddenly find a patient in cardiac arrest, requiring chest compressions, intubation, and defibrillation, that patient becomes your highest priority. Your time and resources are devoted to that individual for as long as it takes, as long as there is a chance. In a Mass Casualty Event, those patients are left for dead.

This is why we do specialized training in mass casualty; this is why we have to study and internalize and accept a triage system that is alien and even repulsive to our oath as physicians and every carefully fine-tuned impulse of our professional judgement. Because the idea of allowing an untimely death that might have been prevented is so terrible to us that it requires a drastic shift, on some level, away from how we’ve trained and even who we are as physicians.

The physicians who wrote this letter are advocating that life return to normal. They are advocating for this from a noble enough sentiment; concern for the well-being of those who they consider to be at Red, Yellow, and Green levels of risk right now. But just as in every mass casualty, their call to shift our standard of care and give our full attention to those groups by abandoning transmission reduction strategies necessitates allowing some to die who might otherwise have lived. This ‘black’ group that should be forsaken, who in the letter’s own words “require too many resources to save”, are the excess dead from COVID-19, who might have been spared by “reopening” with more caution, more national sacrifice, more people-centered policies, and more patience.

Nowhere in their letter do they mention the 100,000 we have already lost, or the thousands more still fighting for their lives. Nowhere in their letter do they mention the suffering of those families, the sacrifices and risk of their caregivers, or the fear of those exposed. Nowhere do they mention the mental health burden inflicted by the virus itself on all those who come in contact with it. All of these should be crucial factors in our decisions about when and how to decrease mitigation efforts. But if you are going to lead a mass casualty response, I guess you have to be willing to walk past some who are dying and force yourself to live with the fact that you had the skills and the tools to save them, but didn’t. The majority of physicians, myself among them, seem to think that we haven’t reached that point yet; that as a society we can continue to protect one another and the vulnerable among us from COVID-19 and still devote time and energy to keeping others from ‘deteriorating a level’ while we fight it, by rethinking the ways we deliver care and support our patients and communities. Maybe that’s typical physician hubris, and maybe the second opinion offered by Dr. Gold and her colleagues is the only real option; to shift our focus to the ‘survivors’ even if it means giving this virus another 100,000 lives, or more. But I don’t believe that’s where we are, and I know it isn’t a decision we can make without counting the unimaginable costs very, very carefully.

I absolutely do look at your insurance (repost).

In late 2019 I began to write about my experiences as a Family Medicine Physician, and particularly my motivations, reasoning, and practice style. Over the last decade of medical school, residency, and practice, I had come to believe that the steadily eroding trust in doctors was a true public health emergency. My theory was that, while some of this was due to profit or power-driven elements like the anti-vaccine movement and alternative health industry, and some was due to legitimately unconscionable treatment at the hands of a relative few unethical and immoral doctors, the vast majority was due to the complex and often confusing nature of medicine itself. I believed, or at least hoped, that if people understood their doctors better and knew how deeply they cared about their patients and how hard they worked for them behind the scenes, they would come to see doctors- and other healthcare professionals- as I do; as their allies and advocates in our deeply broken healthcare system.

Since the COVID-19 pandemic began I have found my attention called more and more to medical misinformation about the virus, which is what ultimately led to my starting this blog. Yet at the heart of so much of this misinformation is that same mistrust and suspicion. So partly to find a home for these few stray essays, and partly to continue pursuing my original goal of pulling back the curtain and helping others better understand the convictions and reasoning their doctors bring to their care, I am sharing these posts here.


Originally posted December 5th, 2019.

30 Days on Doctoring: I absolutely do look at your insurance.

Every day I hear from a friend or a patient, or see an article, a post on social media, or somewhere else where someone has written that your doctor only cares about you if you have the right insurance. Doctors will only order the right test, only give you the ‘real’ medicine, only spend their fair share of time face to face with you if you’ve got the right coverage. The link between your local PCP and the Walgreens across town or the medical equipment company isn’t exactly clear; somehow the doctor is getting kickbacks, though, and those kickbacks don’t happen if you are paying out of pocket or if you have to use a coupon or have the types of insurance that don’t come with a premium ‘gold status’ membership; to have the right insurance is to be in the club, and everybody else is left to suffer and make their way the best they can.

I’d love to tell you that I don’t care what insurance you have. I’d love to say it just doesn’t matter to me, that every patient gets an equal share of my time, energy, and attention. I’d love to tell you that I treat your CHF and shoulder pain exactly the same if you have Medicare, or Blue Cross and Blue Shield, or our local state grant funded coverage program, or are paying out of your own pocket.

But it isn’t true.

My confession: I absolutely look at your insurance. Every day, every patient, every visit. I may even ask you what insurance you have, right in the middle of our visit, just in case that tab on my computer screen isn’t accurate or up to date. Let me tell you why.

Let’s say you come to me for that congestive heart failure that we just mentioned. For the sake of discussion, let’s say you’ve never been diagnosed with it before and have only recently developed the symptoms (dyspnea on exertion, unexplained weight gain, swelling in the legs) and have risk factors (a heart attack a few years ago, years of high blood pressure, a strong family history of heart failure). I’m going to need to do a few things regardless of who you are and what your insurance is like. We are going to spend time talking about your symptoms; when did they start, what have you tried already to relieve them, are they getting worse and if so how quickly? We are going to talk about your history; has this happened before, has it already been worked-up and to what extent, any other medical problems that could be causing these same symptoms, mimicking CHF? And we are going to do an exam; listen to your heart, listen to your lungs, press on your legs to see if and how much swelling you have and whether it is pitting or non-pitting, check your abdomen for pain and free fluid or enlargement around the liver and any signs of cirrhosis (which causes a lot of the same symptoms as heart failure). We are going to do all of this for every single patient presenting for the symptoms of CHF. And then we are going to get an EKG, because it’s quick and fairly cheap and can be done in my office and gives us some good information about your heart.

Then I’m going to look at what insurance you have- and maybe even ask a little bit about your finances- because here’s what else we need in order to figure this out:

  • Basic labs including a complete metabolic panel (CMP- information about kidneys, electrolytes, and your liver), maybe a complete blood count (CBC).
  • A B-natriuretic peptide level. This is a protein produced by the chambers of your heart in response to increased stretch/pressure, and it helps lower pressure and -as the names suggests- works as a diuretic to clear fluid. As a lab test, we use it as a surrogate for how much the pressure within your heart chambers is increased; a marker of congestive heart failure and the resulting overload of fluid.
  • A Chest X-Ray to evaluate whether there is extra fluid both in the blood vessels that supply your lungs and in the pleural space around your lungs, and whether your heart is enlarged.
  • An Echocardiogram; this is an ultrasound of your heart and the most important test in your CHF work-up; it tells whether the heart is actually pumping normally and if not, exactly which chambers, valves, and phases of your heart beat are affected.
  • A referral to a Cardiologist, and probably some associated programs like CHF clinic and cardiac rehab.
  • Treatment! Not only cardiac rehab, but dietary and lifestyle changes and also multiple cardiac medications.
  • A follow-up appointment with me to look at the results of all of these tests, make sure we really have the right diagnosis, and evaluate whether your treatment is helping you at all.

You’ve all been around the block, so I don’t have to tell you how expensive this is all going to be. The answer is: probably very very expensive.

And if you have Blue Cross Blue Shield, or better yet Medicare or Medicaid, that’s probably ok. You’ll have some out of pocket expense and maybe have to meet a deductible; it could still be a financial hardship, but with your insurance it shouldn’t be a true financial disaster, at least not all at once.

But what if you don’t have insurance? Or what if your coverage is grant funded and only applies to the treatments we can do in-house? Well now we have some decision to make.

Labs: Some of this blood work is more expensive than others, and some is more vital for working-up this condition than others. In some situations our in-house lab is going to be your cheapest option, but sometimes it’s going to save you a lot of money for me to order the labs to be done at another site where you pay cash up-front for a cheaper price. This is actually more work for me and my staff, but if it saves you the money you need to put away to get some of this other work-up done (or, you know, pay your rent this month), then it’s worth it. The decision of where to do which labs and trying to figure out how much it’s going to cost you is one I have to make a dozen times a day.

Imaging: Again, we can do some of this in-house, but we’ll need to talk about the cost. I don’t have as many options for outside imaging; we can do your x-rays here and the hospital can do your Echo, but there are costs associated with both. If you are paying out of pocket or only some of these tests are going to be covered, we need to prioritize and work on figuring out exactly how much each is going to cost you. Some hospitals have patient assistance programs; maybe you would qualify, so we need to get you in contact with the right department and start getting cost estimates. Again, more work for me and my staff, not to mention for you, but the alternative is for you to end up with an unexpected $2,000 bill for the Echo I ordered, and then you might not be able to afford the ACE Inhibitors, Beta Blockers, and diuretics you are going to need to actually treat this condition. Which brings us to…

Medications: Do you know how much a month’s or 3 months’ supply of those medications costs? Do you know which is cheaper with HEB or Wal-Mart generic pricing, which is cheaper with a GoodRx coupon (at the pharmacies that will accept one), and which is cheaper at our clinic’s pharmacy? I do, because a medication left at the pharmacy because it was too expensive has just unbelievably poor bioavailability. It looks great on paper if I prescribe all the right, best medications; it does nothing to help your heart if you can’t actually get those medications. So we are going to talk about each medicine and the rationale for it, the risks and benefits, etc.; of course we are. But we are also going to talk about which pharmacy you want to use, how much I expect it to cost there, what the alternative options are, and because I’ve been burned in the past I’m going to say the same phrase at the end of almost every single patient visit; “If you get to the pharmacy and one of these medications costs more than we are expecting, and the cost is prohibitive or just seems really high, please call us before you buy it so we can look for a coupon or recommend an alternative.” The first time your patient tells you they borrowed money from friends and family so they could pay for the $120 medication you prescribed, when you know it was actually $8 at another pharmacy or with the right coupon, you will start saying this at the end of every visit too.

Specialists: We have a lot of excellent specialists in the city where I work, and ideally your CHF is going to be managed through regular visits with a Cardiologist and CHF clinic, with me along for the ride to explain things when they aren’t clear, keep an eye on your other medical issues, and keep you out of the hospital (or get you to the hospital) when you have an exacerbation and your Cardiologist is booked solid or not available in clinic. If you have private insurance or medicare, that will almost definitely happen. Even if you don’t have great insurance coverage, this is still ideal, and I have many patients who have worked with the local specialists to come up with a payment plan; I don’t know the details of those arrangements, but I’m often pleasantly surprised by how much our specialist clinics work with people to get them seen. If that’s not possible, many of the specialists in town create access for our patients by volunteering their time at our clinic. Often times there is a wait list, though, and until then (and in between visits), I get to be your “cardiologist”. Or your “rheumatologist,” “pulmonologist,” “endocrinologist,” or you name it. I put those in quotes because while as a full-spectrum Family Medicine trained Physician I have worked and trained and studied in all of those areas of medicine, I am an expert in none; ours is a Jack-of-All-Trades specialty by design. But if your financial and insurance coverage situation means that you can only see me right now, you can believe our visits are going to be longer and more frequent.

Follow-Up Appointments: I can’t count the number of times that I’ve asked a patient what their co-pay to come see me is, only for them to start explaining when they are going to pay their bill or some similar concern, as though I knew what their account balance was and wanted to make them feel bad about it. I’m grateful to work in a clinic where that is not my job at all. I’m asking because if your Co-Pay is $10, I’m going to be prioritizing some of the above conversation for today and save some of it for 2 weeks from now, so you don’t feel overwhelmed and have time and space to process your diagnosis. If your co-pay is $80, or you have no insurance and so you are footing the entire bill, we are going to address as much as humanly possible because I know seeing me again in 2 weeks is going to be a burden, and if there’s a way we can put it off for a month by doing more today, then we will.

So the TL;DR version here is that I definitely do look at your insurance. Because if you have great access to wraparound care, testing, and specialists then you aren’t any less deserving of my time, but you probably don’t need quite as much of it, at least usually. But if you have limited access, you aren’t any more or less deserving of my time or energy but you are probably going to need more of both; if you only have a few medical professionals in your corner, then each of us is going to have to step up and give some more time, some more creative thinking, and some more effort to get you the closest thing we can to comparable, just care. The only alternative is to simply accept health disparities as an unavoidable and uncorrectable fact of life, and that’s something our Oath just doesn’t allow for, no matter how broken the medical industry we work within happens to be.

Debunking the Latest “Truth the Government Doesn’t Want You to Know” Video.

Last night a friend sent me the latest viral COVID-19 misinformation video. You can view it below, though once it is inevitably removed from YouTube I won’t bother to re-link to it; I am sure it will be popping up on your Facebook feed soon enough (if it isn’t already).

This is the worst one yet.

Having recently spent considerable time attempting to help bring some clarity to the PlanDemic Documentary (26 minutes long) and the interview with the two Bakersfield Urgent Care Doctors (55 minutes long), I was glad that this video was fairly brief; the clip above is very short, but even the full-length video is a mere 3 minutes and 32 seconds. Still, it has over 680 million views, and that degree of viral spread, only equaled by SARS-CoV-2, deserves a response.


Claim #1: Never Gonna Give You Up

It’s hard to know to whom exactly this promise is being made. This was originally written in 1987, and Mr. Astley did not meet his wife, film producer Lene Bausager, until the song was already incredibly popular in 1988. Though I don’t have specific information on his personal life beforehand, it is reasonable to conclude that he did in fact ‘give up’ any former paramours prior to their relationship becoming serious.


Claim #2: Never Gonna Let You Down

The website KnowYourMeme defines the Rickrolling internet phenomenon as:

“A bait-and-switch prank that involves posting a hyperlink that is supposedly relevant to the topic at hand in an online discussion, but re-directs the viewer to the music video of “Never Gonna Give You Up,” a 1987 dance pop single by English singer-songwriter Rick Astley.”

With this working definition, the song Never Gonna Give You Up has itself ‘let people down’ millions of times, as they click on a link to an article, resource, or opinion piece they believe will be relevant or useful and instead are directed to the video, enjoyable as it is. Though Mr. Astley could not possibly have known this in 1987 when he first recorded the single, “never gonna let you down” has nevertheless proven to be a wildly inaccurate statement since.


Claim #3 Never Gonna Run Around and Desert You

While I cannot comment on Mr. Astley’s exercise habits, it is a well known fact that he left producers Stock Aitken Waterman shortly after his first World Tour in 1989. This was largely due to negative press associated with the production company, and in fairness to Mr. Astley may have been a very warranted decision. While it is difficult to assess in retrospect, and from such as distance, whether such a decision could be considered a ‘desertion’, it is at least evident that claims of never leaving are a misrepresentation of the options he considered as viable pathways for the future.


Claim #4 Never Gonna Tell a Lie

Notwithstanding the above claims, I cannot specifically note any instance of Mr. Astley’s having been known to lie. However, I believe it is a truism that all of us have been prone to resorting to untruths on occasion, sometimes justifiable and sometimes not. To claim that he would never tell a lie seems at best lyrical hyperbole (all too common in this era of imprecise musical lyrics) and at worst demonstrates poor introspection regarding his own personal standards of veracity, which even if superior could not be expected to be actually perfect.


Claim #5 Never Gonna Say Goodbye

Mr. Astley actually says “Goodbye” no fewer than 5 times in this song alone.


“A full commitment’s what I’m thinking of, you wouldn’t get this from any other guy.”

This has always struck me as one of the most absurd claims of this misinformation video, and there is solid empirical evidence that Mr. Astley is here mischaracterizing the level of commitment of other guys. As this article from Psychology Today examines in detail, data from Pew Research Center indicates that levels of desired relationship commitment in men, include levels of ‘full commitment’, differ very little from that in women. According to the author,

83 percent of men and 88 percent of women report being “completely” or “very” committed to their partner. Even in the early twenties, well before the average age of marriage, men (and women) report high levels of commitment and often anticipate lifelong unions. 

Elizabeth Aura McClintock Ph.D.

This evidence would suggest that, barring unknown or unusual circumstances, it would be inaccurate (and bordering on emotional manipulation) for Mr. Astley to suggest that no other guy would be interested in a full commitment to the intended recipient of his addresses.

The Paradoxes of PlanDemic


Final Thoughts

I know this seems like a strange place to add my final thoughts (one might have expected them somewhere near… the end), but I want to honor the long tradition of TL;DR that has come before me. PlanDemic has been a fairly unique experience among COVID-19 misinformation videos so far. The production quality is much higher and the narrative, tied to the experiences (questionable though their veracity may be) of an individual scientist, is gripping. The story telling here is far, far better than any of the webcam style videos we have looked at so far, or even the interviews of Dr. Erickson or Dr. Ayyadurai. It’s actually hard to know how to categorize this video; is it an anti-Medicine conspiracy video capitalizing on COVID-19 fears and controversies, or is it a COVID-19 medical misinformation video set in a conspiracy theory narrative? Probably both, but I lean toward the former because while the conspiracy theory is well established and consistent, a brief version of the story Dr. Mikovits has been giving as her own interpretation of the events of her arrest and discreditation for years, the actual arguments surrounding the COVID-19 pandemic are piecemeal and self-contradictory, pulling from any and all vogue COVID-19 misinformation sources rather than forming any new or unified thesis. Still, given the popularity of this video, I will not be surprised if we begin to see more and more of these high production quality misinformation/conspiracy theory pieces; it seems to be an effective amalgamation.

I hope my reflections below prove helpful. My hope is that even if you do not have time to read this entire post (and I can’t blame you there; I don’t have time to read it either), you will be able to navigate to the analyses of one or two of the points from the video that you have particular questions about. If I don’t cover the points you are particularly interested in, feel free to comment below; or better yet, keep digging- I’m sure someone else has done a more thorough debunking on that point than I would have anyway. Thank you to those who have found this analysis relevant enough to share with friends and loved ones who are convinced by or sympathetic to the PlanDemic film; I hope that this information, combined with their affection and trust for you, is enough to open their eyes to the falsehoods being shared so widely, and to convince them to continue exercising caution against this terrible virus.


The link to the video that I originally shared is dead. It is still easy enough to find if you really want to watch it.

First Impression: The production quality here is going to be awesome. (00:04)


Learn about your sources before watching, and then watch critically. (00:10)

This is just good general advice; we trust far too much to our gut feelings (read: confirmation bias) when trying to decide on the veracity of new information. When I wrote about navigating medical misinformation during the pandemic, the first piece of advice I gave was to know your source. I would never argue that arguments can be discounted because of the source; but knowing something about the source is incredibly useful when engaging internally with the arguments, especially when choosing what degree of scrutiny to apply to them. This is especially true with a video like this one. The excellent production quality, the artistic filming and intentional choice of background music, the cinematography and editing, all of it is designed to be emotive and to render the content convincing. That’s not a bad thing; they want you to believe their message, presumably because they strongly believe it themselves. But when all of these features have the net effect of lending credibility to the speakers in the video, we may find ourselves attributing to them a certain expertise or background that may or may not fit. Knowing where they are coming from, who they are, and what they stand for before the emotive music begins gives you some context for weighing their claims outside of how those claims make you feel, or how much you would like to believe them.

By the way, this is the same advice I would give to someone visiting a church for the first time; don’t rely on your gut feeling as a guide to truth; emotive music and a well crafted stage presence can be incredibly convincing.

With that in mind, here are a few links to the main people involved in the video:


Dr. Judy Mikovits is a former researcher who holds a PhD in Biochemistry and Molecular Biology from George Washington University. She published a since-retracted study in Science in 2009 that eventually lead to the legal action she discusses in the video. You can read more about her on her wikipedia page or on the blog Retraction Watch, if it is ever back up again (I believe the viral video has crashed the site multiple times). Since then she is mainly known as a frequent speaker at anti-vaccine events.

Mikki Willis is founder of Elevate, the production company that released the documentary. Their prior work tends to be focused on spiritual energy and positive vibrations (they have a short video talking about restoring your frequency to protect against COVID-19), but this seems to be their first foray into medical misinformation viral videos. You can check out his facebook page here. Before this I believe their biggest documentary was Neurons to Nirvana: Understanding Psychedelic Medicines. Also, as someone who has been interested in televangelists and pseudo-christian faith healers for years, he strikes me as the non-religious, spiritualist version of the young, good looking charismatic faith leader.


The Minions of Big Pharma (O0:38)

This is my first red flag in the video. “For exposing their deadly secrets, the Minions of Big Pharma waged war on Dr. Mikovits, destroying her good name, career, and personal life.” Now, “Minions of Big Pharma” may mean a lot of things; he might be referring to actual lawyers who work for pharmaceutical companies, or to all pharmaceutical employees (although it’s hard to see how drug reps could ruin her personal life), or to some other group altogether. But in the alternative health world this typically refers to doctors and scientists (nurses are generally excluded because as a society we actually like them, so it’s dangerous to the alt-health narrative to loop them in on conspiracy theories)(oh, and happy Nurses Week to my brilliant and beautiful wife!).

Now, I can’t comment much on Scientists working in the lab, since that hasn’t been a major part of my life, but I pretty strongly suspect that they have little to no interest in ruining anyone’s career (and if stereotypes are anything to go off of the only personal lives they are ruining are their own! Bazinga!). I know scientists who have worked for Universities and for major corporations and their main interest has been, unsurprisingly, Science. They love talking about their experiments and research, and their ideas about what might happened next with their project. Remember that these are not nameless and faceless people doing experiments in some hidden lab; these are often the sciency kids that you went to high school with who genuinely loved experiment day in Chemistry class and who were probably reading Lord of the Rings before it was cool. And it’s these science nerds, according to this video, that have now all been recruited into a world wide conspiracy. Tony Fauci calls up one of them and says, ‘we need to discredit a virologist because we don’t like her conclusions about retroviruses; publish a fake study that says she’s wrong.’ It’s really, really far fetched. In fact, if you want evidence of the standards of veracity that scientists generally hold each other’s research to, look no further than Dr. Mikovits’s retracted paper in Science, which was retracted not because she was rocking some boat or bucking some system, but because the methodology was flawed and the results were not reproducible. If you’ve forgotten everything else about those Science Fair geeks from high school, remember this; we loved proving people wrong. The peer review process capitalizes on that, and the conspiracy that there’s a top-down cabal determining what gets published and what doesn’t ignores that one overarching character flaw.

What I can tell you, with no shadow of a doubt, is that your doctor doesn’t work for Big Pharma. In fact, the relationship between your average Physician and the drug reps they interact with range from the politely tolerant to the openly antagonistic.

Though there are beautiful exceptions.

And this is the case for any part of the medical industry that is primarily profit driven, whether it’s the pharmaceutical companies, fly-by-night medical supply companies, pharmacies, or the insurance companies. Because Physicians are not primarily profit driven; we are driven by a desire to help people. We are driven by a desire to help people so much that it is dangerously cliche to even say so on a medical school admissions essay. We’ve taken on hundreds of thousands of dollars in debt, sacrificed our 20’s and 30’s, and worked thousands of hours of unpaid overtime in order to learn the science and the clinical skills that we need in order to do the grueling work of helping people heal physically, emotionally, and psychologically, and there are just much, much easier ways to make money.

So that creates conflict. Conflict ranging from an annoyed ‘I don’t think that’s accurate’ to a pushy drug-rep overselling the latest product, to absolute rage when the price of a life-saving medication skyrockets for artificial reasons and my patients suddenly have to go without. But while we generally regard for-profit pharmaceutical and insurance companies to be side effects of a deeply broken healthcare system, they are still fixtures that we have to work with; and I guess that looks a lot like collusion to the outside world. Once you’ve bought into the myth that those with the most money universally control the people they interact with and endure no dissent, it’s easy to see conspiracies everywhere; of course the scientists are told what results to report, look who signs the checks. Of course the doctors prescribe what they’re told, their education is controlled by big pharma.

But might I submit that maybe ancient, altruistic, and (let’s face it) fairly egotistical professions don’t just roll over quite so easily? That maybe high standards of truth telling and care for the wellness and suffering of human beings are still the honored core of both the clinical and research branches of Medicine? In fact, I don’t think it’s a stretch to say that, to whatever degree drug or insurance companies really have wanted something like autonomous control over healthcare, it has largely been conscientious Physicians who have fought them.

But you don’t get to see those types of interactions that often at your doctors office, and this leads to a lot of pretty demoralizing misunderstandings; for instance when a patient’s medication should be $5 and they end up paying $50 at their pharmacy and think that I prescribed a more expensive medication because I’m getting a cut (this is why I now say to each patient at the end of each visit where I’ve prescribed a medication, “if you get to the pharmacy and any of your medicines are more expensive than you expected, please don’t buy it yet and give us a call instead”). It also means that when it comes to profits being put above people, we’ve probably just about seen it all, and fought against it all. So when even we have to say, yeah this looks like some pretty crazy conspiracy theory stuff, you need to understand it’s coming not from “Big Pharma’s” willing subordinates, but some of it’s most diligent and ferocious watchdogs.

Tell me ZDoggMD is in the pocket of Big Pharma. I’ll Wait.

“The plague of corruption that places all human life in danger.” (00:54)

I think the narrator is just waxing eloquent here, setting us up to understand that the medical field is the real plague or something like that (and if so it’s a good bit of work), but I’ll at least give the video the credit of seeming to take COVID-19 very seriously during the first minute. If you turn this off after minute one, you will at least leave with the idea that 1. there is a plague, 2. human lives are in danger, and 3. it’s a big enough problem that the fate of nations hangs in the balance. That plus the excellent production quality may go a long way towards fighting some of the ‘less dangerous than the flu’ misinformation that is out there already. Way to go, Elevate!


Minute 1 to Minute 10

The bulk of the first 10 minutes of the documentary are spent on Dr. Mikovits’s personal history of maltreatment by the health industry/scientific community. I think people should be able to tell their stories from their perspectives, and I have no doubt that the demolition of her career has been a very difficult experience for her regardless of the circumstances that caused it. Still, it is important to remember that most stories have at least two sides that have to be considered, and other interpretations of those events are available widely on the internet. It’s a very dramatic story and someone other than me will need to dissect it. I will return to this section with a few observations once I have finished the analysis of the rest of the video, but for now my most immediate concerns are the statements related to COVID-19.

Update: Having finally finished this blog post 3 days later, I have had time to read through other articles and watch other videos debunking the claims of PlanDemic. Many do it much better than I can. A great many have focused specifically on the first 10 minutes of the video, and investigating the claims that Dr. Mikovits makes regarding her own history and the conspiracy against her; many have already been familiar with this history and her work in the anti-vaccine movement prior to PlanDemic. I will defer to them. Certainly I have no first hand knowledge of the events and no background in investigative journalism. If you are watching the video, there are 3 things I would point out in this section that I think should at least increase your level of suspicion that you are watching conspiracy theorist/misinformation propaganda. 1. When Dr. Mikovits is talking about her arrest (the video leaves you to assume it was a 5 year imprisonment; it was actually 5 days), they show presumably unrelated footage of SWAT teams and urban tanks in order to inspire fear. 2. The clear implication, towards the end of this section, is that Dr. Mikovits might be assassinated for doing this interview. The credulity people have towards this claim has been amazing, with so many comments along the lines of ‘this woman needs protection now’. Yet, is there any basis for believing that there has been or will be an attempt on her life? And for what? Sharing information about the COVID-19 pandemic that is almost entirely verifiably false? 3. Dr. Mikovits has a book out. I don’t think that this is her primary purpose in giving her interview, and my understanding is that she has been involved in trying to clear her name and garner support against the scientific establishment for years. But so far, financial motivations being tied to viral misinformation videos has been batting a thousand during this pandemic.

A friend on Facebook, supporting Dr. Mikovits’s video.
A commenter, accidentally giving a better rebuttal than anything I could ever come up with.

Is this an anti-vax video? (9:48)

Dr. Judy Mikovits: “And they will kill millions as they already have with their vaccines.”

Mikki Willis: “So I have to ask you, are you anti-vaccine?”

Dr. Judy Mikovits: “Oh absolutely not!”

‘But see, she’s not anti-vaccine! This is totally mainstream stuff, not anti-vax propaganda at all!’

Rest assured that many people in both alternative health and the anti-vaccine movement see the pandemic as an opportunity to anchor their products and agendas more firmly in the mainstream. While this is often for financial profit or accumulation of power and influence (as has been the case with every single misinformation purveyor we’ve addressed on the blog so far), I still believe that here are many honest people who earnestly believe in these ideas, and merely have their facts and narratives skewed concerning vaccines specifically and the medical field in general. I know and really like some of them. In fact, a lot of friends whom you might call ‘vaccine wary’, medically suspicious, or crunchy and oily (their words!) have been incredibly supportive of me personally and other healthcare workers during this pandemic. They have struck a balance they are personally comfortable with that allows questioning their Physicians and arriving at different conclusions (which is a good thing in general) and still recognizing a bedrock of reliable truth telling regarding danger, disease, and treatment. I think all of us are looking forward to the day when we can just get back to arguing about tea tree oil in your belly button again (or was it thieves?), but with a real crisis like COVID-19 there is no question that we are all on the same side.

The problem is that as a counter-culture, these movements have overall tended to have a very low threshold for whom to trust, assigning credibility and reliability to almost anyone who is comfortable using the same verbiage and demonizing modern medicine. This means that while many people have found a balance that remains very safe for their families, many others who begin as simply cautious of certain chemicals or treatments (as likely as not because their doctor didn’t/couldn’t take the time to explain it to them very well) become entrenched in increasing (and increasingly dangerous) depths of falsehood. For some, this video, with it’s emotive music and deep state conspiracy theory, will be their next step. The leaders of these movements know this and see dollar signs, potential converts, or both; and the pandemic is a golden opportunity for them because we are all looking for answers. I’ve seen the fallout from this on the individual level in my own experiences caring for adults and children, and on a larger scale with measles and pertussis outbreaks that were totally avoidable. My fear is that, with something as dangerous as COVID-19, the suffering that occurs for the people believing these conspiracies could be the worst and most widespread yet.


Just past the ten minute mark, we finally get into a discussion of COVID-19.

Do you think this virus came from a lab? (10:21)

Dr. Mikovits is making claims that come off as extremely authoritative, but which nobody actually knows the answers to. Labs that have sequenced the genome of SARS-CoV-2 have said it appears to be a naturally occurring virus strain, but the idea of zoonotic transmission from meat sold in an open air market in Wuhan has seemed extremely speculative from the beginning. BBC has a good article discussing the difficulties in sorting through the origins of the virus. As a Physician my main concern is with the viral syndrome that it causes, not where it came from; but the idea of it being involved in any way with a research lab is extremely appealing to conspiracy theorists that would like this to be a Dr. Evil style attempt to conquer mankind.

But look what Dr. Mikovits is actually saying here; she doesn’t think this is a bioterrorism weapon that was designed or engineered, but that doesn’t matter because “You can’t say naturally occurring if it came by way of a laboratory.” Um… Why not? A few moments later she says ‘studied in a laboratory’ like it’s damning evidence. But the thing is… laboratories are exactly where you study things. She’s done a fair bit of it herself in the past. I spent a Summer studying Passalidae Beetles in a laboratory and they are pretty naturally occurring.

The REAL super-bug (and an important forest decomposer!)

What they are saying here, really, is that the origin of the virus doesn’t matter for their purposes; whether it had been engineered as a weapon, whether it was accidentally released from a lab, or whether it just happened to be transmitted from an animal that was being studied in a lab. What matters is the word “laboratory”, because with the degree of fear and paranoia about scientific processes already experienced by many of their target audience, combined with anxiety about the pandemic, that is enough to score points as one more piece of evidence of a global conspiracy.

Finally, at the end of this section Dr. Mikovits claims that SARS-CoV-2 must have undergone “accelerated viral evolution” because if it were naturally occurring, it would take 800 years to develop from SARS. First of all, that’s a pretty specific time frame without any further explanation, so I’m going to call ‘citation needed’ on this one. But the biggest problem with that claim is… Nobody thinks it evolved from SARS in the first place. There are a lot of Coronavirus species, and we don’t yet know (and may never know) the evolutionary history of this dangerous, novel virus. It is called ‘SARS-CoV-2’ because it is a Coronavirus (CoV) that causes Severe Acute Respiratory Syndrome (SARS), and it is the 2nd one identified that does this (because MERS is the Rodney Dangerfield of Coronaviruses; it gets no respect).


Ebola couldn’t infect humans until Dr. Mikovits taught it to in 1999. (12:04)

The first major known outbreaks of Ebola occurred in 1976, 23 years before Dr. Mikovits taught it how to infect humans. So this is pretty nonsensical. The CDC has a good article on the history of Ebola Virus, but I suppose if you have chosen to believe the claims in this video you will probably see this as propaganda? The conspiracy theorist world is a much more interesting world, when even fairly blandly written (though quite interesting, to me at least) and well hidden disease history pages on government websites are all deliberate and carefully crafted deceptions.

But if course, she’s not talking about Ebola virus here, not really; the implication of the video is that somebody had to teach the COVID-19 virus how to infect humans. Add this to the list of claims in the video that have zero empirical support, but that devotees will come away 100% believing.


The COVID-19 death toll is inflated (12:22)

The tabulating of deaths from COVID-19 has been written about time and again. I wrote about it here a month ago when these conspiracy theories about doctors faking death certificates and being told to call everything COVID-19 were already being circulated. It’s been debunked thoroughly and frequently, and our best guess is that the actual death toll has actually been underestimated. We’ll do a little more debunking here, yes, but honestly it’s getting a bit old.

But the first thing I want to point out is how this video, as a smorgasbord of COVID-19 conspiracy theories, ends up mixing it’s message and contradicting itself time and again. We just spent several minutes focusing on their belief that the virus was created in a lab, that it was intentionally taught to infect human cells, and that it is part of a government plan (I mean, that’s the name of the video, PlanDemic), and now we are talking about how it really isn’t that dangerous. This video would like to have its virus and eat it too; it wants the numbers to be inflated, but it also wants the deadly disease to be an evil plot. Now, you could come up with some scenario that fits both conspiracy theories; the virus was released by Scientists (the minions of Big Pharma) but wasn’t as deadly as they had hoped, so they have had Physicians (the other minions of Big Pharma) inflate the death numbers. Sure, if you add enough layers to your conspiracy theory you can account for apparently contradictory sub-plots; but you also have to involve more and more willing participants in the conspiracy, and at some point you have many millions of people colluding in order to… what? Get some people to take a vaccine? Credulity can only be stretched so far.

The other thing you need to recognize is that Dr. Mikovits is about to step firmly outside of her training and experience, which has nothing to do with clinical medicine. When she speaks about discerning the cause of death, the interaction of chronic diseases with acute infections, and the realities faced by doctors fighting this horrible virus, she is speaking entirely as a layperson.


COPD deaths are being counted as COVID-19 deaths?! (12:49)
  • I am sorry her husband has COPD. That really stinks.
  • COPD (Chronic Obstructive Pulmonary Disease) and Pulmonary Fibrosis are different types of lung damage (maybe her husband has both, which is absolutely possible)…
  • …and neither looks like SARS.

“But he has no evidence of infection”. Well, that’s a really wonderful thing; it’s also an important point on the natural history of COPD. Most COPD patients do not have thickened mucous, extreme shortness of breath, severe dyspnea, and prominent wheezing all the time. When those symptoms occur we call it a COPD Acute Exacerbation. And when you have an exacerbation, it absolutely is a sign of something acute happening, usually a viral or bacterial infection.

(13:10) No they absolutely wouldn’t. If he walked in with no evidence of infection, he shouldn’t be walking in at all; the ER is a dangerous place for him now more than ever. But if he comes in with acute worsening of his pulmonary symptoms, the worst COPD exacerbation he has had in his life, requiring high levels of oxygen and even intubation and ventilator support, with exposures to the COVID-19 virus or symptoms consistent with the disease in an endemic area, are you really saying that politically motivated incredulity about the virus’s infectivity and lethality trumps the doctor’s diagnostic skills? The thing they have been working their entire lives to develop?

My friend and classmate, and ER doc in New York, on the shortage of tests.

The Doctors are telling us the numbers are inflated. (13:15)

I know hundreds of doctors personally, maybe thousands, and have read or heard from even more. Some of them work in the front lines in places like New York that have been hit hardest (so far) by the pandemic. Throughout this crisis I have reconnected with classmates and friends I hadn’t talked to in years to touch base on how this whole thing is going for them, how they are holding up. None of us are being told to fudge numbers. Even if we were being told to, we wouldn’t. There are over a million doctors in the USA and I am convinced that almost every single one of them would blow the whistle and be on youtube tomorrow if the government was asking them to artificially inflate numbers or lie on death certs. This is ridiculous.

My ER Doctor Friend in New York, battling COVID-19 daily

But more to the point, the guidance that has come from the CDC has actually been really reasonable. Even the images shown in the video, which are supposed to be some sort of damning evidence, are reasonable:

What this is saying is that if it walks like a duck and quacks like a duck, but the COVID-19 test is negative or not available, it’s still reasonable for a Physician to rely on their clinical judgement to determine the diagnosis. This is the opposite of a top-down mandate, and more to the point, it’s already how we practice medicine anyway. If you have a sore throat, fever, red and swollen tonsils, and your son had strep, I don’t test you for strep throat, I treat you for it; you have it, regardless of what the test says. And that test has a much higher degree of reliability than the SARS-CoV-2 antigen test. If you have symptoms of the flu, and it’s flu season, I only test if it would actually help me make a treatment decision, which is fairly rare; the sensitivity of the test is only 50% to 70%, which means that up to half the time you have the flu your test is going to be negative. It’s too early to know exactly what the sensitivity of the COVID-19 test is, but early reports said somewhere around 70%; so doctors very wisely chose not to defer their clinical decision making to a test result.

Finally, there’s the case the doctor in the video discusses around the 13:40 mark: the 86 year old patient who dies from pneumonia, who wasn’t tested for COVID19, but her son later tested positive for the virus. The doctor asks, incredulously, whether it would be reasonable to list COVID-19 as a possible cause of death?

Every practicing clinician: Um, yeah, it would. In fact, these are the exact people we know are most susceptible to the virus, and the ones we are working our butts off to protect. Most of my 86 year old patients treat me like a grandson; we are treating this virus like it can kill them because it can.

13:50: Dr. Erickson owns Urgent Care Centers in a low-prevalence country in California. He is not being pressured to write COVID-19 on anything, and if he’s writing death certificates with any degree of frequency that is a big, big problem. He would like this pandemic to be not that big of a deal just like the rest of us, only in his case, it’s at least partially because his Urgent Care business is suffering right now. (Update: He has also released a statement saying he has no association with the PlanDemic video).


“You don’t die with an infection, you die from an infection.” (14:38)

While this is not technically true (people die with infections all the time. You can get hit by a bus on the way back from your abscess drainage), I actually completely agree with Dr. Mikovits here. This is the inverse of the common saying for Prostate Cancer, “most people die with prostate cancer, not from prostate cancer.” It’s a common form of cancer that grows slowly and often near the end of life; most people with it will die from something else. Contrast this to COVID-19, which is an incredibly dangerous virus that has killed 75,000 people as of today in the US alone, and even if you don’t believe those numbers has overwhelmed healthcare infrastructures, exhausted doctors and nurses (and driven some to take their own lives), and decimated entire countries. This is a dangerous virus. It increases risk of blood clots, it seems to be causing strokes, it shuts down the lungs; the idea that people are suddenly dying in large numbers from these types of syndromes and their having the virus is just a coincidence is insane. You die from the virus; not with it.

The numbers have to match the real-life narratives, but by avoiding any discussion of the experiences of doctors, nurses, patients, and families that have been affected by the virus, the misinformation promoters hope to bypass your compassion and even your sense of rational self-preservation and deeply ingrain the idea that the virus isn’t dangerous with fake numbers and false dichotomies between acute infection and chronic disease. If they are successful, then you will be automatically suspicious of any images, narratives, or personal accounts you hear that paint a picture of a deadly virus causing real human suffering. The word ‘trauma actors’ is not far off. Don’t let them rob you of your empathy for their own personal gain.


Doctors are being incentivized to list COVID-19 (14:44)

Check-out this article from PolitiFact that covers this question in some detail. Yes, part of the CARES act was to provide a 20% stipend for treatment of COVID-19 cases. This is being done because hospitals that are hardest hit by the pandemic are also the ones that are going to have trouble staying afloat; they will be cancelling elective cases and other more profitable treatments for longer and focusing entirely on COVID-19, often in the midst of needing to pay nurses and doctors overtime, hire outside help, and wildly exceed their budgets for PPE and supplies. Now, we can talk about whether or not I think hospitals being for-profit is a good model in the first place (hint: I don’t), but the idea that a bipartisan government stimulus for hospitals in the hardest hit epicenters of the pandemic automatically equals corruption and conspiracy is awfully flimsy.

But more importantly, I want you to watch the way the video, with it’s excellent background music and high production standards, weaves this part of the narrative. Go back and watch the 15 seconds from 15:00 to 15:15 and notice the way that the words “you’ll get paid $13,000” and “if that COVID-19 patient goes on a ventilator you’ll get $39,000” are overlaid against medical professionals, in PPE, treating patients in the ICU. Look at all of these doctors just waiting to cash their $39,000 checks from medicare, the video is telling you. The reality is that decisions about diagnosis and decisions about treatment are made by Physicians, who are not paid $13,000 for a certain diagnosis or $39,000 for initiating life-saving treatment. Depending on the way their compensation agreement is structured, they may or may not see any of that additional money (I certainly won’t should we get hit hard here in Waco and I have to admit COVID-19 patients or intubate the critically ill).

Also listen to Mikki Willis’s statement right at the beginning of the segment; “I’ve spoken with doctors who have admitted that they are being incentivized…” This is the verbal equivalent of the above cinematography trick, and is the type of sentence you can utter with impunity because there are so many doctors it would be impossible to prove he hadn’t talked with doctors who said this. But notice how doctors are only a reliable source of truth telling if they are blowing the whistle on some big conspiracy, and not when they are saying, en masse, ‘this virus is dangerous. we are doing the best we can to take care of patients but please stay home. there’s no conspiracy here, just a really, really bad bug.”


The ventilators are what’s killing patients! (15:15)

I’d like you to understand that Dr. Mikovits, who is a PhD virologist and not a medical doctor, is here repeating what she has heard or read and is not speaking as an expert by any means. I’ve had a friend write to me extensively about how dangerous ventilators are. I’ve seen videos and articles and facebook posts saying “88% of people who go on ventilators die”, as though that were proof that ventilators were dangerous, instead of that the virus is dangerous. (here is an article working through those ventilator numbers, by the way). You see, we only intubate the sickest patients, so they already have the highest chance of dying. There’s a confounding variable, and it’s called severe respiratory distress.

Now, I do think there is a discussion to be had here in terms of the best use of our ventilators. The myth here seems to be, as best as I can understand it, that “ventilators” are a discrete treatment the way “ibuprofen” or “knee injections” are discrete treatments; either you do a knee injection or you don’t (ok that’s also not accurate), either you give ibuprofen or you don’t. But ventilators are incredibly complex tools and their use is not monolithic. Here is a very basic but extremely helpful (at least to someone like me who doesn’t use a ventilator on a daily basis) guide to vent strategies from some people I admire over at EmCrit. Did you read it? You got all of that? This is the tip of the iceberg. Even the clip that PlanDemic shows at 15:18 is an ER doctor from New York early in the course of the pandemic arguing for a different ventilator strategy, not against the use of ventilators. His name is Dr. Cameron Kyle-Sidell, and he goes on to say:

Now, I don’t know the final answer to this disease. I do sense that we will have to use ventilators. We’ll have to use a great number of ventilators, and we need a great number of ventilators,  but I sense that we can use them in a much safer way, in a much safer method.

So they’ve shown this clip to make you think, doctors are using ventilators because they get paid more money, even though it kills people, but a few doctors like this one are speaking out against this corruption. The real narrative behind this clip is a lot more reasonable and a lot more hopeful, and it’s this: doctors are trying to fight this new virus with the best tools they have, and impassioned discussions and debates about how to use those tools well are already happening. I am a part of a number of Physician COVID-19 groups on facebook, and both there and in private conversations and discussions within my own clinic system, every aspect of when and how to use ventilators to support COVID-19 patients is being dissected and discussed. It’s a good thing that we know more than we did a month ago, and the more we can delay the spread of this virus, the more we will know when it finally hits your area.

But let me make one thing abundantly clear; this is not a choice between using a ventilator and making more money, and not using one so the patient can get better; that is a false narrative and, frankly, on the grossly cynical side even for the conspiracy theory people. When you intubate a severely hypoxic patient, having tried everything else you know of to keep them off the ventilator, your decision is to use a ventilator or watch them slowly die gasping for air. Unless you’ve been in that situation, your theories on doctors putting patients on ventilators because they were told to or are thinking about their next paycheck don’t carry much weight with me.

And let me just state, for the record, that if you suspect a doctor at your hospital is putting people on ventilators or doing any procedure in order to make more money, you should report that person right away. That’s what I did the one time in my education or career I thought I had seen it happen. And if you believe it’s happening on a large scale, that doctors all over the country are doing it, please start thinking now about what you will do when your child or loved one becomes terribly ill at some point in your life, because if you have that little faith in the good intentions and integrity and medical knowledge of doctors and nurses, I cannot imagine why you would ever come to a hospital (though I honestly hope you do, because I believe we’d have the best chance of helping them, even if you don’t right now).


What about Italy? (15:35)

I just want to say that as little as I’ve found in this video to agree with, I really respect even the willingness to address the parts of the Pandemic that simply can’t fit it into their narratives (ok, I’ve actually found nothing to agree with; but there is at least plenty I can’t comment on. For instance, I can’t say whether or not someone planted evidence in her house before she was arrested).

When the Bakersfield Doctors, misled by their shoddy statistics, concluded that the virus wasn’t at all dangerous, they simply hand-waved New York and Italy as ‘hotbeds’ and moved along; it didn’t fit their narrative and so they didn’t even make a show of trying to explain how a non-dangerous virus could cause such catastrophic damage. The narrative here is infinitely more interesting.

Reason #1 is good; Dr. Mikovits says that Italy “has an older population, and they are very sick with inflammatory disorders.” Now, I don’t have any data on whether Italy has a higher rate of autoimmune disease, which I believe is what she means by inflammatory disorders; but I think we can accept the idea that older populations with more chronic illnesses are going to be at higher risk for complications, including death, from COVID-19. That is very consistent with the data we have seen throughout the pandemic. I would also point out that Italy is not alone in having an older population; many US States have similar demographics. 22.8% of Italy’s population is older than 65; but so is 20.6% of Maine, 20.5% of Florida, and 19.9% of West Virginia. If Italy can experience a surge of cases bad enough to overwhelm their healthcare infrastructure, there is nothing to prevent it from happening here. And of course, age isn’t the only factor; it has happened in New York, and only 16.4% of their population is greater than 65 years old. But the point is, saying ‘Italy is old’ doesn’t explain how a non-dangerous virus can kill so many.

But at 15:47 she loses me. Her claim is that in 2019 Italy had a new, “untested” form of Flu vaccine, and that this explains Italy’s high COVID-19 burden. She says the vaccine was grown in a dog cell line, and that ‘dogs have lots of coronaviruses.’

So, does that even make sense? Well, someone will have to tell me whether the flu vaccine used in Italy last year was new in the sense of being designed or developed differently from flu vaccines used in prior years or in other countries (in another sense, the flu vaccine is new every year because epidemiologists have to decide which flu strains to include based on which are most likely to become endemic). By the way, Italy had a particularly light flu season; so if it was new it may be a really good vaccine. However, the mechanism she is describing isn’t logical. First of all, the flu vaccine they use in Italy includes only killed viruses; your body is exposed to the antigens and can mount an immune response, but the virus cannot ‘come to life’ and cause the flu (or any other ‘inflammatory reaction’ she is hinting at here). The antigens of the dead virus are picked up by circulating white blood cells and presented to the immune system, so that the next time the body sees the virus it has the ability to rapidly produce a robust antibody response, usually before a person is even symptomatic (it does not work by creating a magic forcefield around your body that flu germs bounce off of).

Glad I got that flu shot

But the trick is preserving the dead flu proteins without eradicating them completely. The idea that Coronaviruses have somehow come from a cell line used to develop the vaccine, have survived the process of creating the vaccine (all of the ‘harsh chemicals and toxins’ we are always hearing about), and have tagged along and actually entered the person’s body through the flu shot is nonsensical. Even if that were true (it’s not), she gives no clear mechanism by which that would have literally anything to do with COVID-19. Remember, Coronaviruses are a big, big family of viruses, and exposure to one would at worst have nothing to do with infection by another, and at best give some degree of cross-reactive humoral immunity, which sadly does not seem to be the case for COVID-19. Really, ‘dogs have lots of coronaviruses’ is little more than word association.

But the title of this article is “The Paradoxes of PlanDemic”, and here is another one. Just 5 minutes ago Dr. Mikovits told us that the COVID-19 virus, SARS-CoV-2, was created in a lab in Wuhan China, and was accelerated and manipulated in bats. So what would a flu vaccine in Italy, created in a dog cell line, have to do with COVID-19? There isn’t even a theoretical mechanism here; just the hope that by saying flu vaccine and Coronavirus close enough together in the video, their viewers will believe that the 30,000 deaths in Italy are actually another crime of the scientific community, instead of a stark warning of how bad this pandemic can become.


At this time the video has been removed from YouTube, Facebook, and Vimeo, the three sources I had used to view it while writing this post. I have mixed feelings about this. I don’t believe in censorship in general, but I also worry about allowing verifiably false propaganda to deceive millions in the name of freedom of speech, and the real human suffering that could occur if these videos were spread unchecked. I am a Physician, and it’s probably more a question for a philosopher or at least a constitutional scholar.

That said, if you do have a source for the video, feel free to send it my way via the “contact” page. Otherwise, the rest of my comments will be given without any time-stamp or specific quotes, though I have viewed the video in it’s entirety prior to now.


Hydroxychloroquine is a miracle drug, which is why they won’t let us use it.

I remember back in March (oh those carefree days, where have they gone?) when an OB/GYN I know, a friend from undergrad, first shared the French study showing promising results in COVID-19 patients treated with hydroxychloroquine, an immunomodulator we use mainly for Lupus, and azithromycin, an antibiotic (but you already knew that because they give it to you every single time you go to an urgent care…). At the time the responses of the clinicians I know ranged from cautiously hopeful to very skeptical. Hydroxychloroquine and azithromycin are not anti-viral drugs, some argued, and the study was so small that the results shouldn’t change our practice. Others argued that both medicines have some theoretical anti-viral properties, so even though they are not anti-virals per se there is at least a reasonable mechanism of action in play. For azithromycin, this involves anti-viral effects on the epithelial cells of the lungs; for hydroxychloroquine, prevention of viral entry into the cytoplasm of host cells.

Since this wasn’t a large randomized double-blind placebo controlled trial, this small article coming from France hardly constituted a gold standard of treatment; but since the medications were fairly safe and somewhat promising, and since it is the middle of a global pandemic, many doctors and hospitals began to use one or both. There were even some promising, but ultimately anecdotal results. Locally we used hydroxychloroquine but not azithromycin, generally, because of the concern that the combination of both could cause prolonged QT syndrome (which can, you know, kill you). Here is the very measured guidance from a field guide a friend sent me:

As far as I know, each hospital and Physician had to weigh this evidence for themselves. The FDA did release an emergency approval for hydroxychloroquine for COVID-19, and at no point were doctors told we weren’t allowed to use it, unless this came from their own clinics, hospitals, or medical societies; certainly I’ve never heard of any of the ‘doctors being threatened if they use hydroxychloroquine’ that they mention in the video. Unfortunately, subsequent larger and more intentionally designed trials have not shown a benefit; not to fault the French trial, they were trying to save lives and were publishing the modest but promising results they had so far, not trying to empirically prove the efficacy of the medicine. Here is an article from the New England Journal of Medicine that explains this all in greater detail, and the rationale by which the authors chose to stop using the medicine to fight COVID-19.

So that’s the story of hydroxychloroquine, and it’s hard to imagine how anyone could think there was any conspiracy behind that pretty straightforward sequence of events. Really, that’s how these things are supposed to work; if the treatment is safe and cheap and seems to help, it’s reasonable to use it while you are waiting for more reliable data. If that data then shows that the benefit just really isn’t there, you stop using it. When the president touted the drug as being promising, it was with his usual bravado but to some degree reflected the hope many of us felt about it at the time; when Dr. Fauci advised caution and stated the evidence was anecdotal, he was right, and was saying exactly what your local Physician might say at that point if she had been reading up on it. I don’t know anything about the doc yelling in the clip they showed, but unless he was actually treating COVID-19 patients and had some really excellent anecdotal results, I really can’t understand the vehemence he felt about the medicine; it hasn’t been warranted at any point by the evidence.

But before we move on, there’s one more thing I wanted to mention (and here is where I feel most keenly the loss of the video itself), and it’s that the idea of anyone in the healthcare industry actually trying to block doctors from using a medication because it is working is obscene in the highest degree. I’ve seen enough corporate espionage movies and read enough Spider-Man 2099 comics to have a healthy suspicion of the big pharmaceutical companies, but I really believe this is beyond even them. But if you wouldn’t put it past them, at least consider this; if the government or big pharma or whoever were really telling doctors they couldn’t use a medicine that the doctors knew was saving lives, how would the doctors react? Would they go along willingly, because their one and only interest is obeying their corporate masters? Would they shrug their shoulders and watch people die who they could have saved?

Would you see just that one angry doctor ranting on YouTube, or hundreds of thousands?

Another Doctor Webb

Wearing masks increases your risk of infection, reactivates your own COVID-19.

To me, this is the strangest claim in the entire video, and it’s hard to understand for a number of reasons. First, how in the world is asking people to wear masks a conspiracy? Many of the masks we give to patients even in our own clinic are homemade, so it can’t possibly be Big Mask trying to turn a profit. I know many people chafe under any sense of the government trying to control them; but does this actually count, asking us to wear masks in public, that we’ve either made ourselves or gotten for free at our doctor’s office, to keep ourselves and especially others from getting sick? I don’t like wearing masks much either (unless it’s for Comic-Con), but it always strikes me as a particularly troublesome part of our highly individualistic culture that we oppose on principle so much that we ought to do voluntarily the moment there is even a hint of it being mandatory, particularly acts of charity (financial and otherwise) toward our neighbors. Remember, you don’t wear a mask for yourself; you are wearing it to prevent transmission if you have SARS-CoV-2 and are asymptomatic, to keep from spreading it to others.

Will protect against certain Psionic attacks; but not against COVID-19

Of course, this demands the question of whether or not wearing these homemade masks actually is an act of charity; that is, if it really does protect our neighbors from the virus. And as easy as it would be to simply say, ‘yes, masks obviously decrease transmission of respiratory viruses by blocking droplets’, the reality is that in science, what feels right or makes sense intuitively isn’t always a reliable guide to what’s true (hence this blog). So the real answer is; yes, they probably help. LiveScience has a good summary of the most current info and recent studies. With promising but limited evidence we have to weigh the risks and benefits. Remember what we said about using hydroxychloroquine earlier; if a treatment is promising, cheap, and safe, it’s reasonable to use while waiting for more data, and the same is true about prevention strategies. In this case, while we may well get more data we will likely never have a definitive answer about the degree of benefit. What would it look like, exactly, to do a large double-blind placebo controlled trial of wearing masks?

But Dr. Webb, you said the masks are only a good idea if they are safe, and the video says they aren’t. There is a very strange claim in the video, The idea that wearing a mask is somehow dangerous. I’d be remiss if I didn’t mention that they are once again contradicting themselves, but this time in rapid fire sequence. They want at once for the masks to be bad because they keep viruses and bacteria out (they show the clip of Dr. Erickson talking about how touching your face and eyes is vital for your immune system, failing utterly to distinguish between a deadly pathogen and mere microbes), and for them to be bad because they expose you to your own microbes. This is not only poor science, it’s also poor debating. To borrow from Scott Adams (Dilbert), it’s like saying Sorry, I never got the message to call you. And when I did return the call, you didn’t answer. One excuse is better than two.

But I think what’s really going on with this claim is two things; an appeal to the deep desire we all have for a sense of normalcy, and an exploitation of the sensationalization of wearing masks. The truth is that wearing masks isn’t new, and we do it all the time anyway. I wear a mask frequently at work because it both protects my patients when I have a cough that might be infectious, and protects me from respiratory organisms. But you wear a mask too. You wear one when you have the flu and don’t want your kids to get sick; people ask me for them all the time when they are at the office. You wear them when you go snow skiing, or when you are around dust, or when you are painting or staining wood or doing projects with strong fumes, or at Halloween. I’ve never heard of anyone, health conspiracy theorist or otherwise, crying out that they were dangerous, that they reactivated your own viruses or starved your brain of oxygen. But now that it’s a matter of admitting how deadly and dangerous this virus can be for the people you are interacting with and following a reasonable recommendation from the government, all of the sudden they are part of a conspiracy, a symbol of oppression?

All of that said, there is one situation where wearing masks really is dangerous, and it’s when people treat them as though they alleviate the need for any other safety measures; as though it made them invincible from the virus. With only limited efficacy at protecting against respiratory viruses, masks are not the ultimate answer to COVID-19, and physical distancing, hand washing, and careful mitigation strategies are still vitally important. But most of us can remember to do those things while still wearing a mask.

Even if it makes you look silly

Healing microbes in the Ocean.

I’m sorry, I’m just totally lost here guys. Maybe she means these?


COVID-19 Deaths from the day PlanDemic was released:

Lies, Damned Lies, and a Few More Statistics – Dr. Erickson and COVID-19, Part 2

Link to Part 1: Dr. Erickson and the 3rd kind of lie (Statistics)

So the video has resurfaced (thank you to all who provided the links), and rather than any “DOCTORS CRUSH COVID-19 CONSPIRACY!” headline, it has been posted with the much more subdued (though still fairly inaccurate) “Doctors report from Front Lines.” The whole point of their video is that they really haven’t been at the front lines because the surge isn’t there yet; but since that is exactly where I find myself as well (albeit gratefully), maybe I shouldn’t put too fine a point on it.

A note on timing: Since the original video on YouTube was removed, I’ll be working off of the video on Facebook here, which is about 12 seconds ahead of the video used in part 1.


In the last post we went through the first 15 minutes or so of Dr. Erickson’s video, addressing the gross errors in his statistics methodology that leads him to the clearly erroneous conclusion that COVID-19 is not very dangerous. For state after state and country after country, he multiplies the total population by the results of non-random testing that is not representative of that population, to arrive at outrageous figures for prevalence (number of cases) of COVID-19. This mathematical trick shrinks the death rate, certainly, but it isn’t founded in reality; these are figures that can only exist in Dr. Erickson’s mind and on his calculator. He does this while ignoring the best data we have available that shows very high case fatality rates for known COVID-19 patients, framing that data as a good thing. “New York has a 92% Recovery Rate! If you get COVID, 92% of you will recover!” This is exactly the same as saying that COVID has an astronomically high 8% case fatality rate, but he has chosen to frame this as a good thing by flipping the statistic.

Now that the video is available again (for better or for worse), we will move on to the other arguments in the video.


9:16 “Is this significantly different than Influenza A and B?”

This is a question I have already addressed here, but frankly it’s absurd to still be comparing COVID-19 to influenza this late in the game. We are less than 2 months in from the first reports of deaths from COVID-19, and already it has killed as many people as the worst flu seasons we have experienced; and most places have not yet experienced a surge in cases. Our comparisons for COVID-19 are the bubonic plague and the Spanish Flu, not seasonal influenza; even in a very bad year like 2017-2018.

Comparisons to the flu do not match the reality of the people facing this virus as patients or healthcare workers, and can only be clung to by those who have not yet been affected by the pandemic. This is an argument from privilege, pure and simple. And yet, all of us in healthcare sincerely hope that as many people as possible will still go on unaffected; I sincerely hope Dr. Erickson never has to recant this silly argument because the deaths in his own community have made him do so.

But a few more lines on statistics won’t hurt the discussion.


9:24 COVID-19 Vs. Flu in the USA.
  • USA – COVID-19
    • Tests: 4,000,000
    • Cases: 802,590

“Which gives us a 19.6 positive rate out of those who were tested (emphasis mine). If this is a typical extrapolation (his term for ignoring all sound statistics and epidemiology principles for arriving at accurate prevalence data)”… ‘That’s 64 million people with COVID-19.’

So to summarize his math for the USA:

  • Known COVID-19 cases in the USA: 802,590
  • Dr. Erickson’s number of COVID-19 Cases: 64,000,000
    • 63,197,050 without a confirmed diagnosis.
  • Actual number of cases: Unknown, because we do not yet have large scale, random antibody testing; in other words, we cannot yet actually do the type of math that Dr. Erickson is only playing at, because we do not have the data.

By the way, this also means that of the imaginary 64 million people who have had COVID-19, 79 times more people had the virus and didn’t have symptoms, or didn’t meet testing criteria, than those who actually had a confirmed case. This is a big, big logical leap from the rallying cry of ‘we need more testing’ that we have all been saying for a month, and it should be another check for Dr. Erickson when deciding whether or not to trust his data. He has talked briefly about quarantining the sick only, but the implication that his data leads to is that only a very small number of cases will even have symptoms. It’s hard to say if this is simply another oversight on his part, or if he is deliberately playing into the ‘we all had this back in December’ myth that has already been popular.

10:06 Why not the data for 2018-2019 you ask? Or average over multiple years? Because 2017-2018 was the worst flu season we’ve had in decades, and did nearly overwhelm the healthcare system in many places. He is cherry-picking his data; deadliest flu season vs. artificially minimized COVID-19 deaths.

10:00 “50-60 million with the flu (compared to his 64 million for COVID-19). 43,545 deaths. Similar death rate.”

Estimates vary, but most commonly reported is closer to 60,000 deaths from flu that year (not sure where he got the 43k figure from). But how is this data derived? Well, what they didn’t do was multiply the ratio of tests that were positive by the total US population (his methodology); this method would give us over 180 million cases. No, they used actual statistical modeling (https://www.ncbi.nlm.nih.gov/pubmed/25738736). They also didn’t then divide the number of deaths by some crazy high number to get a low case fatality rate; instead they did much more complicated math to determine the excess attributable mortality. So already we are comparing apples to oranges, except that since his data is the product of his imagination, we are really comparing apples to… well, to some made up fruit.

Oh, and they didn’t do any of those calculations early in December before most places had even experienced their peak flu season, which is what attempts to ‘close the book’ on COVID-19 data right now amount to.

10:25 Again, he is talking about a flu season that lasts for 4-5 months, for which there is a vaccine (he will say this in a moment), and which has a much, much lower mortality rate. And we probably should be considering some of those things, to some extent, each flu season anyway.

10:55 Resisting the urge to dig on Urgent Care’s here. Testing everyone for flu is not sound clinical medicine. But that’s a different rant entirely.


13:47 Here he compares California to Sweden briefly. Again, do not trust anyone to do statistics work for you if they are comparing regions without looking at population size. He is comparing the number of deaths in California (“with isolation; 1,220”) to the number of deaths in Sweden (“without isolation; 1,765”) and saying they are similar, with just a quick nod to their populations; “we have more people, but…”

Here’s how he should have phrased these numbers, if he really wanted to compare the impact to date of COVID-19 in these two regions:

  • California Population: 39.51 million
  • Number of Deaths: 1,220
    • Deaths per 100,000 People: 3 “with isolation”
  • Sweden Population: 10.23 million
  • Number of Deaths: 1,765
    • Deaths per 100,000 People: 17 “without isolation”

It isn’t fair to compare these two places in the first place, since a true surge hasn’t hit California yet (at least partially because of social distancing/mitigation measures), and because California and Sweden have very different healthcare structures and very different population vulnerabilities and demographics. But if we did a Dr. Erickson style extrapolation from Sweden to California, we would estimate 6,817 deaths so far in a California “without isolation”, 5.7 times higher than “with isolation.”

But again, these aren’t meaningful comparisons because statistics is a real field of mathematics and it doesn’t work that way. You can’t just take number of deaths from one place and multiply it by the population of another place and say ‘well this is the best data we have so we might as well trust it’, just like you can’t take data from very limited symptomatic testing and ‘extrapolate’ it to the entire population. The assumptions underlying the calculations are every bit as important as the calculations themselves, and so these particular ‘statistics’ I’ve just made up are probably only marginally more helpful than the ones Dr. Erickson made up.


14:00 Brief discussion of Sweden (1,765 deaths) and Norway (182 deaths) in Part 1 as well; the difference in how these nations have been affected by COVID-19 is only “statistically insignificant” (and not even then) when you invent tens of millions of phantom COVID cases to minimize the deaths, injury, and suffering of real life people.


14:58 Weird one to include, but ok.


15:14-16:47 Secondary effects of COVID-19

It’s pretty ridiculous that I’ve been trying to finish this overlong video analysis for 4 days now, writing between patients and during lunch, at the end of long days of clinic and pausing to read the Hobbit to my children, and have only made it to the 15 minute mark. But this is where I’ve been trying to get to, wading through all of the bad statistics and the misleading numerical comparisons, because it is this segment that I’ve been wanting to get to.

Because here, at least, I 100% agree with Dr. Erickson.

Doctors hate disease. We hate suffering. We hate abuse and neglect. We hate that people find themselves in dark places where there seems no way out. We probably hate it more than anyone except those experiencing them and the people who love them. The less wise among us take on far, far too much of that anguish in hopes of offloading a little of it from our patients; sometimes with tragic results. We took an oath to First Do No Harm and we take it pretty seriously. There’s a cultural myth that doctors like illness because without it we wouldn’t have jobs; which is a bit like saying that teachers like ignorance or soldiers love the enemy… although in the latter case, they really ought to, even if they still must fight them. Every doctor I’ve ever met would joyfully find a new line of work tomorrow (most of them are very talented) if they woke up to suddenly find disease, mental illness, physical pain, and all human suffering had suddenly ended forever (and some of us firmly believe that this is exactly what will happen).

In spite of everything, I believe this is probably true even of Dr. Erickson, and that when he is speaking of the suffering that will result from the necessary measures to fight COVID-19, he is speaking for the first time in this video as a Physician and not as an Entrepreneur. I think that’s why he’s had to dive so deeply into his false numbers in order to justify essentially ignoring COVID-19; because if he didn’t really convince himself that it wasn’t the threat that it so clearly is, he probably couldn’t bring himself to risk lives by making this video. At least, that is my sincere hope.

We are all concerned about the secondary effects he is talking about here. I wrote over a month ago, “All of us are afraid of a second spike in COVID-19 deaths if social distancing measures are discontinued too soon, but we are also concerned about a third spike; a spike of all-cause mortality and morbidity from the disruption this pandemic is causing to our normal modes of treating patients. That’s why we are working around the clock to figure out the best way to take care of the patients under our charge while at the same time preparing for and fighting the battle with COVID-19.”

I’ve written about it elsewhere, so I won’t go into details about all the things my clinic has done to work hard to address these very real threats. I work with some amazing people and they have been working their butts off. Since day one we have talked about what this would do to mental health in our community, about children trapped at home with abusive parents, about those with already tenuous chronic medical conditions or severe anxiety and depression, those with addiction, those with food insecurity, those with so-far silent conditions that need to be caught early.

Honestly, these are the things we worry about anyway. I worry about my mental health patients every time I take a vacation. I worry about patients with severe chronic illnesses not being able to get seen every time I make the difficult choice to cut back in clinic, in any way, because I’ve been drowning at my job since 3rd year of medical school. When I don’t have the mental bandwidth or the time to ask a more in depth question or allow a few more seconds of silence that gives the patient time to respond in a less guarded way, I worry what might have been missed. These are the realities of being a Physician in modern healthcare.

Which means that at whatever point doctors can in good conscience advocate for lifting the burden of social (physical) distancing and quarantine and sheltering-in-place off of our patients, friends, families, and selves, we will be the loudest and most persistent voices. If Dr. Erickson’s numbers were at all reputable, we would be thrilled; we would shout it from the rooftops. But they aren’t. And as someone who takes care of many of the patients in my city that our data tells us have the highest risk of complications and death from COVID-19, the only choice I can make is to work hard on my patients’ and community’s behalf to mitigate not only the very real risk of this one deadly virus, but also all of these secondary threats he is naming.


16:55 See discussion of the flu above (didn’t realize he was going to jump around so much). All I’ll add here is a reminder that the CDC is calculating the death rate as a comparison of deaths to estimated cases based on the best methodology available. If we used the Dr. Erickson method, the death rate for flu in 2017-2018, the worst flu season in decades, would be 0.03% instead of 0.13%. But again, it’s not a method any statistician would be tempted to use, not on a dare.

17:26 “The lethality of COVID-19 is much less.” There it is; don’t let anyone tell you that this doctor is just saying that COVID-19 is like the flu in some vague way. He is definitively telling you one is more dangerous than the other, and he’s got it exactly backwards.

17:28 Could someone explain to me how a ‘hotbed’ of a not-at-all-dangerous virus can overwhelm an entire city and kill thousands?


17:44 “I’m sick of following the science. I’m just going to ask it where it’s goin’, and hook up with it later.” -Mitch Hedberg if he were a doctor, probably.


18:00 I would like to know where Dr. Massihi taught immunology. Maybe they will fill in the gaps later, but at this point this could mean absolutely anything. I taught Kaplan MCAT and LSAT test prep courses after college and I was fairly bad at it I’m afraid; do I also get to claim to have taught immunology? What about logic and analytical reasoning?

We all have courses in microbiology, biochemistry, immunology, pathophysiology, virology, etc. It’s part of our curriculum from pre-med onward; what he is describing is the same education that all Physicians have. But the thing is, just because we’ve all had that training doesn’t make us experts; relative experts compared to the general public, sure, but there are people who have studied these systems a lot more. It certainly doesn’t mean we are each entitled to our own opinion about how the human body works, because medicine is a hard science. If he is going to make claims about the immune system, his authority as a doctor isn’t going to get him very far; the immune system is the authority on the way that it works, so we need to check his facts against it.


18:35


18:18 – 19:38 This is something that seems to crop up in almost every single medical misinformation video. I’ve written about it here, and here, and did an entirely overwrought Star Wars analogy about it here; and other people have written about it much better and in more detail than I have. It’s a common theme among alternative health “experts” who are spreading misinformation right now; don’t hide from the virus they say, your body needs it to build up the immune system! It plays into a lot of the cultural myths that Physicians are only interested in giving chemicals and harsh drugs, think all bacteria are bad, and don’t know anything about the body’s own immunity; ideas that are popular in alternative health spheres. So it’s pretty shocking to hear it from a doctor.

Uh oh. Now you’ve got to pick a side; Dr. Erickson or Dr. Ayyadurai

The major failure here is to distinguish between microbes and pathogens. Pathogens are microbes that can cause disease in humans, and some pathogens are so dangerous that either vaccination or avoidance are the best strategies to prevent the terrible, possibly life-long suffering and death that can result. Yet these misinformation purveyors want to pretend that when public health experts and epidemiologists recommend practical methods to decrease transmission of just such a deadly virus, they are actually saying that you can’t go outside, you should live in a sterile room, and your kids can’t play in the mud. Dr. Erickson wouldn’t tell you to touch your face and not wash your hands if you had been around Ebola. He wouldn’t tell you not to wash the surface of your kitchen counter if you had been cutting up raw chicken. He wouldn’t tell you that exposure to viruses is important to building a healthy immune system if you were about to pet a rabid dog.

But because his fake statistics have convinced us and especially himself that COVID-19 is about as dangerous as the common cold, he is willing to spend several minutes expounding the value of touching your face and eyes and not washing your hands so you can get that good IgG and IgM and have a healthy immune response… in the middle of the worst pandemic in a 100 years.

19:26 Just to be clear, you do NOT need SARS-CoV-2 to survive.


With that I am going to pause for the night. Thank you to all who have read these two very lengthy posts, despite my failed endeavor at choosing a format specifically intended to force me into some sort of brevity.

If this video continues to be widely circulated among friends and family in the coming days, I will return to finish the other half. I haven’t even met Dr. Massihi yet; maybe he’s a super reasonable guy who is going to give a balanced counterpoint to Dr. Erickson’s perspective? (Update: Nope.)

But my guess is that we are only hours away from the Next Big Thing in COVID-19 misinformation, and I’ll be forced to abandon this particular analysis at 19:26, just under halfway. If there is anything that particularly needs to be expounded on later in the video, I’ll quietly post it above; but feel free to leave a comment if there is a statement or section you would like me to address. Otherwise, I hope my perspective as a Physician has helped you to make sense of the dangerous errors my peers have fallen into in this video.

“Without education, we are in a horrible and deadly danger of taking educated people seriously.”

― G.K. Chesterton

Dr. Erickson and the 3rd Kind of Lie (Statistics)

There are three kinds of lies: lies, damned lies, and statistics.

Now that the video is back up, Part 2 is in progress.

Yesterday a friend sent me the following video and asked two things; would I write about it, and would I try to make it short! The second skill is not really in my wheelhouse, and it is a very, very long video, clocking in at 52 minutes; I am currently writing a 2 part essay on a video that is less than 5 minutes long. 

I’ve chosen the “live tweet” format (I don’t know what else to call it) in order to keep my comments brief and in-line, chronologically, with the video itself; I am sure I will have some additional closing remarks, however.   

While most of what I try to address on this blog falls into the first two categories of ‘lies’ and ‘damned lies’, Dr. Erickson’s analysis belongs primarily to the final category. Dishonest statistics are extremely difficult to dispel because those who don’t have a background or training in interpreting them are apt to chalk up disagreements to a mere difference of opinion about what the numbers mean. They are often right. However, in this case Dr. Erickson is actually creating false statistics out of thin air, and then framing his arguments with these imaginary numbers.

Edit 4/28/2020: The video is available again here: https://www.facebook.com/watch/?v=537566680274166


(Note on time: with the original video removed from youtube, these time stamps are going to be a bit off. The facebook video above is about 12 seconds ahead of the original video; so 0:22 becomes 0:10, 0:27 becomes 0:15, etc. Sorry for the inconvenience.)

0:22 Kern County California.


0:27 This is my first yellow flag; “ER Physician/Entrepreneur perspective.” Most doctors wouldn’t describe themselves in that terminology even if they run their own practice, so I’m listening very carefully for what the “entrepreneur” angle is. 

Over and over again with these misinformation videos, we have seen that the creating of false information has some direct link to attainment of money, power, or fame for the person in the video.


0:45 “If that still makes sense.” This is the question on every person’s mind, and rightfully so. For medical people, clinicians and nurses, it’s a definitive and resounding “yes,” so I’m interested to hear his perspective. 


1:00 Already this video is different from most of what’s going around, because these guys are actual doctors.


1:34 Here we reach the “entrepreneur” piece; my understanding is that Dr. Erickson is an owner or partner of Accelerated Urgent Care, a group of 5 Urgent Care centers around Bakersfield CA. 

Two things about this: First, we do need to recognize that while Urgent Care centers can and do provide services that help take the pressure off of over-utilized hospital emergency departments, they are NOT emergency rooms, and so unless Dr. Erickson is also working in a hospital context it is not quite accurate to treat him as a practicing ER Physician; he is likely ER trained, but not currently working in that context. 

Second, Urgent Care centers are indeed entrepreneurial ventures; they are for profit, like so many fixtures of our broken healthcare system. During this entire video we are going to have to ask ourselves how the pandemic is affecting his business, and how that is implicitly affecting his understanding of the situation and statistics. 


1:44 See above. 


1:58 I don’t know what “furloughing patients” means, but otherwise this is the exact situation in Waco; we’ll get into this in more detail later because I think it’s an important topic.

One note for now; do not fall into the trap of thinking that “empty ICU’s” means that the pandemic is not real. Cancelled elective cases and alternative delivery of care is part of containment measures in areas where COVID-19 has not yet surged, like Waco or Kern County California.  The worst is yet to come. 


2:03 Make note of this. Everything else that is said in this video needs to be understood in the context that even Dr. Erickson recognizes that this virus can overwhelm healthcare infrastructures; it’s doing it in New York right now.


2:30-3:02 He’s absolutely right, in a way. As I’ve written before, every single clinic I know of is working hard to make sure that their patients with chronic medical and mental health needs are still receiving the best care possible under the circumstances.

But there is another side to ‘secondary effects’ of COVID-19 as it relates to chronic conditions, and it’s this; as deadly as this virus is for people with the very conditions he is listing (in other words, their fear or caution is not unfounded), an overwhelmed healthcare system is also dangerous even apart from the virus. When patients who have heart failure or diabetes, or depression, or any other medical or mental health condition cannot get care because the healthcare system is overwhelmed with a pandemic, that is no less dangerous than not getting seen for other reasons; and probably much more dangerous in many cases because at least with the ‘minimum capacity’ healthcare usage he is discussing they could still get timely treatment in a true emergency, which is not a guarantee when the local ER’s are overwhelmed. These are difficult decisions that every clinic, hospital, and system is weighing carefully; and the quality of that decision making depends on reliable COVID-19 data, as we will see shortly.

One more note; this absolutely is being talked about, and extensively. Don’t fall for the “why are the higher ups keeping quiet” argument about very complex medical systems and situations; these conversations are being had on every level and have been for months (I have yet another Zoom meeting this afternoon about this very issue). 


3:17 I think this is a really misleading way to frame the amount of data we had 1-2 months ago, and at the beginning of our social/physical distancing measures. Cases began to rise outside of China in early to mid February, and We already had 100,000 confirmed cases worldwide by March 7th. It was officially declared a pandemic on March 11th. So those (not) early (enough) decisions to begin social (physical) distancing measures were made based on data, not in the absence of it.


3:33-3:50 This is a false equivalence, and actually rather silly. What would it look like to quarantine the healthy because of ‘normal’ infectious diseases? “Sorry Billy, no school today; somebody at your school has pink eye so everyone is staying home.” “We can’t go to Church today kids; the pastor’s daughter had Hand, Foot, and Mouth Disease.” Pretty ridiculous, right?

But our template for COVID-19 is not pink eye, or strep throat, or even the seasonal flu; it is the 1918 Spanish Flu pandemic, smallpox, and the freaking Black Death. He is acting as though he didn’t study these diseases and periods of history in pre-med and Medical School.

In a Pandemic, social (physical) distancing, what he is calling ‘quarantining the healthy’, absolutely saves lives. If you don’t believe me, read this article. Or go play the Plague, Inc flash game and try not to throw your phone across the room when Madagascar shuts down it’s seaports.

https://www.contagionlive.com/news/analysis-spanish-flu-pandemic-proves-social-distancing-works


4:21 I didn’t realize what he was trying to say here right at first, but it’s worth pointing it out here instead of 10 minutes later when it finally hit me, since this is actually his main thesis throughout this video.

  • Kern County:
  • People tested: 5,213, Positive Cases: 340
  • Dr. Erickson: “That’s 6.5 percent of the population.”
  • Wait, no, it isn’t!
  • “Which would indicate that there’s a widespread viral infection.”
  • No, it doesn’t.

You see, this is where the statistical bungling really begins; he’s saying that since 6.5% of the people tested were positive for COVID-19, we can conclude that 6.5% of the entire population has it. But that’s an absolutely erroneous conclusion, because the testing wasn’t random. This testing was done, especially early on, primarily on patients who had symptoms of upper respiratory illness and fever, had known medical conditions that made them high risk of complications from COVID-19, and who had some degree of known exposure to the virus.

Do you remember how just a couple of weeks ago so many people were upset that they couldn’t be tested because the criteria for testing was so strict? The fact that only 6.5% of even these patients had positive tests shows that the virus is not yet widespread in Kern County California, just like it isn’t here in Waco, or in any city that hasn’t yet hit a surge in COVID-19 cases yet.

This data cannot be “extrapolated” to the general population to determine the prevalence of the virus because the testing, so far, has not been random or representative. His methodology sounds reasonable enough on the surface, but it is actually leading him to wildly inaccurate numbers and conclusions that are the exact opposite of the case.


“We think it’s kind of ubiquitous throughout California. We are going to go over the numbers a little bit to help you see how widespread COVID is.”

This should properly be understood as Dr. Erickson’s thesis for this video.

  • 4:40 California:
    1. 280,900 Tested.
    2. 33,865 Positive for COVID-19.
    3. *dubious math*
    4. “That means that 12% of Californias were positive for COVID”
  • Except it doesn’t, because you can’t get data on the number of cases in the state from non-random testing of symptomatic individuals with known exposures.
  • It actually shows the opposite; even in patients who met the until recently very strict testing criteria, only 12% of those patients tested positive; California has NOT hit it’s peak yet. https://www.latimes.com/projects/california-coronavirus-cases-tracking-outbreak

5:08 These projections were based on what would happen without social/physical distancing, shelter in place orders, and other mitigation strategies. The fact that it “hasn’t materialized” is evidence that mitigation is working. We have been saying since day 1 that as soon as these strategies started to show success, people would say they weren’t necessary.

But don’t worry; if we work hard to return everything back to normal and forego all mitigation efforts, we can still make these numbers materialize.

5:20 You cannot extrapolate prevalence data from testing of symptomatic individuals. We will explore how you could get this data later on, but for now, each time he ‘extrapolates the data’ you need to realize that the number that results doesn’t actually mean anything.

5:32 “That equates to 4.7 million cases in the state of California.” (No epidemiologist believes this; this is a nonsense number.)

“We’ve had 1,327 (now 1,651) deaths in the State of California with a possible prevalence of 4.7 million.”

“That means you have a 0.03 chance of dying from COVID-19 in the State of California.”

Dr. Erickson

Do you see what he’s done here? He’s multiplied the percentage of tested cases that were positive by the population of the entire state and called that number, 4.7 million, “prevalence.” He’s then divided the number of deaths by that gigantic made up number in order to make the death rate seem incredibly small.

You are supposed to think, “wait, I heard something like a 3-4% death rate, but he’s saying it’s 0.03%. They’ve blown this whole thing out of proportion!” But the number he is deriving is incredibly small because the fake denominator he has come up with is gigantic; and that is going to be the case for any location regardless of whether they have yet been hit hard by COVID-19, because while he is multiplying the percent of positive tests by the entire population, the number of deaths stays the same. He is comparing known COVID-19 deaths not to known cases, but to a wildly inflated ‘guess’ at the number of cases that is not based on sound epidemiology statistics principles.

In fact, while he isn’t really calculating anything, what he’s closest to deriving by comparing number of deaths to population is what’s called the mortality rate, and since most people don’t die in any given year, this number is always going to be small compared with the general population; any number of deaths looks small compared with 328 million people. This is the reason we talk about mortality and attributable mortality rates in terms of ‘per 100,000 people’, because most of us (myself included) can’t conceptualize the significance of very, very small numbers. If I told you that the mortality rate of heart disease is 0.122% and the mortality rate of cancer is 0.049%, that’s going to be much less helpful than the more typically reported figures of 165 deaths per 100,000 vs. 37 deaths per 100,000, respectively.

So, what he’s giving us is an erroneously calculated ‘death rate’ that is so impressively tiny it cannot be conceptualized and compared well, in place of the commonly discussed and oft debated case fatality rate, which is the chance of dying if you do get the virus.


6:10 “I also wanted to mention that 96% of people in California who get COVID recover.”

Here he has tipped his hat; this is the case fatality rate. You see, the opposite of ‘recovering’ is ‘not recovering’, i.e. dying. He’s sharing the actual case fatality rate, what laypeople call the death rate, but in a form that is unrecognizable.

This is a classic spin technique; flip the statistic so it suddenly sounds like a good thing. “96% is really high! Recovery is good! See, the good thing has a high number, so we are fine!” But if 96% recover it means that 4% die, and that number is astronomical for a case fatality rate, far closer to the Spanish Flu epidemic (2.5%) than to the seasonal flu; and this is just in an area where the healthcare system is otherwise slow due to COVID-19 concerns; in places where hospitals are overwhelmed, the death rate (case fatality rate) is much higher.


6:12 “With almost no significant continuing medical problems (sequelae)”

It is way, way too early to know what the long term sequelae from surviving this virus are going to be.


6:28 “This is our own data, this isn’t data filtered through someone.”

Like, for instance, an epidemiologist who could help make sense of it for you? Sorry, I’m getting snarky again.


6:42 This is exactly backwards; the more the prevalence data goes up, the more positive tests you will get; but because it’s the real prevalence and not the erroneous prevalence he has calculated, that increasing prevalence will be accompanied by increased hospitalizations and increased deaths.


6:47 He’s just admitted to the calculation error I was talking about earlier. Incredible.


6:53 “Millions of cases, small amount of death”.

He says this over and over again; it may as well be the title of the video. Except it isn’t true; there isn’t any evidence that there are millions and millions of cases in California (41,000 confirmed at this point), and the number of deaths is anything but small. By the end of this week we will likely have passed the deaths from the worst flu season I’ve ever experienced, 2017-2018 (62,000 deaths), and epidemiologists believe we are underestimating the number of deaths from COVID-19. Moreover, this hasn’t peaked yet in most areas of the country; if we stop mitigation efforts, this could blow anything in our lifetimes right out of the water.


7:058:56 “So I want to look at New York State.”
  • 25,272 Positive Cases
  • 649,325 Tests
  • 19,410 Deaths (not sure where he got this number from)

“That’s 39% of New Yorkers tested positive for COVID-19”

At this point one of the reporters clarifies that it is not 39% of New Yorkers, but only 39% of people who were tested in New York State, and how if it were 39% of New York’s population that would be nearly 10 million cases of COVID-19 in that state alone. This is an incredibly important distinction. Dr. Erickson acknowledge this but fails to understand the implication; he is still insisting that you can “extrapolate” data from the testing that has been done.

An explanation of why we can’t extrapolate the information he thinks we can, and how we could get that data.

This data can’t be used for the purposes he is trying to use them for, for at least three very compelling reasons. First, it’s the wrong testing strategy. He keeps saying you can extrapolate the test data we have to the general population, but the people who were tested do not represent the general population. They have self selected due to exposure or illness and, especially early on, had to meet very strict criteria (or be an NBA player or celebrity) to even get tested in the first place because of the shortage of tests; these tests were done on the people who were already the most likely people to have COVID-19, and so their percentage of positive tests (39% in New York, 12% in California per Dr. Erickson) is going to be far higher than any other group. Even accounting for asymptomatic carriers, there is no reason to believe that asymptomatic people would have the virus at anywhere near the rate of people who have symptoms of the virus. This is… pretty common sense stuff, actually. For testing to be used to extrapolate to large numbers that give us population level data, it has to be random, and this is the opposite of random. So it’s the wrong strategy for the conclusions he is drawing.

But even if it were random, it simply isn’t the right sort of test for that. The current tests detect COVID-19 (SARS-CoV-2) antigen; circulating proteins specific to the virus; it is detecting the virus itself. It can do this before the patient is symptomatic if the virus is replicating inside them, but not once the virus has been eradicated from the body. Because of this, it’s actually the wrong test for the job; a person can test negative once they have recovered, so they would be miscategorized as a ‘negative’ test even though they had already had the virus. At best, a sufficiently large number of (random) tests done on the same day could give you a snapshot of how many people have the virus at any given time; this is called point prevalence. If this were at all possible, it would indeed be helpful for knowing the current risk of being exposed to the virus (though it would change quickly and require serial rounds of testing). But you can’t use it to determine a death rate; for that we need period prevalence, the total number of cases throughout the time period of the pandemic, and for that we need to know who has had the virus, not just who has it now. So, it’s the wrong test.

But it’s also the wrong time. If we want to know the final, true case fatality rate for COVID-19, which we all expect to end up being very high but much, much lower than the astronomical numbers we are seeing now, we are going to need that period prevalence for the entire period of time of the Pandemic. Even if Dr. Erickson’s calculations were correct up till now (and they are so, so not), it would still be the wrong time to rely on them because many of the regions he is discussing, including his home state of California, have not yet hit their surge. We don’t know what the death rate in California will be because the virus hasn’t come and gone yet; their healthcare system, doctors, and nurses are yet to be tried. It is the same in Waco; we are still in the long calm before the storm, hoping that something will give (a vaccine, a brilliant epidemiological strategy, a radical new treatment being discovered, seasonal decrease in transmission, etc) and we won’t have a surge at all.

So, what would an ideal testing strategy look like if we really wanted good quality case fatality data? It would use antibody testing (which tells us if the person has ever been exposed and had an immune response to the virus, not just if they have it right now), would be random, and would be done after or at least at the tale end of the pandemic. This would take into account asymptomatic and minimally symptomatic cases, and people who had symptoms but never got tested at the time. With a sufficient number of tests it could be used to extrapolate data for the entire population with a good degree of reliability. He’s probably right that we won’t ever do testing quite like that; but since there are potentially lots of other uses for antibody testing, and some of it involves testing people who aren’t actively ill, it is likely that we will get data that can at least be legitimately used to derive some idea of prevalence and true case fatality rate.


While we are discussing New York and possible testing strategies, it is important to note that there is some preliminary data about the actual prevalence coming out based on the antibody testing we discussed earlier, and the news is indeed hopeful; but even the most optimistic numbers so far only get the case fatality rate down to about 0.5% in New York, when you include asymptomatic carriers, assuming the sample is representative; 5 times higher than the number Dr. Erickson has landed on, and still incredibly dangerous. This is a number most of my colleagues would believe sooner than something apocalyptic like the 8-12% in overwhelmed healthcare systems across the globe, and Physicians and Epidemiologists have anticipated and said from the beginning that these numbers would drop significantly once broad-based testing and antibody testing were available. But unlike Dr. Erickson, most doctors I know are not comfortable making that kind of stuff up and would prefer to wait for data that actually has a logical connection to the questions we are asking.

https://www.livescience.com/covid-antibody-test-results-new-york-test.html

But even as more random antibody testing is done and death rates for COVID-19 hopefully trend down away from the utterly incomprehensible numbers they are at now, please remember; it isn’t just the case fatality rate that makes a disease dangerous, it’s also the degree of infectivity. Even if COVID-19 settles out to be less deadly per case than the bubonic plague or ebola or the Spanish Flu Pandemic of 1918, it can still kill incredible numbers of people if it makes up the difference by being highly contagious… Unless our mitigation strategies can prevent it from spreading.


8:12 Reporter: “Those models were based off if we did no social distancing.”

Dr. Erickson hand waves this off, but it’s an important point for understanding the timeline of this pandemic and understanding that those models are still a real possibility if we stop mitigation efforts.

It’s also an important opportunity for demonstrating some intellectual integrity, since the reporter is correct that those models were for scenarios where social distancing wasn’t followed, and Dr. Erickson has been dismissing them as ‘wildly inaccurate’. Sadly he fails to rise to the occasion and acknowledge this.


8:54 “We extrapolate out and use the data we have, because it’s the most accurate we have, versus the predictive models that have been nowhere in the ballpark.”

This is a blatant false dichotomy. The predictive models were done to show the range of possibilities of the impending danger if no action was taken; the antigen testing strategy to identify and isolate cases. Neither can be used to establish actual prevalence, but he wants us to think we have to accept his calculations, based on erroneous assumptions, because it’s the only option.


8:59 “So how many deaths do they have? 19,410, out of 19 million people. Which is a 0.1% chance of dying from COVID in the state of New York. And they have a 92% recovery rate! (Edit: That’s an incredibly high known case fatality rate of 8%!) Millions of cases, small amount of death. Millions of cases, small amount of death.

I want to be as generous as possible here. I really believe that this could be me, were the circumstances different, going on youtube and sharing these false statistics. Yes, Dr. Erickson has financial interests at stake here, but so far I’ve been inclined to think that he really believes his numbers. When you are pouring over data like this for hours or days and you think you’ve hit on some vital statistic that nobody else is picking up on, and it confirms what you already really, really want to believe, it can be so easy to get tunnel vision and not check your math against the backdrop of reality.

But New York should have been the “Aha!” moment for him; the point where he sees the house of cards he’s built collapse so he can start over from scratch with all of his equations. 19,000 deaths; 19,000 deaths in one state, in one month. Overwhelmed hospitals, too few ventilators, nurses and doctors collapsing at work. These stories from the front lines should be enough to make him question the conclusions he is drawing.

If you are calculating a pediatric dose of antibiotics and arrive at instructions that tell the parents to give 28 teaspoons three times per day, you’ve made a mistake somewhere; it doesn’t matter if your math was perfect, something must have gone wrong because those numbers don’t mesh with reality. If you are trying to figure out how long it will take you to drive from San Antonio to Waco and google maps tells you it’s 22 hours, something went wrong; it doesn’t matter how good their calculations and traffic algorithms are if the app thought you meant Waco, Montana instead of Waco, Texas. And if you are trying to derive real-life mortality data from numbers available on google and discover that a virus that is killing tens of thousands in a short amount of time, overwhelming hospital systems, and leaving your colleagues in New York with post traumatic stress disorder is actually not that dangerous, you’ve probably made some flawed assumptions before you even fired up your calculator. Your mathematical conclusions have to line up with reality, and his don’t.

He has concluded that COVID-19 is no worse than the flu, which in any given year will kill between 10,000 and 60,000 people nation-wide over 3-5 months. But the deaths of 19,000 human beings, with friends and families, who wouldn’t have ‘died anyway’ at this time, many while their doctors and nurses looked on helplessly because they had not the time or lifesaving equipment to intervene, in one state in one month, should be a wake-up call even for him.


9:48 “We’ve tested 4 million people. Germany is at 2.” The population of the US is 330 million and the population of Germany is 83 million; their tests per capita is double ours. He hand waves this with ‘sure I realize their populations are lower, but…’ Don’t trust anyone with your statistical analysis who waves away the single most important statistical number for comparing countries, their respective populations.


And at this point, mercifully, the video has been removed from Youtube for spreading verifiably false information. This is a double-edged sword, because it inevitably means that copies of it will be spread elsewhere with the heading “BANNED FROM YOUTUBE!”, and even more people will click, watch, and be deceived (or more likely, further entrench the false narratives they have already chosen to believe before watching). If someone does have links to the video when it’s up again, please send it my way so I can finish the other (checks notes) 45 minutes of the video.

But some sanctions cannot be waived away by your being popular with conspiracy theorists. The American College of Emergency Physicians and the American Academy of Emergency Medicine today released a joint statement condemning the irresponsible and flawed information in the video. And while the parts that we have covered so far have been mainly bad statistical analysis disconnected from reality, there are statements made by these doctors later (which I cannot now quote verbatim) that much more flagrantly disregard the oath they took in medical school. I honestly hope these are played back for them the next time they are set to renew their board certifications, and indeed their medical licenses.


With the video down, I’ll have to conclude here for now, and considering the number of charts I need to close for clinic, I can’t thank YouTube enough for taking down the video when they did.

Over the next 10 minutes or so, Dr. Erickson applies his same flawed methodology to other countries, multiplying their positive test rate by their total population to come up with his fake prevalence numbers, and then dividing the number of deaths by that to show how not dangerous the virus actually is. “Millions of cases, very small deaths.” If the video ever comes back, you can watch him do it time and time again, as a tutorial of sorts, so that you too can enjoy creating your own fake statistics at home.

And this leads him to conclusions which, while obvious from his erroneous numbers, defy both our reason and the experience of our fellow human beings. He concludes, remarkably, that the COVID-19 virus has not been that bad even in Italy and Spain, where it decimated the healthcare infrastructure and killed tens of thousands. He concludes that the difference between Norway’s 200 deaths and Swedens’ 2000 deaths is statistically negligible, and therefore social (physical) distancing measures don’t actually matter. He does this because, again, he’s invented a sufficiently high denominator for his “prevalence” that literally any number of deaths is going to seem “insignificant,” at least statistically.

  • Sweden’s Population: 10.2 million.
    • Deaths in Sweden (without mitigation strategies): 1,765
  • Norway’s Population: 5.4 million.
    • Deaths in Norway (with mitigation strategies): 182

14:30 Dr. Erickson: “1,700 (deaths), 100 (deaths); these are statistically insignificant.”

I want you to stop and say that out loud a few times. Go ahead.

These lost lives are not insignificant; statistically or otherwise.


One more thing I remember specifically, because it was so shocking to me at the time. He goes on to talk about the way that the mortality data is being ‘manipulated’, even saying that a deceased patient with COPD (Chronic Obstructive Pulmonary Disease) who contracted COVID-19 has not actually died of COVID-19, but from 25 years of smoking… As though the medical vulnerabilities that predispose a patient to becoming a victim of this horrible virus and the pathology caused by the virus itself are mutually exclusive. As though tens of thousands of COPD patients who have been smoking for decades were suddenly going to go into respiratory distress in April 2020, apart form any exacerbating factors, and their happening to have the virus that is also killing people with heart disease, diabetes, compromised immune systems, and even the young and healthy is just some weird coincidence.

Bad at statistics is one thing. This is bad at being a Doctor.


Now that the video is back up, Part 2 is in progress.

Treat Your Immune System Like The Death Star (A Slideshow)

The amount of medical misinformation out there right now is staggering. Would-be alternative health celebrities see the COVID-19 pandemic as their opportunity to make a name for themselves and increase their fame and fortune, and their videos seem to range from 5 minutes of mostly benign half truths, to one I saw today that was 48 minutes of crazed rantings. As a Physician, I despair of being able to address even a fraction of the misinformation my friends and family are being exposed to right now.

But you have to start somewhere. One of the biggest areas around which falsehood and distortion crops up consistently is the role of your immune system in fighting disease in general, and in protecting you against COVID-19 in particular. And in this area there are two dangerous distortions that seem to crop up again and again. But to address those, I think it’s important that we think of the immune system as a Death Star.

 

The Church and Medical Misinformation During COVID-19

Preamble 1: This is written to Christians, and intended as a call to my fellow believers in Christ to hold to very high standards of truth telling, particularly as it relates to the COVID-19 pandemic we are currently facing. I do think that the general principles I am espousing here apply to others as well, and all our welcome to read and comment.

Preamble 2: In this post I do talk quite a bit about holistic healing/alternative medicine. This is an area of complexity and nuance, but here I am primarily talking about self-proclaimed alternative health “experts”: modern day snake-oil salesmen who are seeking to use the COVID-19 crisis to create a name for themselves and garner greater fame and fortune. I know many of my friends lean towards ‘holistic’ alternatives or adjuncts to modern evidence-based medicine (modern medicine IS holistic but that’s another soap box entirely). I have FB and real life friends who are into essential oils, I have family that swear by their chiropractor, and I myself have received acupuncture in the past (it was kind of fun, to be honest). Most of them, thankfully, also choose to bring their children to the doctor when they are ill and to vaccinate them to prevent communicable diseases. Most of them have been very, very supportive of healthcare professionals in general and of me personally during this pandemic, and I have seen them both seek out and share good, reliable medical information. In short, I have been quite proud of these crunchy, oily friends of mine. If you are reading this as someone who identifies strongly with holistic or alternative medicine, I would ask you to please consider carefully whether the conspiracy theorists and COVID-19 deniers who are so prolific on the internet right now really represent your movement well and are espousing the same values that you find important in your area of wellness. My hope is that you wouldn’t be deceived by them easily just because they are comfortable using the same terminology that you hold close to your heart; an error we in the Church have all too often made with false teachers of all stripes.


“Finally, brothers and sisters, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy—think about such things.”

“Keep your tongue from evil, and your lips from telling lies.”

When the initial wave of concern over COVID-19 began for our clinic system a few short weeks ago, there seemed no end to the things that needed to be done. We had to rapidly prepare to protect our staff and patients by minimizing transmission risk and eliminating fomites, go through all of our processes with a fine toothed comb and revise or rewrite a fair number, and innovate and implement novel ways to deliver high quality primary care under circumstances where it was no longer safe for our patients to sit in a crowded waiting room as they wait to see their primary care Physician, or even pass each other in the hallways on the way to the lab or radiology. This all in addition to learning how to work-up and treat the virus itself. During those first few weeks many of us worked until the wee hours of the morning each night and through the weekends, all the while continuing to see patients, return phone calls, and refill medications. But as these systems have been put into place and fine-tuned, and as the physical distancing and other epidemiology measures on a community level have effectively limited the spread of the virus in our area, life has thankfully slowed somewhat again.  Many of us that do hospital work are waiting to see whether more doctors will be needed to cover shifts, or if the shelter-in-place orders and distancing measures will be enough to avoid a true, overwhelming surge. In the meantime we read and stay up to date, we see our patients via telemedicine or in outdoor COVID-19 clinics and work hard to make sure they don’t fall through the cracks, and we prepare, personally and professionally, for worst-case scenarios. Throughout all of this we have each continued to ask ourselves what our next responsibility is as Physicians in the midst of this pandemic.

In answer to that last question, I have found myself more and more called on to provide an answer to misinformation around COVID-19, as friends and family have attempted to sort out the unprecedented amount of misunderstanding and abject falsehood that has been circulated over the past month. To be clear, even in the best of times there is already an overwhelming amount of misinformation around health and healthcare. The nuances of human health and disease and the means available to protect the former and fight the latter are unbelievably complex, and because of this it is easy for an individual who hasn’t spent a lifetime studying this area to feel overwhelmed and disempowered. The temptation of easy answers and quick fixes is very real. More to the point, Physicians have historically done a fairly poor job, in my opinion, of helping our patients to feel empowered and knowledgeable to the greatest degree that is possible without them actually entering the medical field themselves. In this context, it is no surprise that during this time of increased health anxiety and uncertainty, and with a myriad of political and economic motivations to obscure the realities around the virus, the amount of misinformation has increased dramatically. Between my day job, extra duties related to the virus, and this small matter of having a wife and four children, I consider it a real privilege when I have the margin to address a video or article that a friend has ‘tagged’ me in asking for my input.

But though there are plenty of unaddressed articles, videos, and memes spreading medical misinformation on my facebook feed this very day, I am writing this afternoon with a slightly different, though related, purpose. I am writing to call the Church to participate in this work with me.

We are called to be a people of the truth; we are not called to be a people of truth and falsehood mingled. When discussing his conversion to Christianity, G.K. Chesterton wrote, “My reason for accepting the religion and not merely the scattered and secular truths out of the religion… I do it because the thing has not merely told this truth or that truth, but has revealed itself as a truth-telling thing.” As followers of Christ, Christians ought also to have a reputation of truth-telling. Truth-telling in love, when the truths are difficult. Truth-telling in courage, when the the truths are spoken to those in places of power. Truth-telling in humility and repentance when those truths reflect poorly on ourselves or our conduct. We cannot afford the damage done to the witness of the Church by our gaining a reputation as unreliable sources of truth. Yes, physical health in general and the COVID-19 pandemic in particular, as devastating as it is, are still ultimately minor issues compared to the eternal importance of the Gospel; but how can the world around us look to us for the Truth of the latter when we have only provided them falsehood about the former? “Whoever can be trusted with very little can also be trusted with much, and whoever is dishonest with very little will also be dishonest with much.”

For this reason, I believe that our willingness as a people of Faith to perpetuate misinformation, particularly when it may truly injure our neighbors, is not a political issue or even an integrity issue, but a spiritual issue. There is no truth, whether philosophical, metaphysical, or scientific, that does not belong to our Creator; there is no Truth that we as Christians should fear, and there is no falsehood, no matter how convenient to our preferred narratives, that does not originate from our Enemy.


What follows is my take, as a Physician, on what a lay person can do when trying to weigh truth and falsehood and judge the reliability of medical information during the COVID-19 pandemic. I want you to know that I realize it is often very, very difficult. As a Physician I have the privilege of years of education and training in thinking about real and reliable truths about our bodies and the diseases that affect us; it is never my place to judge someone for sharing information they find convincing because they do not have those same experiences and have spent their time in other important work. It is my job, I think, to help my fellow believers supplement their God-given discernment with reliable data and professional insight; we are all one Body, but made up of many parts.

1. Understand your source.

Returning to Chesterton, I think it is reasonable to ask whether the author of the article or the self-purported expert we are listening to has a track record of providing reliable medical information; have they proven themselves to be a ‘truth-telling thing (er, person)’. Many of the people generating widely shared false information are political partisans who have no medical or other scientific background; are they sharing the perspective of actual experts, or are they merely creating false narratives and opinions out of thin air? If the source is not a politician but instead claims to be an expert, what is their education and background? So often we give our trust to people whose primary credentials are an attractive and disarming physical presence and a high verbal IQ but who do not have even the basic science background to understand the frameworks they are tearing down. I have seen youtube videos captioned ‘so and so DESTROYS the COVID-19 pandemic myth’ or ‘Dr. X crushes the CDC and WHO conspiracy’, etc., only to find that not a single intelligible sentence of valid scientific information was uttered during the entire 15 minute video. These are the ‘used car salesmen’ (no offense to actual used car salesmen; I am very pleased with my 2012 Honda Odyssey) of medical information, and their true area of expertise is in pretending to be experts.

Please understand what I am not saying; I am not saying that you must have a certain degree or a certain prerequisite combination of education or work experience in order to have a valid take on the pandemic. But often these videos are made by people putting themselves forward as experts without the credentials to support that claim; the first piece of misinformation is imbedded in their own self presentation. An example is a video a friend recently asked for input on, from a doctor putting himself forward as an expert on the immune system. It turns out that he was not an immunologist or a microbiologist, but a disgraced chiropractor turned “cellular detox diet” specialist. Again, this does not negate what he has to say; but it is a vital piece of context for weighing the claims he goes on to make.

This research is sometimes hard. These people are often incredible at building legitimate sounding resumes for themselves and at using terminology on their websites and bios that smacks of authenticity and scientific rigor. Moreover, there are also those who do have impressive credentials yet have strayed from any integrity in their work and have become deeply unreliable sources of healthcare information in their pursuit of fame or fortune (a fellow MD friend and I often joke, darkly, how easy it would be to make tons of money as a Physician, if it weren’t for these pesky morals). But even if you cannot establish someone’s reliability with a few minutes on google alone, conducting such research will help to answer a few basic questions that should set the tone for the information itself. Is there a direct link between the reach of this person’s social media influence and their opportunities for attainment of power and profit, such as a political office being at stake or a website that sells services or goods directly? Such a relationship would be fairly rare in medicine or academic science. Are the claims this person makes the types of things that would fall within their area of knowledge based on their education and work experience? Are they setting themselves up as experts in areas, such as clinical medicine, immunology, or epidemiology, where they seem to have had little to no experience? Finally, do they have a history of fraudulent claims, moral turpitude, or failed (or successful) scams in the past?

This step is sometimes a bit tedious, but I believe vitally important, especially when some of these videos are made by people who have spent a lifetime mastering the art of convincing others with their looks, manners, and likability. When it comes to medical misinformation, these are the wolves in sheep’s’ clothing of the moment.

2. Do your research.

This second point is so similar to the first that I won’t spent much time on it. Though understanding whether the source is reliable is important, I firmly believe that the content of the argument is more important still. When considering any degree of medical information shared on social media, or even mainstream media, pause to reflect on the main themes and content of the article or video. What was the driving point? What information contradicts that which is already widely available? What data seems shocking or seems to rely heavily on the existence of widespread conspiracies? For that matter, do those conspiracies depend on the sudden cooperation of diverse and often opposed sectors of society, such as the sudden cooperation of politically unaligned nations or the widespread collusion of large groups of healthcare professionals? What part of the information is benign and widely accepted already, and is it being presented as such? Or is there a claim that commonly accepted facts are denied by or unknown to ‘the powers that be’ (the CDC, the medical establishment, etc), and does that seem very likely? What would the major implications be if this video were true, and who would stand to profit by its widespread acceptance if it were false?

This list could go on, and in another time we would have only these important critical thinking questions to guide us to the informational content itself. But we live in a technological age and the odds are that if we are seeing a video, or at least a popular video, it has been critiqued or fact checked already. Read these critiques; seek them out. This alternative perspective, even if it comes from a source you normally don’t subscribe to personally (I know people who despise certain fact checking websites), may be enough to give you the ‘aha!’ moment you need to reach conclusions on the information for yourself. And if you believe the information and think it is worth sharing, then understanding the arguments against it will only strengthen your position.

3. Be honest with yourself about your political leanings.

I’ll keep this one brief because I don’t particularly want to be dragged into a specific political debate, at least at this time. As people of faith who are committed to the truth, we will find ourselves politically homeless a fair amount of the time, and holding onto important caveats and a sense of tension even in our areas of agreement with political movements. When the truth conflicts with the narratives of the political groups with which we most closely align, our choice is clear. Before sharing information from questionable sources, that our research tells us is not reliable, we have to check our politics; we have to be very honest with ourselves regarding whether our impulse to perpetuate the information stems from a real belief in its veracity or from a mere desire for it to be true. I have heard fellow Christians tell me “all politicians lie” (generally to excuse untruths from one group or individual), and then have seen them blindly re-post the lies that come from their own side. I may very well have been guilty of this myself. If we believe that politicians are not reliable sources of information in general (and we can debate later if some are worse than others to an almost unprecedented degree), it means that we will sometimes choose for reasons of discernment not to pass along information that, were it true, would be extremely convenient to our party or candidate. In contrast, if we find ourselves always repeating the party line and reinforcing the narratives of those in positions of power, I fear that we are in danger of rendering unto Caesar something that never belonged to him.

4. Beware of easy answers.

“Reality, in fact, is usually something you could not have guessed. That is one of the reasons I believe Christianity. It is a religion you could not have guessed. If it offered us just the kind of universe we had always expected, I should feel we were making it up. But, in fact, it is not the sort of thing anyone would have made up. It has just that queer twist about it that real things have. So let us leave behind all these boys’ philosophies–these over simple answers. The problem is not simple and the answer is not going to be simple either.”
C.S. Lewis wrote this when discussing the reality of Christianity and the complaint heard so often that ‘religion ought to be simple.’ But I think this quote is informative for us in this discussion of medical misinformation. Alternative health popularizers like the ones we are seeing in video after video right now have long mastered the art of combining oversimplified ‘common sense’ arguments with the right kind of complex medical vocabulary (some real, some fake), to appeal at once to both our desire that healthcare should be fully comprehensible and explicable to us and our desire to know we are hearing form an expert. They are experts in tickling the ears, in confirming our biases and ingratiating themselves to a public that is anxious over health and disease. For someone who has actually studied both the real concepts they are distorting and the real vocabulary they are misusing, these arguments are as transparent as they are ridiculous; but they are not trying to convince me, they are specifically trying to convince people who don’t have medical training.

That said, you don’t have to spend your life studying pathophysiology and be intimately familiar with medical terminology to spot these patterns for yourself and know when to be wary. These false arguments tend to fall along a few common themes, and once you learn to spot them you will be a big step closer to at least being able to ask the right questions.

  • The real solution is easy but they don’t want you to know that.

This one has come up a lot recently as people advocating against social/physical distancing measures (for political or financial purposes) are pushing the idea that other simple measures would actually prevent getting sick from COVID-19. Typically these are oriented around the immune system, and the idea that having a healthy immune system would actually prevent the disease entirely. Aside from being untrue, this is extremely problematic for two big reasons. First, I think we should recognize the degree of victim blaming involved in this line of reasoning; if these 41,000 people who have died from COVID-19 in the US had just taken enough Vitamin C or eaten a healthier diet they wouldn’t have died. Certainly the interaction between health and lifestyle, including limitations in choices and socio-economic vulnerabilities, is complex. But there is not a set of choices that can make someone immune to illness in general, and in the case of infectious diseases specifically there is not a combination of lifestyle and nutrition that can make a person invincible (even Chris Trager got the Flu on Parks and Rec). Second, just consider the sheer number of people who would have to be in on such a conspiracy. Millions of doctors, nurses, and public health experts, many of whom have themselves become ill or lost friends and loved ones. The idea that all of these people are interested in covering up that a certain number of milligrams of Vitamin C or a certain number of hours of sunlight exposure could have alleviated all of this suffering is not only incredibly naive, but also unbelievably calloused.

  • Germs are good for you.

This is an argument that crops up when discussing any infectious disease, but it is particularly popular now. Many alternative health and particularly detox and microbiome style wellness salesmen are all too quick to tell you that viruses, bacteria, and fungi are important for us; that without them we wouldn’t have functioning immune systems. And they are right. But like so many of their arguments, they have taken just one piece of the incredibly complex story of human health and disease and have extrapolated it to illogical and harmful proportions. I have written about this more extensively recently, but they are essentially failing to make two important points. First, the difference between a microbe (any bacteria, virus, or fungi, etc) and a pathogen, which is a microbe known to cause human disease; it is absolutely not true that because ‘germs are good for us’, therefore infectious diseases are good for us. This virus can definitely kill you. And second, the role of an acute infection in establishing a secondary immune response. Yes, exposure to a pathogen does generally cause some degree of enhanced natural immunity against that same pathogen later (this is the entire principal upon which vaccines are based); but it is not necessary to allow yourself to get ill or indeed become as sick as possible in order to build that robust secondary immune response, and sometimes the risk is much greater than the reward. “Whatever doesn’t kill you makes you stronger” still implies that dying is at least on the table.

I won’t rehash all the points I wrote about last week, but instead will share a quick story. When we lived in Denver we were visiting with a friend after church who showed us a fairly deep cut to his finger, near the joint, which he had received that morning. My wife, an RN, asked what he had used to clean the wound. He explained that he had NOT cleaned the wound because his body needed the germs to build an immune response, and that soap and water would prevent his body from fighting off the infection ‘naturally’. Katie attempted to persuade him otherwise and explain the roll of his immune system and ways he could help his body prevent an infection, but he wasn’t convinced. Two weeks later we saw him again, this time with a large bandage over his finger. We asked about this and he explained how his finger had become infected and he had to go to the emergency room, undergo and incision and drainage procedure to remove the pus, and then take antibiotics. He went into glorious detail about the procedure and the appearance of the infection and even showed us pictures. He did all of this without any sign of chagrin, and to this day neither of us is sure whether he had forgotten the first conversation entirely or if he is just the world’s most humble man.

And while what happened to my friend is funny in retrospect, because his finger fully recovered, it is certainly not funny when someone contracts a deadly illness because they are misled into thinking it’s actually better for their health.

  • The doctors don’t understand (or indeed know about) the immune system.

I’m always amazed when this one makes the rounds because it’s just such an incredibly goofy thing to say. We could spend paragraphs discussing the thousands of hours spent in medical school understanding every aspect of the human body and the huge swaths of microbiology, biochemistry, pathophysiology, infectious disease, anatomy, and pharmacology coursework that were devoted to understanding our fearfully and wonderfully made defenses against infection. I promise you we spent so much time studying the immune system that we dreamed of angry macrophages and inflammatory cytokines. So why such a silly and nonsensical lie? They are setting up a false dichotomy between your own immune system (which they would like to sell you products and services to augment) and the “big-pharma model of medicine”, a red herring of their own invention, which only believes in harsh chemicals. They have to reduce modern medicine and the scientific discoveries of the human body to just this one aspect in people’s minds so that they can claim for themselves the parts of it which seem to sell best. Whether the hucksters making such claims have actually studied the immune system in an intellectually honest and scientifically rigorous way themselves, however, is a question that perfectly justifies speculation.

I explore the rest further in the next section, but a few more, briefly:

  • The doctors want you to stay sick.

This is 100% a lie. Don’t be fooled by ‘common sense’ arguments that suddenly call for millions of well-meaning people to act nefariously.

  • The doctors are being controlled by big pharma.

Don’t be fooled by arguments that require passionate, notoriously difficult to control, and (let’s face it) often egoistic people to suddenly be submissive. Physicians are one of the primary reasons that pharmaceutical and insurance companies don’t yet control all of healthcare.

  • The doctors mean well but have been tricked.

Don’t be fooled by arguments that require very smart people to suddenly be easy to dupe.

5. Ask your brothers and sisters in Christ.

One of the many false narratives that Christians seem to believe at an alarming rate is that the medical field is somehow opposed to the Church. It is easy to point to controversial areas of medicine, or even the general principles of understanding illness and health as primarily physical phenomenon, to say that modern medicine is at it’s core agnostic or secular, and thus antagonistic to the Faith. This is an incredibly profitable narrative for televangelists and healing charlatans who would like you to believe that pursuing any means of healing aside from the overtly miraculous is a sign of lack of faith, and who exploit our fears and insecurities around health to sew mistrust in Physicians and other health professionals for their own profit. Perhaps a step down from the overt chicanery of these false prophets, we also see a strange marriage between Evangelical Christianity and unproven and sometimes even dangerous alternative health measures, which are marketed, sometimes, with a heavy mix of pseudo-Christian spirituality.

But if this is true, what then do we do with the millions of doctors, nurses, scientists, epidemiologists, and others within the healthcare sector that are faithful followers of Jesus Christ? I think the first temptation, too often, is to treat them like they are ‘one of the good ones’; as though a Christian Physician you know personally may be a reliable source of health information, but the medical field, in general, is not. I think this is incredibly problematic. As someone whose 20’s and 30’s were devoted to medical training, I have known hundreds (maybe thousands) of doctors personally. My older children who grew up during my residency thought that “Dr.” was just a gender-neutral way to say “Mr.” or “Mrs.”.  Because of where I have trained, many of these have been believers; but just as many that I have trusted and respected have not. Yes, I have certainly met doctors I would not trust with my own care or that of my family, but these have been remarkably, surprisingly few compared to the number of doctors I have known and worked with. In general I can say that Physicians as a group have self-selected for (and certainly this has been reinforced by training) both their desire to see people well and their commitment to scientific accuracy. To be clear, some of these doctors I disagree with vehemently on issues within medicine and the associated underlying moral and societal values. Nevertheless, and regardless of the cultural misrepresentations, your doctor wants you to be healthy and is, in general, a good and reliable source of information about health and disease. If they aren’t, you should get a new doctor immediately.

As we touched on earlier, a second and similar way to treat Christian Physicians and healthcare workers is as well-meaning but ultimately misled pseudo-experts with only a narrow scope of understanding regarding the human body. This is the view pushed by many in alternative health businesses; doctors are generally altruistic or noble, but they have had the wool pulled over their eyes, their education is controlled by Big Pharma and hospital administrators, and really all they are learning is essentially spreadsheet after spreadsheet of ‘if the patient has this, give them one of these drugs (and here are the prices; pick the most expensive one)’. Medical schools and residencies exist to train doctors to create profits for drug companies. Now, this is an incredibly silly idea and we could devote as much time as we wanted to this. I could explain that I never met a drug rep until after residency, because they generally aren’t allowed to interact with medical students or residents, and have never made a medical decision based on the advice of a drug rep in my life (except for Burton “Gus” Guster, of course). I could (and should, at some point) explain the very complex and often antagonistic relationship between systems within medicine that prioritize profits over people, including pharmaceutical companies, and the physicians, nurses, and clinical staff who exhaust themselves to help their patients find something like justice and equity in their healthcare. But these are areas I am passionate about, and I’m afraid this one section would eclipse the rest of the essay entirely.

Instead, I’m willing to bet that if took a step back and consulted even your own experiences with doctors you know personally, you would realize that their knowledge, education, and personal characteristics does not seem to match this narrative. If you have physicians in your family,, or in your church or Sunday school class, or have attended high school or college with them, or have friends who are doctors- in short, if you do know believing medical experts that you would ask for input on these videos and articles being circulated- ask yourself if they are a reliable source of information even aside from their medical background. Are they the type of people who are easily duped? Do they hold to questionable morals or a low view of the truth? Do they seem to possess discernment? Essentially, are they the type of people you would trust outside of a pandemic to answer questions unrelated to viruses and immunology and epidemiological data? If they are not, I would humbly suggest that you do not turn to them now, regardless of how closely the information you need clarified matches their field of work. But if they are, I would recommend showing them the courtesy to believe that they have applied at least that same degree of critical and independent thinking and that same spiritual discernment to the endeavor that has taken up the majority of their adult lives; namely the study of human health and disease.

Finally, my advice when framing these questions: be specific. When I am asked by a friend or acquaintance to address a viral video or a healthcare related article or meme, I try to be as thorough and complete as possible (I do find that after a few thousand words of my ramblings, they usually don’t ask a second time…). This can be time consuming, but I believe it is important work, and I personally have no problem being asked a general “would you give your input on this.” Not all healthcare professionals have the inclination to be quite so verbose, and of course many of us want for the time to do so now more than ever. If you ask for an opinion on a 20 minute video or a 2000 word article, let them know what your specific question is, or what about the content you found either particularly compelling, surprising, or questionable. If you are only looking for a ‘yes this is trustworthy’ or ‘no this isn’t trustworthy’ and are willing to take their word for it without a long explanation, let them know that as well.

6. Repent (or at least, redact).

I hesitate to make this last point because there is no way to express this without sounding somewhat judgmental. I hope it is clear that I intend to hold myself to this same standard as well, and hope that when (not if) I also fall into the ‘fake news’ trap and share misleading or unreliable information, I have the courage to follow my own advice.

What do you do when you have found information available on the internet and outside of your own area of expertise to be convincing and have passed it along, and through the (hopefully) kind input of friends have later discovered it to be untrue? I think there are a few good options. The simplest is to take it down; to delete the post so that others will not either follow you into believing the false information, or else in disbelieving it themselves begin to associate you with it. I think this is the minimum standard we should expect regarding our interactions with falsehood. However, I think an even better idea is what I have seen a family member do consistently in recent years; whenever she has shared a fake article or untrue information, she has then edited her post to clarify that the information is not reliable and why. Rather than distancing herself from those mistakes she embraces them, and in doing so helps protect others against the same errors. I believe that even better than Christians being known for never spreading false information (which is surely not the case now) would be us being known for the integrity and humility to publicly repent of error and embrace truth; in fact I can think of no more Christian way to deal with such a situation.

There is one thing we cannot do. Once we are aware of the falsehoods in something we have shared or promoted, we cannot choose to cling to it because we like the way it sounds or want people to believe that it is true. I have seen this done far too often; when it has been shown clearly that a source is unreliable or has even told outright lies, I have seen friends choose to continue to endorse and share it. There are myriad reasons, from liking a few of the points that weren’t exactly dishonest to wanting people to accept the overall message even if the content isn’t reliable. As people who believe that truth is authored by our Father and that we have an enemy who is only the father of lies, we cannot be comfortable with the mingling of the two. We cannot say, “yes, 7 of his 12 points were deliberately dishonest, and maybe or 3 or 4 were fairly dangers, but I really liked the other 5 and he’s just such an engaging speaker.” We must hold to higher standards of veracity than this. If we really want to promote those other ideas we should be incredibly, unmistakably clear that the rest of the content is not trustworthy… But better still, we should do the difficult work of finding a more consistently reliable source, and say of the first only that “he is a liar and the truth is not in him.”


I will conclude with the words of our Lord from Matthew 10:16: “Behold, I send you out as sheep in the midst of wolves. Therefore be wise as serpents and harmless as doves.” This pandemic is unlike anything we have seen in our lifetimes, and it is already the number one cause of death in the United States. We are living in an era of human history when reliable, true information is really capable of saving lives and when false information endangers our friends, loved ones, and neighbors. As we seek to obey the command of our Savior, let us reflect that we may never again in our lifetimes see such a moment as this, when these two concepts are so closely linked and refusal to be as wise as serpents can lead so directly to a failure to be as harmless as doves.