Texas doctors trying novel treatments (the trap of anecdotal evidence).

I’m seeing COVID-19 patients every day.

Last week I saw about 80 patients who had screened positive for either exposure to COVID-19 or possible respiratory viral symptoms; this week more of my time is devoted to working in outdoor COVID-19 testing clinics, so it will probably be well over 100. Some of those patients had been ‘caught’ by our screening questions but really had no COVID-19 exposure or symptoms; the lady with a chronic cough who was really just coming for her high blood pressure, the gentleman with a fever that was caused by an abscess under his axilla (we call it ‘axilla’ because ‘armpit’ sounds so un-doctory). I treated them too, of course. But for the most part people were seen in our COVID-19 focused clinic specifically for COVID-19 related concerns. I don’t have exact numbers in front of me, but of the 70 or so I tested for the virus, about 20 came back positive (Epidemiology note: this is too small of a sample to calculate anything like a test positivity rate or prevalence from), and there were at least a couple that, due to certain combinations of exposures and symptoms, I’m convinced had the virus despite a negative test (way, way too small of a sample to make any calculations from; please don’t go and quote me as saying that based on my sample of 2 out of 50 negative tests I think there is a false negative rate of 4% or something crazy like that)(although now that I look at prevalence estimates and test sensitivity, 4% is actually about right. Hmm…).

I called each patient who tested positive personally to give them the news and answer their questions. Amid the many questions I was asked (‘Should I go to the hospital’?; not now, but let’s talk again about red flag symptoms and emergency precautions. ‘Should I isolate from my children?’; that’s really complicated, and it depends on the age of your children, your support structure, and their specific developmental, physical, and emotional needs), one question that came up over and over again is one I sincerely wish I had a better answer to; ‘what medicine can I take to make sure this gets better?’

This is a big and important question. Doctors kind of like medicine; kind of a lot. After all, prescribing them is a big part of our job, and even though adding a medication is not always the right answer (more on this later), it is incredibly satisfying to prescribe the right medication or therapy for the right diagnosis and then see your patient get better. It can also be fairly stressful at times, because no medication (except prenatal vitamins) is perfectly safe; giving someone a medicine, especially one that wasn’t actually necessary, and then seeing them suffer because of drug interactions or unexpected side effects is devastating to a physician. We have taken an oath to ‘first do no harm,’ and we take it seriously. This is why I’ll spend 10 minutes carefully explaining to a parent about how viruses and bacteria infect the body differently and how antibiotics work rather than spend 2 minutes prescribing their child an unnecessary antibiotic for a viral illness, which would surely feel more satisfying for both of us. It is also why, as certain as I am that some of the patients I have shared the news of a positive COVID-19 test result with will end up getting sicker, and as nervous as that makes me on their behalf, I have not been prescribing unproven, untested medications out of desperation, but have instead focused on teaching those patients how to keep themselves and others safe and how to recognize the early signs of a severe infection.

It’s also why I check for new or updated studies or professional recommendations, and review information being shared between doctors and other clinicians on COVID-19 social media groups every every single. The moment that there is a proven, safe early therapy to prevent COVID-19 infections from becoming severe, I will be the first to start using it.


Dr. Richard Bartlett discovers silver bullet for COVID-19.

Last night I came across a viral video, which has since been sent to me multiple times, which seemed to promise exactly this. A doctor here in Texas went on a morning news show to discuss the 100% effective, perfectly safe COVID-19 treatment he is using to prevent severe illness in his patients. If you have any degree of medical training or even personal experience with medical issues, you are probably just as skeptical as I am about both the ‘perfectly safe’ and the ‘100% effective’ claims; few medicines are ever either. We will go through Dr. Bartlett’s interview in detail below and try to evaluate the quality of data he is relying to make these claims, and answer two questions; should you call and ask your doctor for this ‘new’ treatment, and should I call back all of my patients and tell them, much to my satisfaction, that we do have a medication I can put them on after all?

One quick note: the video is about 30 minutes long and trails off a lot into conspiracy territory concerning mandating vaccines, instituting lockdowns to destroy the economy in order to hurt President Trump’s reelection chances, and quite a few other areas. We’ve covered a lot of that before, and frankly a lot of it falls outside the realm of medical misinformation. We will try to cover the most important parts of Dr. Bartlett’s interview regarding his new COVID-19 therapy, but I won’t try to write the 10,000 words it would take for a rebuttal to all of these ideas.

Here is the video:


00:16: Midland Texas is located in Midland County, about 6 hours West of Waco (golly, Texas really is huge). With a population of 138,000, it is almost exactly the size of Waco. Just like for us and the rest of Texas, they began to see a significant increase in COVID-19 infections about 3 weeks ago. Before this, they had seen very few cases total, like most pre-surge areas. You can review their data here.


00:33: The article is here; it provides some additional details and we will reference it later.


01:48: Dr. Bartlett’s book is entitled Journey of a Medicine Man: Doctor Confirmed Miracles.


COVID-19 in the USA compared to around the world.

At 02:04 Dr. Bartlett begins his discussion on COVID-19 treatment in earnest by discussing the context for the pandemic in America, namely a comparison to both nations that have fought the pandemic successfully and those who have struggled more with a higher number of infections and deaths. He begins with Taiwan.

02:07 “In the country of Taiwan there’s over 25 million people, they’re stacked on top of each other, if they did social distancing they’d be out in the ocean floating around.”

He goes on to say that there isn’t enough room to social distance, and yet the country has seen only 7 COVID-19 deaths, “as many people as you could stack in a minivan.”

The problem here, besides Dr. Bartlett’s strange obsession with stacking people, is that Taiwan has done social distancing. Dr. Bartlett goes on in the video to assert that Taiwan has foregone both social distancing measures and widespread face mask use (which he associates with Communist China). Do any reading on Taiwan’s response to COVID-19 and you will find widespread wearing of face masks and aggressive physical/social distancing measures since the earliest days of the pandemic, in addition to other mitigation strategies such as providing social support for quarantined patients to help them maintain a high level of isolation, and using mobile phone technology to perform extremely precise contact tracing. This is all in the context of a strongly collectivist culture willing to engage in such measures for the good of their neighbors regardless of official mandates, with a history of understanding the stakes in such a pandemic because of their experience with SARS in 2003.

So as Dr. Bartlett moves forward talking about Taiwan later in this video, you need to understand that, perhaps entirely unintentionally, almost everything he has said about their success in fighting COVID-19 so far is the opposite of what they have actually done.

02:41 At this point Dr. Bartlett also mentions Iceland, Singapore, and Japan, who all engaged in some combination of extensive masking and social distancing except Iceland, who used aggressive contact tracing and quarantine measures. Dr. Bartlett’s assertion that they have been successful because they have used similar treatment plans to what he uses for his patients seems entirely unfounded.

02:59 “That’s not possible according to what we’re being told in the mainstream media.”

Literally nobody is hiding this data. If you google “Taiwan COVID” you get this:

“You can even look it up in the Johns Hopkins COVID website and you’ll see those numbers. They’re hidden in there, but I’m pointing them out.”

Hidden” in the sense that geography is hard.

I’m concerned that what Dr. Bartlett is doing here is contributing to a false narrative that the powers that be, especially the CDC, the WHO, and the medical establishment (i.e. he and I), doesn’t want people to have access to good reliable data. Maybe this is where Dr. Bartlett’s search for reliable information to back up his COVID-19 treatment has led him; not trusting the available information because he wasn’t able to find the scientific verification he is sure must be out there for his new therapy. Maybe this is strongly ingrained in his political position (he recently ran for office) and he is interpreting the ready availability of this kind of data through a lens of suspicion, or knows that his audience on this show will affirm the idea that this information is being hidden from them and that it is harmless to reinforce that belief. But I am always a little suspicious of physicians who want to weave these tells of conspiracy theories and hidden truths about the pandemic while promoting their own unverified findings, and part of me wonders if they are certain they will face pushback from their fellow doctors and scientists, and want to head it off at the pass by encouraging the idea that those doctors and scientists don’t want you to know ‘the truth.’ I certainly hope this isn’t the case with Dr. Bartlett, but part of me thinks it must be an easy trap to fall into without realizing it.


It isn’t Hydroxychloroquine

03:32 “(In these other countries) they’re doing what I’m doing, which is not hydroxychloroquine, although that works….

Before he reveals his miracle drug, he gives a brief shout-out to Hydroxychloroquine, stating it does work but not providing further explanation as to how he knows it does or why he doesn’t use it as well. I almost wrote today about a viral post by a doctor in McKinney Texas again promoting outpatient, widespread hydroxychloroquine use in patients regardless of test results and risk factors. We covered this pretty extensively over a month ago following his colleague Dr. Lozano’s speech at the Set Texas Free Rally in Dallas. He also claims that masking, social distancing, and even testing are ineffective. I’ve chosen to write about Dr. Bartlett’s video instead, but in terms of relying on anecdotal evidence and not understanding representative sample sizes, there are a lot of similarities. If things are quiet this week I will try to write about Dr. Procter’s social media post as well and try to tackle hydrochloroquine one last time.

I want to talk hydroxychloroquine.
I want to talk about these scripts that you’re writing;
Put down the pen, stop prescribing.
I want to talk about what I have learned,
About the research you have spurned…


The Silver Bullet: Inhaled Budesonide

03:36 “So what they’re doing is an inhaled steroid. So my silver bullet is inhaled budesonide.”

Dr. Bartlett finally reveals his miracle drug, inhaled budesonide; a commonly used inhaled corticosteroid that is commonly used for patients with Asthma or COPD.

This is the first good place to stop and look at this idea in more detail. The first two questions we need to ask when someone proposes a novel use of a medication or therapy are 1. Is there a proposed mechanism by which this would work? 2. Why did nobody else think of this (has this been tried/studied before)?

Dr. Bartlett’s rationale is that since this is an inhaled respiratory anti-inflammatory, it should work for COVID-19 which is a ‘respiratory inflammatory condition.’ Part of the problem here is that this is gross oversimplification of the virus’s pathophysiology, which is still not completely understood (see below). It is supposed to make you go “wow, that’s just common sense! It causes inflammation in the lungs, so an anti-inflammatory breathed into the lungs will cure it!” But if you reflect on whatever extent of experience you have with medicine, you will realize that things are never quite that simple. If you came to me for your severe, debilitating back pain you’ve been struggling with for years and I said, “oh I’ve got it, back pain is caused by inflammation of the muscles and joints, so I’ll give you a medicine to decrease inflammation; here’s some ibuprofen,” you’d probably lose a great deal of respect for me. You’d be right to. NSAID’s (non-steroidal anti-inflammatory drugs, like ibuprofen) may well be part of your treatment plan, but your back pain is complicated and is going to require more thorough evaluation and treatment. In medicine, you are right to beware of easy answers.

Sentences like these are why I went into clinical medicine.

Budesonide is a common medication, as he points out repeatedly beginning in a few minutes, and I think this is actually the strongest argument against his proposed use of it in COVID-19. You read that right; I’ll explain. The usual dosing of budesonide is twice a day as a maintenance medication; by decreasing inflammation and swelling in the airways, it can eventually (it may take weeks to months) lead to less frequent asthma and COPD symptoms like cough and chest tightness, and fewer exacerbations. However, Asthma and COPD patients still have acute exacerbations despite using inhaled corticosteroids. We still see patients on budesonide in the clinic and in the hospital for acute worsening of their symptoms due to respiratory infections. Sometimes these are bacterial infections, but more often they are viral; including coronavirus species. Sometimes these patients go into respiratory distress, and sometimes die, even when the virus they have isn’t nearly as deadly as COVID-19. If budesonide was able to completely prevent viral respiratory illnesses from causing inflammatory respiratory symptoms like cough, shortness of breath, wheezing, and chest tightness, we would never see these patients getting sick from respiratory viruses; but we do, because the medication doesn’t really work that way. If Dr. Bartlett consulted his complex understanding and professional history of treating respiratory infections he would realize that his proposed mechanism really doesn’t make sense, especially as the 100% effective silver bullet he is promoting it to be.

Later in the video (around the 06:36 mark) Dr. Bartlett does talk about the “cytokine storm” in COVID-19 and prevention of the body’s own inflammatory response to the virus. Is it possible that the medication he is using, while not preventing all respiratory viral infections, at least treats this one? Without getting into the weeds too much here (the idea of a cytokine storm being the underlying cause of ARDS in COVID-19 is still controversial), we need to understand that you don’t just have this one thing called ‘your immune system’ causing this process called ‘inflammation’, so that if ‘inflammation’ (or in this case, ‘cytokine storm’) is the problem we can just suppress the immune system and call it a day. The immune system is incredibly complex, and any given immunomodulating medication is going to work on parts of the immune system (and not always in the ways we hope or expect) while not significantly affecting others. As an example, the primary cytokine implicated in the COVID-19 cytokine storm seems to be interleukin 6, a pro-inflammatory cytokine that budesonide, in previous studies unrelated to COVID-19, doesn’t seem to affect appreciably. Studies focused on medications that do appreciably decrease IL-6 activity are currently underway.

I’m having bad flashbacks to 2nd year of med school right now.

The second question, if the mechanism did make perfect sense, would be to ask whether anyone has tried this before. Dr. Bartlett indicates that it has been tried elsewhere; he states that this is what they are doing already in Taiwan and Singapore. I was unable to substantiate this; I cannot find any evidence that these nations have used anything like widespread protocols with inhaled steroids to treat COVID-19 early in the disease course. There are some ongoing trials with use of inhaled corticosteroids (not budesonide, at least that I could find), as Dr. Bartlett mentions, but there is not any data available from them yet; if they prove safe and beneficial for COVID-19 patients, we would start using them in all the clinical contexts where they were shown to be effective.

There are two other data sources we could look at. First, the most successful trial we have right now with use of steroids in COVID-19 is the RECOVERY Trial out of Oxford, which I wrote about recently. In this study patients were put on systemic steroids (dexamethasone) once they were already hospitalized. You might argue that this isn’t what Dr. Bartlett is talking about at all, that he wants to use budesonide before they are sick enough to go to the hospital. I understand that; but the study showed a reduction in mortality in both the groups needing oxygen and those requiring mechanical ventilation, but not in those who didn’t require oxygen. You can only extrapolate so much from this, but if Dr. Bartlett’s theory of the earlier the steroids the better panned out, you would expect the non-oxygen group to see at least as much improvement in outcomes as the patients who were already very, very sick; but that wasn’t the case. We need to remember that even though our first successful randomized drug trial for COVID-19 is indeed a steroid, the role it plays is complex and the benefits limited to certain clinical scenarios; the data still shows that immunocompromised patients, including those on medications that modulate the immune system, are at a higher risk for COVID-19 than those who aren’t.

We can also look at the two closest viruses to COVID-19 that we have experienced, SARS in 2003 and MERS in 2012. These are both Coronaviruses that seemed to involve a ‘cytokine storm’ causing acute respiratory distress syndrome. During these outbreaks inhaled corticosteroids were used more widely, but results were mixed; there was no strong evidence of benefit, and some evidence of worsening of the disease, including increased risks of secondary bacterial pneumonia and prolonging the time it took for the body to clear the virus.

Edit: When discussing this issue, a colleague also pointed that this idea of ‘what about decreasing inflammation in the lungs’ is not novel, and studies have tested inhaled corticosteroids on practically every lung infection (infection is a very pro-inflammatory state) over the past 30 years, not just SARS and MERS. Results have been extremely unimpressive, but there has been consistent evidence of increased risk of certain types of lung infections, including tuberculosis, non-tuberculosis mycobacterium infections, and severe drug-resistant bacterial pneumonia.

So I’ll conclude this section where many people with much more expertise in this area than myself have, by saying that the balance of risks and benefits still doesn’t justify use of an inhaled steroid in people without asthma or COPD who are already taking one or would benefit from one anyway. There is no reason to believe that they will appreciably decrease the chances of developing the severe acute respiratory distress syndrome that makes the virus so dangerous for some people, and for the vast majority of people who will do fine with their own innate immune system fighting the virus, steroids would potentially increase both the risk of worsening infection and delayed clearance of the virus, and the risk for associated bacterial infections (in addition to a host of other potential side effects). If we were to begin using this in patients who don’t have COVID-19 as prophylaxis, we could conceivably increase their likelihood of getting the virus. The mechanism of causing these types of harm is at least as strong as the proposed mechanism of preventing worsening of the disease.


03:46 “It’s super cheap, it costs about $200 for the total treatment if you pay cash.”

I understand that he is probably intending this as a comparison to a hospitalization for COVID-19, which is disastrously expensive, as he truly believes the budesonide will prevent hospitalization. Still, all I can say is that Dr. Bartlett and I have different ideas about what constitutes super cheap medication; most of my patients could not afford a $200 medicine.


“But what does all of that matter? He said it is working for his patients.”

There are some more problematic statements in this video, including the idea that our numbers in Texas are only going up because of increased testing (17:05), revisionist statements that totally invert the sequence of events and thus cause and effect of social distancing and masking measures in the most affected countries (21:50), a troubling statement about Japanese people ‘crawling all over each other in Sushi bars’ (22:55), and strangest of all, repeated statements about how waiting to treat someone until they have symptoms is un-American, whereas early treatment is the American way (both preventative and acute care are part of every healthcare system in the world; there is nothing particularly American about throwing medications at people before you know whether or not they need them).

I hope to update this post with some rapid-fire answers to these issues later, but I want to focus here, for now, because I sincerely believe this is the part of Dr. Bartlett’s interview that people find most convincing.

“One hundred percent of my patients are alive. I’ve been treating this since March.”

I’ve written before about the dangers of anecdotal evidence. I think as physicians we are prone to fall into this trap for a couple of reasons. One is because we want so badly to help our patients, and if we hit on a medication that really feels like it is working, it’s hard to let go of that feeling. Another is because we spend so much time thinking about our patients and working for their well-being that their stories loom very large in our minds, and it’s easy for the relative importance, as data, of our personal small numbers of cases to become overinflated. With that in mind, I think it’s worth looking at Dr. Bartlett’s evidence from the outside and asking whether it really has the value he credits to it.

According to the local news article featuring Dr. Bartlett back on May 21st where he first publicly called budesonide his ‘silver bullet’ against COVID-19, at that time he had treated 12 people. Twelve. This is an incredibly small sample size, but we could hardly expect larger; Dr. Bartlett is not the only doctor in Midland, and throughout March, April, and May the entire county only had 1 or 2 new cases of COVID-19 most days; there just weren’t that many COVID-19 patients to go around. Dr. Lozano had previously gotten around this issue by saying that she wasn’t even testing, but was treating empirically based on symptoms or possible exposure, which doesn’t really make sense in a pre-surge area with incredibly low prevalence. Dr. Bartlett has stated that he believes in testing, and although his comments are mixed on whether he is treating only confirmed COVID-19 cases with budesonide, I think we could credit him with such qualms. Twelve cases over 3 months is an extremely small sample size, and it is important that we understand that this is not coming from someone who has been inundated with COVID-19 cases like our peers in New York; at the time that Dr. Bartlett decided that budesonide was a miracle drug he had practically no experience with the virus. It is certain that his numbers have come up by now, with cases rising all across Texas; but with lag time between exposure and the onset of symptoms, and a second lag between the beginning of symptoms and severe respiratory complications, it is not possible to say that all of Dr. Bartlett’s recent COVID-19 patients are out of the woods yet.

So Dr. Bartlett’s first error is over valuing the data from his sample size, but his second error is in thinking this disease is more dangerous than it actually is. I know that seems like a strange thing to type; the disease is plenty dangerous, and I have encouraged the utmost caution on this blog more times than I can count. We have looked over and over at the hundreds of thousands to millions of lives that might be lost if we do not discover effective drug therapies and if the virus continues to spread unabated because of poor adherence to mitigation strategies like face masks and physical distancing. But the virus has never been estimated as having a 20% fatality rate as Dr. Bartlett says in the video. Dr. Bartlett has no doubt been worried about COVID-19 since March, just like me. Just like me, he probably has friends and classmates working in ER’s and hospitals in New York and New Orleans and other areas that have already been hit hard, and has heard the horror stories about what this can do to both individual patients and entire healthcare systems. Like me, as soon as he started thinking about this respiratory virus he probably immediately thought of the names and faces of two dozen patients that he was particularly worried about. Due to this anxiety, surviving the virus has become, in his mind, the exception rather than the rule. We see this in his account of the woman battling cancer; he says “she should die according to what you hear from the CDC and the WHO,” even though we know that COVID-19 is not universally fatal for any group. By increasing the danger of the virus in his mind, or at least increasing the probability that any given patient will go to the hospital or die, it makes it seemingly unlikely for people to get better without some specific intervention, even though we know that is what happens most of the time; thus the interventions he has chosen (budesonide, zinc, antibiotics) receive the credit for his patients’ recovery.

Put these two biases or statistical errors together and it may be easy for a physician to believe, based on the slightest of clinical experience with this virus, that he has discovered a cure. Each patient you treat this way will confirm it for you, as long as they get better, even if they would have gotten better anyway, and particularly if they tell you they feel better right away, which is such a wonderful feeling even if it doesn’t always correlate to their eventual outcome. If you are willing to loosen your treatment criteria to include people who have had no test or negative tests, or who are fully asymptomatic as Dr. Lozano seems to have done with hydroxychloroquine, you can inflate your treatment numbers even higher. And if you top-out at something manageable for a small-town physician, say in the low 100’s, you might never see a fatality from COVID-19. Imagine that we were back in May when Dr. Bartlett had only treated 12 COVID-19 patients. He states boldly that 100% of his patients were alive, yet we think the death rate is around 1.3%. If just one of his 12 patients had died we might still find this convincing because we are so easily swayed by anecdotal evidence, but that would have been a fatality rate of 8.3% in his budesonide patients. We would have fallen into the same trap as Dr. Bartlett, of picturing those 12 patients heading toward certain demise and all but one rescued by his treatment plan, without which they would have died, when in reality there is no evidence to suggest that they would have been any worse off without the treatment. Dr. Bartlett’s experiences with the virus so far are exactly what we would expect without budesonide and antibiotics.


“Look, he says it is helping his patients and you don’t have to use it for yours, so why does it matter to you?”

Great question, hypothetical person who keeps arguing with me on the internet. Any time we begin talking about someone’s personal experiences, the temptation is to treat their narrative as incontestable; I wasn’t there, I didn’t see his patients, so I don’t have the ability to second-guess his clinical judgement. In a way this is actually sort of fair; Dr. Bartlett had just as many years of medical school and residency as I did, and has many years more clinical experience, and to some degree each physician has earned a degree of professional trust to practice in a way we see fit with accountability only to ourselves and our patients, at least in many circumstances. But we know that this professional leeway has been abused in the past, and even in the absence of abuse of that privilege, lone-wolf medicine is a real problem because by it’s very nature it is disconnected from one of the best tools we have to improve our clinical abilities and correct our errors; the honest feedback and accountability of our fellow doctors. If a physician feels that a patient’s clinical situation calls for a unique approach that is not supported by evidence, this can often still be tried as long it is accompanied by an honest and careful explanation to the patient of the reasoning behind this approach, the unproven nature of the treatment, and the risks involved. If we begin to make a habit of such practices, and particularly if we do so ignoring the voices of our peers around the world saying we’ve tried this before and it didn’t show reliable results on a larger scale, or the voice of researchers and scientists saying that doesn’t actually work the way you think it does, then we are doing so at our own, and more importantly at our patients’, peril.

In many ways I think Dr. Bartlett is actually going about this fairly well. He seems to imply that he is using the medication, which does have a theoretical mechanism of action after all, only on those who really do have COVID-19. He does not seem to be doing television interviews or talking with newspapers in order to make a name for himself and attract clientele from all over the state to help his business, as seems to be the case with some other doctors prescribing unproven treatments, but in order to ‘get the word out there’ to other doctors (as one of those other doctors, I deeply appreciate this impulse), although I am not sure why he has not utilized any of the many avenues on social media that many of use are using to get physician specific feedback and share ideas; maybe he is and we just aren’t part of the same COVID-19 doctor groups. Most importantly, he states that he has written and is submitting a paper for publication, which will provide both more details about his patients, their demographics, commodities, and clinical presentations, and allow for peer review and a higher degree of detail and scrutiny than we could possibly get through a TV interview.

But there are at least three ways (besides the tacit endorsement of several conspiracy theories) that I find Dr. Bartlett’s approach truly troubling. First, he is not presenting his treatment plan as an entirely unsubstantiated experimental approach driven by hope and a hunch, which is what it absolutely is, but as a “Silver Bullet” that is perfectly safe and cannot fail, which is certainly is not. One would hope that this is bravado or enthusiasm for the TV audience and not hubris; in other words, we have to hope that whatever confidence in his treatment regimen he shows in this interview, he is still very carefully explaining to his patients the limitations of his evidence and the potential risks they are taking on if they use it, and the red flags to look for in case it doesn’t work.

Second, he is not just promoting his unproven treatment but also discouraging mitigation measures, such as physical (social) distancing and wearing masks, that actually have been proven to save lives. It is unclear whether he believes the misinformation around these strategies not working or is just so confident in his treatment approach that he no longer thinks they are necessary, but the effect will be the same; as Dr. Bartlett’s video goes viral there will be increased pushback against wearing masks and observing distancing measures by those who find him convincing, which will ultimately lead to more cases, more hospitalizations, and more deaths. His evidence is too weak and his scientific rationale too shaky to convince a conscientious doctor to start using his treatment approach; but he speaks with enough confidence and sincerity to convince some people on the fence not to wear masks. The net effect of his interview, like any viral misinformation, is to make the pandemic more dangerous for everyone.

And third, by presenting his treatment plan as something that it isn’t and ascribing to it all of the confidence and reliability of a truly proven treatment, he is spreading misinformation that blocks out the transmission of reliable information for the public and pollutes the relationship between his listeners and their own doctors and healthcare systems. When I explain to patients that I do not have a proven medication I can in good conscience prescribe them to prevent their COVID-19 from progressing, their exposure to voices like Dr. Bartlett’s, Dr. Lozano’s, and Dr. Procter’s have already sewn the seeds of mistrust in the information I am providing, and they are less likely to believe the other recommendations I am carefully trying to give, such as isolating within their home and monitoring for red flag symptoms, and the reassurance I am trying to provide to alleviate their fear and anxiety as we discuss their individual chances of having a severe course of the virus. It may lead anxious patients to seek additional visits elsewhere and shop for a doctor that will prescribe them what Dr. Bartlett says they need, further increasing their chances of exposing others and potentially increasing the costs associated with their medical care, both to them personally and to an already strained system. It may even lead some patients, convinced by these doctors and desperate for medicines they now believe are their only hope of beating the virus, to misrepresent their symptoms in ways they think might push their doctor into prescribing them.

When lone wolf doctors promote unproven therapies and set themselves up as experts with miracle cures, without having actually done the clinical research to validate their claims, it erodes the fragile trust that we work so hard to build with our patients when we are unwilling to engage in that same type of speculative treatment. This unearned mistrust has the potential to breakdown the patient-physician relationship and affect our patients’ health for years to come. Millions of doctors, nurses, and other medical professionals around the world are working as hard as we can to both care for our patients in the midst of this pandemic and stay up to date with the latest diagnostic and treatment options. Viral voices drowning out the excellent work that is being done researching potential treatments, and calling out any doctor not willing to follow their lead, should humbly re-evaluate their limited clinical experiences in the face of this global pandemic and bring forward their innovations, not with less hope or enthusiasm, but with much more care and a realistic appraisal of the strength, or lack thereof, of their evidence.

COVID-19 Questions and (attempts at) Answers, Part 3: Isn’t a surge a good thing? Herd Immunity and the RECOVERY Trial.

I’ve had quite a few questions about COVID-19 put to me by friends and family members recently, and so last week I had intended to begin trying my best to answer them. This plan had to be put on hold when Waco (and various other cities in Texas) issued a requirement to wear a face mask inside of businesses and restaurants, and the whole world sort of lost it’s collective mind. I think things have calmed down now, at least locally, and as I’ve driven to clinic and back and the one or two other places I couldn’t really avoid going, I’ve thankfully seen a noticeable increase in masking, either in compliance with this decision or in response to the efforts of so many to share reliable information on the benefits and safety of wearing a face mask. Thank you all for fighting the crazy amount of misinformation out there. For my take on wearing masks you can read my previous blog post on masking.

Now in 8-bit Color!

Now that we’ve made it through another week without another viral misinformation video, I’m finally taking the time to sit down and write that original post I had planned on. I’ve tried to limit myself to just two paragraphs for each topic (paragraph length unspecified), but given just how many questions


Due to length, I’ve broken this post up into multiple parts.
Warning: These got really ‘mathy’ on me before I realized it was happening.
Part 1: Is the rise in cases just due to more testing?
Part 2: What about antibody testing and asymptomatic cases?

Question #3: Isn’t a surge a good thing since it will give us herd immunity?

The concept of herd immunity, susceptible persons being protected from infectious diseases by a sufficiently high number of people in their community already being immune, was controversial even before the COVID-19 pandemic. I don’t mean it was a controversial area of epidemiology; the science behind it is very well established and pretty straightforward (and if you are going to read about the eradication of smallpox from that link, you should also read about a man called Onesimus, a slave in Boston whose knowledge of West African inoculation saved hundreds or thousands of lives and paved the way for Edward Jenner’s eventual invention of vaccination techniques). I mean it was something that we’ve had to argue about constantly in recent years because the anti-vaccine movement uses herd immunity as one of its many arguments against vaccination, while at the same time undercutting its effectiveness by seeking to decrease the number of people who are immune through being vaccinated. The idea is great in principal; just weather the storm now and then we will all be safe from the virus forever. The problem (one of the problems, for there are numerous) is that we don’t yet know exactly what percentage of the population needs to be immune to confer protection to everyone else. Most estimates have put this number somewhere between 60-70%, but a recent model published in Science estimates it at a much more attainable 43%. These numbers are based on several parameters that tell us both how easy the virus is to spread and whether certain activities, situations, or even individuals are more likely to spread it than others (you can read about the median reproduction value and dispersion factor if you want to dive a bit more into the math of it all). Because these numbers are incredibly hard to definitively determine in the midst of a pandemic, any percentage we arrive at is going to be a best guess; an estimate derived from multiple assumptions that will only be proved wrong if many more people get very sick even after we’ve achieved the required numbers for herd immunity. Herd immunity is a gamble because Virology, during a pandemic, is an applied science; the virus will correct all of our miscalculations and false assumptions for us. (other questions, such as whether immunity to SARS-CoV-2 is indeed long-lasting and whether the virus will mutate in such a way that it causes future outbreaks despite our acquired immunity are also important, but outside the immediate scope of the discussion).

*This is from early in the pandemic, but a great visualization tool

But even more important than the difficulty in calculating the necessary percentage of people being immune to confer protection to everyone else is the question of how dangerous it is to get there in the first place. Let’s talk about measles for one moment. We know that the herd immunity required for measles is somewhere around 93%, which is part of the reason we have seen outbreaks of the disease recently in areas that have a substantial anti-vaccine sub-culture; it isn’t hard to fall below that number. Let’s say there wasn’t a Measles vaccine; that means 93% of people would need to develop immunity by living through the disease. With modern medical advances the case fatality rate for measles is a lot lower than it used to be, but it is still around 2.2%. This means that in a country of 330 million people that had no immunity to measles, 306 million would need to contract the disease to confer herd immunity to everyone else; of those, 6.75 million would die, not to mention the longstanding residual neurological deficits and other health complications in tens of millions more. Without effective vaccination, herd immunity would simply never have been an option for Measles; the cost in human life and suffering would just be too high. But what about COVID-19? We know that SARS-CoV-2 is thankfully less contagious, and we believe less deadly (see the last post for a discussion on this) than measles, but is it enough to make herd immunity a viable option? Let’s apply those same calculations based on the current estimates we have for infection fatality rate. If we accepted a 1% death rate estimate, then to achieve the widely accepted 60% mark for herd immunity we would see 198 million cases and 2 million deaths, while if we accepted the recently released 43% estimate and assumed an even more conservative 0.5% death rate, that would be 709,500 deaths; and neither accounts for the longstanding health deficits or the cost in human suffering of those who survive, or the other deaths and suffering that come with an overwhelmed mid-surge healthcare system. Now, could we devise some clever epidemiology strategy that uses emerging data about the already-immune, super-spreaders, natural resistance, new drug therapies, contact tracing, and protection of the most vulnerable? Of course; assuming that we could get a high degree of buy-in (we can’t even get people to wear masks), that’s exactly what we are all hoping for. But that’s not ‘herd immunity’, and it’s clear that the cost in lives and suffering from a “just get it and get it over with” ‘strategy’ would be astronomical even with our most optimistic estimates. Trust me, I’m tired too; I completely understand the pull towards a roll the dice approach that just gets this over with and lets the chips fall where they may; that approach completely appeals to my intellectual and emotional fatigue. But the longer we can work together to flatten the curve, the more time we create to discover those new therapies, improve our understanding of the virus, and collect high quality data about transmission and vulnerability that can help us develop novel, strategic mitigation approaches (which would probably incorporate something like herd immunity); and we are already seeing the benefits of the work of this kind that we have done so far as a society.


Question #4: What is the RECOVERY Trial?

(Confession: nobody asked about this, but I’m going to write about it anyway)

The RECOVERY Trial is a randomized (poor British researchers spelled it wrong) clinical trial out of Oxford that has shown benefits from using low-dose dexamethasone (a cheap and readily available steroid) for hospitalized COVID-19 patients on oxygen or on a ventilator; you can read a more detailed analysis of the trial from First10EM. This is still in the peer review process but results have been incredibly promising; the study showed a relative decrease in mortality of 20% in hospitalized patients requiring oxygen, and up to a 35% decrease in patients requiring ventilator support. Unlike many of the drug therapies that have been touted up until now, this is based on a randomized trial and not on anecdotal evidence, so it is much more likely that these results will be reproducible when used broadly. Already this has become the standard of care in the hospitals in your city, and if we see these results persist with widespread use it has the potential to save tens or hundreds of thousands of lives. I wanted to write about it for two reasons. First, I want to call on us all now to not let this become the next hydroxychloroquine. The study has established the benefits of this drug therapy only in a specific group of people; hospitalized patients requiring oxygen or ventilator support. They also studied hospitalized patients who were not sick enough to need oxygen, and it showed no benefits whatsoever. There is no reason to infer that this medication is protective in those without severe symptoms or in asymptomatic individuals, and so there is no reason for individuals to ask their doctor for an outpatient prescription or for pharmacies or clinicians to stockpile the medication as we saw done with hydroxychloroquine. We can be thankful that we have at least one helpful medication for our sickest patients without that immediately translating into figuring out a way to get it for ourselves whether it would actually help us or not. And if peer review and follow-up studies and the increased clinical experience that comes with widespread use of dexamethasone ultimately shows that it actually isn’t helpful for COVID-19, that will be tragic; but we should all understand now that that is just how science works, and won’t be part of some big government conspiracy to prevent people from getting the medication, just as it wasn’t with hydroxychloroquine.

But even more importantly, I wanted to talk about the RECOVERY Trial because it illustrates exactly what it looks like to fight this virus by engaging in mitigation and flattening the curve. Since April people have been saying (and we have all been feeling, to some degree or another) that if a certain amount of death and suffering from the virus is inevitable, we might as well just get it over with. We have also heard the slightly more sophisticated position that as long as our hospitals aren’t overwhelmed and we aren’t running out of ventilators and other equipment and resources for sick patients, then we have reduced the danger as much as is helpful and anything more is unnecessary. The RECOVERY Trial is a powerful illustration of why flattening the curve is beneficial even beyond these important goals. If you had a severe case of COVID-19 one month ago and had to be on a ventilator, you would have been treated with hydroxychloroquine and not with dexamethasone; today, you would be treated with dex and not with hydroxychloroquine, and your chance of dying would be 35% less; and that doesn’t even take into account the less quantifiable benefits from all that your doctors have learned about this virus in the meantime. A month from now, with more high quality trials and more clinical experience, who knows what the new standard of care will be and how much better a very sick person’s odds of surviving the virus will be because of it. The reason I wear my PPE with every patient and am a stickler about fomites and transmission, the reason I wear my mask when I’m in public, and the reason I am writing from home instead of a coffee shop today and attended church online this morning, isn’t because I’m afraid of the virus; it’s because when and if (and for me it has always felt more like an ‘if’ than a ‘when’) I get COVID-19, I would rather be treated by doctors and nurses and respiratory therapists who have had ample time to learn how to fight it, who have perfected their approach to ventilator settings and other supportive techniques for this virus specifically, and who have access to medications that have been carefully studied and have been proven to be effective; and because I would like to have that knowledge base and those techniques and medications available if and when I have to treat you.

COVID-19 Questions and (attempts at) Answers, Part 2: What about antibody testing and asymptomatic cases?

I’ve had quite a few questions about COVID-19 put to me by friends and family members recently, and so last week I had intended to begin trying my best to answer them. This plan had to be put on hold when Waco (and various other cities in Texas) issued a requirement to wear a face mask inside of businesses and restaurants, and the whole world sort of lost it’s collective mind. I think things have calmed down now, at least locally, and as I’ve driven to clinic and back and the one or two other places I couldn’t really avoid going, I’ve thankfully seen a noticeable increase in masking, either in compliance with this decision or in response to the efforts of so many to share reliable information on the benefits and safety of wearing a face mask. Thank you all for fighting the crazy amount of misinformation out there. For my take on wearing masks you can read my previous blog post on masking.

Now in 8-bit Color!

Now that we’ve made it through another week without another viral misinformation video, I’m finally taking the time to sit down and write that original post I had planned on. I’ve tried to limit myself to just two paragraphs for each topic (paragraph length unspecified), but given just how many questions


Due to length, I’ve broken this post up into multiple parts.
Warning: These got really ‘mathy’ on me before I realized it was happening.
Part 1: Is the rise in cases just due to more testing?
Part 3: Isn’t a surge a good thing? Herd Immunity and the RECOVERY Trial.

Question #2: Do antibody testing and asymptomatic cases prove the virus isn’t as dangerous as we thought?

Asymptomatic Cases

The short answer here is, yes. And also in a very real sense… No. When antibody testing first began to confirm that a certain percentage of people contracted the virus but never developed symptoms, or had symptoms that were so mild they failed to associate them with the virus (‘weird how my allergies just acted for a couple of days’), it was great news for everyone. What it was not (and I’ve been on this soapbox for a while now) was proof that the ‘experts were wrong’ about how dangerous the virus is. I’ve been reading every model and study and expert opinion about COVID-19 I could keep up with for the past 3 months, and I cannot tell you the number of times that physicians and epidemiologists and researchers have either implied or explicitly stated that the mortality rates we were seeing from the virus didn’t account for asymptomatic and minimally symptomatic cases. I’m no expert, but I’ve typed it more times than I can count myself.

Actually I counted; it’s been 6 times. That’s still a lot.

Those scientists anticipated that a certain percentage of the population would contract the virus but never develop significant symptoms, but had to work from the best numbers they had until such testing was actually available. And it’s a very good thing that those assumptions were correct, since the original case fatality rates we were seeing were in the civilization ending range of 8-15% in certain countries. If antibody testing had been developed and found only a negligible amount of asymptomatic and minimally symptomatic cases, it would be devastating news for everyone; not least for the doctors, nurses, epidemiologists, and others who have turned their lives upside down to fight the pandemic. Accounting for asymptomatic and minimally symptomatic cases would clearly yield a much lower death rate, but still firmly in the very, very dangerous range. For instance, large scale antibody testing in New York in April found antibodies in 13.9% of the population (WBUR has an excellent article picking through the wildly varied estimates of asymptomatic cases) , which reduced their overall estimated fatality rate from 6% to 0.5%. Many current estimates place the overall fatality rate between 0.5% and 1.3%. For a virus this contagious, these are still scary numbers. Even here at the end of June, many people are still wanting to compare this to the flu to dismiss the danger, even though these much lower death rate estimates are still 5 to 13 times higher than seasonal influenza’s commonly accepted 0.1% fatality rate, and even though the flu itself regularly threatens to overwhelm our healthcare systems. Please keep in mind that this is at best an apples and oranges comparison. We don’t routinely measure influenza antibodies to determine the percentage of asymptomatic cases, focusing instead on those who are symptomatic, and our death rates for flu are based on a totally separate set of calculations (I talked about this in more detail in my response to the Bakersfield Urgent Care doctors). If you want to compare oranges to oranges we can look at excess mortality for both viruses. Consider the graph below from New York State: the first cluster of red crosses is the peak of the 2017-2018 flu season, the worst flu season I have experienced since starting medical school; the second is COVID-19 during New York’s surge in April.

Not the Flu.

Before we move on from asymptomatic cases, we need to mention two more things. First, while knowing the overall infection fatality rate including data from those who never had significant symptoms is great from an epidemiology standpoint, it doesn’t mean that the case fatality rate for people with symptoms is a ‘fake number’ or falsely elevated. If you develop symptoms and test positive for the virus, and especially if you end up in the hospital, it would be small comfort to know that some people didn’t get sick from it at all. We still need to know what the specific risk is for people with symptoms, and for people with severe symptoms, in order to properly counsel those patients and to inform our medical response. Second, asymptomatic cases are a double edged sword; yes, it means that some people will become immune without actually getting sick themselves, but it also means that some people can spread the virus without ever knowing they’ve had it. We all need to exercise caution even if we don’t have a cough and fever.

I realize this is the same joke from earlier. I just really like it.

Antibody Testing

One of the problems in determining a final overall death rate (besides the fact that we are still in the middle of the pandemic) is the accuracy of antibody testing, since we have to rely on this to tell us how many people had the virus and were either asymptomatic or didn’t get tested for it at the time. And this in turn relies on something called the positive predictive value, how likely it is your ‘positive’ test result has really detected the antibodies, which depends both on how well the antibody tests are designed (and their not being fake, which is apparently a problem now as well), but also on the prevalence, or in this case cumulative incidence, of the virus. The higher the percentage of people who have actually had the virus, the more likely it is that a positive test really represents a true positive and not a laboratory error. It’s a relatively simple concept, but honestly it’s just unintuitive enough that I’ve struggled with it myself for years. Basically, every lab test has some degree of error; sometimes these tests will tell you that you have the antibodies when you don’t, and sometimes it will tell you that you don’t have them when you really do. The more rare the virus has been in your area, the more likely that your ‘positive’ test was the result of such an error instead of actually having the antibodies. Carry this to the logical conclusion; if you brought an antibody testing system back in time to last Summer when nobody had SARS-CoV-2 antibodies, or for that matter back to Medieval England, you would still have some tests turn positive; but they would clearly all be from laboratory error because the prevalence of the disease then would have been 0%. When doing these tests, we cannot ignore the importance of how common or rare the virus has been in the region where we are testing.

Still less useful than bringing Sony Walkman

Calculating positive predictive value based on prevalence can be done with just a few numbers (test sensitivity, test specificity, and prevalence) and the simple equation PPV = (sensitivity x prevalence) / [ (sensitivity x prevalence) + ((1 – specificity) x (1 – prevalence)) ] (Um, there’s also an online calculator if you’d rather follow along that way), and it’s always shocking to me how quickly the lab error for even very good tests becomes relevant when the prevalence of a disease is low. Most manufacturers rate their antibody tests in the extremely accurate range of 95-100% for both sensitivity and specificity (because of course they do); some have performed well in independent testing, but others not so much. Let’s use the online calculator (or the equation above, if you just really like that sort of thing) and plug in a few of these numbers.


  • Scenario 1: Post-Surge New York City, excellent quality antibody test.
    • Let’s say you never definitively got diagnosed with COVID-19 during the surge in New York, and wanted to get an antibody test to see if you have already had it and are immune.
      • Sensitivity: 95% (.95)
      • Specificity: 95% (.95)
      • “Prevalence”: 20% (.2)
    • Results: Positive Predictive Value = 82.6%
      • This means if you get a positive results from this very accurate test done after your city has survived a severe surge, there’s still about a 17% chance you don’t actually have the antibodies after all.
I hope you guys are having as much fun with this as I am.

  • Scenario 2: Pre-Surge Texas, excellent quality antibody test.
    • Now let’s say you had the antibody test done a few weeks ago here in Texas, again with a test that has excellent accuracy.
      • Sensitivity: 95% (.95)
      • Specificity: 95% (.95)
      • “Prevalence”: 4.6% (0.046)
    • Results: Positive Predictive Value = 47.8%
      • With a lower prevalence, a positive antibody test on the same machine is now about the same as a coin toss.

  • Scenario 3: Pre-Surge Texas, sub-par antibody test.
    • Same scenario as the last, but the quality of the test isn’t quite as good as the manufacturer funded studies seemed to promise.
      • Sensitivity: 88.6% (.886)
      • Specificity: 90.2% (.902)
      • “Prevalence”: 4.6% (0.046)
    • Results: Positive Predictive Value = 30.4%
      • At this point you are probably better off just switching the ‘positive’ and ‘negative’ labels on the readout…

Now, savvy statisticians will note three things in looking at the above numbers and playing around with the data. The first is that I’ve used the very antibody testing methods I’m questioning to fill in the prevalence, which is itself part of my calculations. Figuring out the real prevalence is a complex problem epidemiologists are still trying to solve; this is a simplification for illustrative purposes. But more importantly, you will notice that as the prevalence goes down so does the likelihood that a positive test was really positive; in fact, it drops quite precipitously, especially as you get below 5%. However, as the specificity– the likelihood that the test correctly calls a negative result negative– approaches 100%, the number of false positives actually drops to 0. If we want to make sure we never tell someone they are immune when they aren’t, we need a very high specificity; but because no test is truly perfect, this will mean some sacrifices in actually being able to detect the antibodies when they are there, which hurts our ability to accurately estimate the number of asymptomatic cases. To get a perfect specificity, you will lose some sensitivity, and vice versa; the right balance depends on what you intend to use the test for.

So all of that to say, when that antibody test you got comes back positive and the manufacturer says their test is “95% accurate,” you may be tricked into thinking it means there’s a 95% chance you really have already had the virus and now have antibodies against it. But they are only telling you half the story, and you either need access to some more data to make your calculations and determine the real positive predictive value, or at the very least you need to take it with a grain of salt and still exercise caution; especially if your area hasn’t actually had anything like a true surge yet. After all, only a great fool would accept what he was given, and you are not a great fool.

Sorry, I’m not going to say “inconceivable.”

COVID-19 Questions and (attempts at) Answers, Part 1: Is the rise in cases just due to more testing?

I’ve had quite a few questions about COVID-19 put to me by friends and family members recently, and so last week I had intended to begin trying my best to answer them. This plan had to be put on hold when Waco (and various other cities in Texas) issued a requirement to wear a face mask inside of businesses and restaurants, and the whole world sort of lost it’s collective mind. I think things have calmed down now, at least locally, and as I’ve driven to clinic and back and the one or two other places I couldn’t really avoid going, I’ve thankfully seen a noticeable increase in masking, either in compliance with this decision or in response to the efforts of so many to share reliable information on the benefits and safety of wearing a face mask. Thank you all for fighting the crazy amount of misinformation out there. For my take on wearing masks you can read my previous blog post on masking.

Now in 8-bit Color!

Now that we’ve made it through another week without another viral misinformation video, I’m finally taking the time to sit down and write that original post I had planned on. I’ve tried to limit myself to just two paragraphs for each topic (paragraph length unspecified), but given just how many questions


Due to length, I’ve broken this post up into multiple parts.
Warning: These got really ‘mathy’ on me before I realized it was happening.
Part 2: Do antibody testing and asymptomatic cases prove the virus isn’t as dangerous as we thought?
Part 3: Isn’t a surge a good thing? Herd Immunity and the RECOVERY Trial.

Question #1: Isn’t the rise in cases just a reflection of more widespread testing?

This is a question that has been on everyone’s minds since the very earliest days of our testing woes, back in March when we had barely any testing available. It has ranged from a very fair question to a rhetorical device for spreading misinformation, with at least one prominent political figure even seeming to say that it would be better if we didn’t test so much so that our numbers looked better. I honestly believe most people really are curious about the relationship between our testing numbers and our numbers of cases and are not asking to try to minimize the appearance of the surge we are facing in Texas right now. In one sense, we will always find more cases of a disease when we test for it than when we don’t; that’s a truism. But if we want to determine whether cases are really going up we can look at a few other parameters than the absolute number of positive tests that will inform our understanding of the ’75 new cases’ or ‘5,747 new cases’ we are seeing in the news and on social media each day (To go through these numbers I highly recommend you spend some time navigating the Texas DSHS COVID-19 Dashboard; both their case data and testing and hospital data sections).

The first number is the percentage of positive tests. Ever since testing became more widely available in April and we were able to shift away from testing only those with a high likelihood of having the disease and/or of developing complications, we have been testing essentially the same types of cases; people with some combination of cough, shortness of breath, fever, loss of taste and smell, etc. and/or known or suspected exposure to the virus. There are many causes of these types of symptoms, from allergies to other respiratory viruses to chronic conditions like asthma and COPD, and in our pre-surge days these explained the symptoms in the vast majority of people we tested. If you look at the Texas testing data from April you will see two things; an overall low number of tests (a very modest 5-10k per day) and a fairly high percentage of tests that are positive, between 10-14%. This reflects our very strict testing criteria at that time; we were only testing the people we already really thought had it. In late April and all through May we see an ever increasing number of daily tests and a falling rate of positive tests, a reflection of liberalizing testing criteria and strong evidence of overall low prevalence in our State. Throughout June, and especially over the last 2 weeks, we continue to see an increasing number of tests each day; but we are now also seeing our percentage of positive cases rising again. This isn’t because we’ve tightened up or restricted our testing criteria again; it’s because more people actually do have the virus.

Percentage of positive tests

This exactly matches my own clinical experiences; back in May I was testing for COVID-19 based on essentially the same criteria and clinical judgement I am using right now, but it was rare to get a positive case; I would know, because being told you have COVID-19 can be a very stressful experience, so I still personally call every patient I’ve tested who has a positive result in order to answer their questions and help them process that information. This past week I have had to make multiple of those phone calls daily and have been feeling the strain on my time that it has created. As a physician I was on the front lines in May just like I am now, and I can tell you that we are definitely feeling this surge in a way we didn’t then; it isn’t a statistical artifact.

The second kind of data that should inform our understanding of that increase in cases is the number of people who are hospitalized with COVID-19; and the number of people who are dying from it. A raw increase in cases without a change in the test positivity rate could certainly be explained by more widespread testing; but it could not explain why more people had severe enough symptoms to be hospitalized, and there is no question that we have seen an increase in hospitalized cases.

Hospitalizations

Many people will quickly point out that we don’t know what percentage of those people were hospitalized for COVID-19 related symptoms and what percentage just happened to have a positive test when they came to the hospital for other reasons. This is a seemingly fair argument on the surface, but it is guilty of two fallacies. First is the idea of COVID-19 infection being a coincidence that doesn’t effect the trajectory of someone’s chronic illnesses. For months now I have heard the argument that the people whom we know have the absolute highest risk of COVID-19 complications, elderly people with chronic heart and lung disease, have not died from COVID-19, just with COVID-19. Yes, they happened to have the virus but actually died, in large numbers, from their chronic illnesses all getting worse at the same time, during a surge in COVID-19 cases in their area. This is the tired conspiracy theory that doctors are misattributing the cause of death to inflate COVID-19 death numbers, and it’s one I’ve had to debunk over and over again on this blog; it willfully ignores the pathophysiology of the virus, the normal course of those illnesses, and the way that doctors understand and report contributing causes of death. The idea that we are suddenly seeing a huge uptick in COVID-19 hospitalizations as an artifact of testing patients when they come in and unrelated to the virus itself is just another version of that same conspiracy theory. It’s also a very hypocritical argument, considering the types of sources it is coming from. One of the criticisms about mitigation efforts from the beginning was that people who needed care might not come in to the clinic or hospital because of fear of the virus; it’s a very real concern and a problem I’ve fought against daily as a physician, and have been writing about since my earliest social media and blog posts during the pandemic.

Their argument has been that telling people that the virus is dangerous and taking mitigation measures would discourage them from seeking care for conditions that were really dangerous, like congestive heart failure or blood clots in the lungs, because they were more afraid of catching COVID-19 at the hospital. Our argument has been that the virus is dangerous, and that it also makes congestive heart failure more dangerous and actually causes blood clots in the lungs, so we have an obligation to keep people safe from the virus and help them navigate when and how to seek care for other health concerns; it’s work we are doing constantly in our clinics and hospitals. Now these same sources are arguing that in the midst of a dramatic increase in cases and our first real surge in Texas, thousands of people with conditions that put them at risk for complications from COVID-19 suddenly aren’t worried about the virus after all and are all seeking hospital care at the same time, and just happen to test positive for the virus while they are there. There may well be some situations where this actually is the case, and people who were overlooked by our healthcare systems really are now getting very sick from their diabetes or coronary artery disease at the same time as our surge (you can only ignore a worsening chronic illness for so long before hitting a crisis point), but the idea that this would happen on a broad scale, all at the same time, and that enough of those patients would be positive for COVID-19 that it would cause a state-wide spike in hospitalized virus cases is a very, very, frustratingly silly argument.

The final number we need to consider is the number of deaths, and here at least there is some good news; we are not seeing a substantial increase in the people in Texas dying from COVID-19, at least not yet. There are two ways to understand this. The optimistic way is to think that something has changed; either the virus has somehow become less deadly than before, or our increased understanding of COVID-19 has led to a better ability to fight the virus; improved disease-specific ventilation strategies, effective drug therapies, and more efficacious supportive care measures. In fact, there is a great deal of evidence that the latter really is true, as we will discuss in another post. But the pessimistic view (and the truth is probably a combination of both) is to realize that most people do not just get admitted to the hospital with severe COVID-19 infection and pass away the same day. There is a significant lag time as those patients are treated and fight against the virus, and our surge in hospitalized cases is only a little more than a week old.

Many of those hospitalized patients are fighting for their lives in the ICU right now, as the hospitals are starting to fill up around them and their nurses and doctors are becoming fatigued. Many of those people will recover, but many will not; and it will take a couple of weeks, and often times much longer, to see how many, and who. As we’ve seen elsewhere, the ratio of those who don’t recover will only increase if resources and the margin for careful attention and heroic efforts on their behalf begin to run short. Yes, our improved understanding of the virus and more effective therapies gives us a better chance to fight the virus than Italy had in March or New York had in April; but doubling down on the difficult work of mitigation now to prevent our healthcare systems from being overwhelmed in a couple of weeks when more and more patients reach their crisis point is every bit as important.

What will next month’s data look like? It’s still partly up to us.

On Masking

I had intended to write this weekend on a variety of topics, including herd immunity, the recent RECOVERY trial using low-dose dexamethasone in critically ill COVID-19 patients, antibody testing, and the question of whether the increase in cases is really just due to increased testing (answer: unfortunately, no). But when I woke up this morning the world seemed suddenly, vehemently, and inexplicably divided on just one subject: wearing masks.

Part of this can be accounted for, at least locally; yesterday the City of Waco issued an order requiring businesses to create and post mask policies for employees and customers. As with anything that has been unnecessarily politicized and sensationalized, I recommend you read for yourself what the order actually does and does not require. This morning I had half a dozen messages asking for my thoughts on whether or not masks are an effective strategy, and several people shared pieces of misinformation they wanted to bring to my attention.

So while I would still like to write about all of the above issues, I think this one will have to take priority today.


Are masks safe and effective?

G.K. Chesterton said that he was most convinced by evidence that is ‘miscellaneous and even scrappy.’

“A man may well be less convinced of a philosophy from four books, than from one book, one battle, one landscape, and one old friend. The very fact that the things are of different kinds increases the importance of the fact that they all point to one conclusion.”

G.K. Chesterton, Orthodoxy

So while we will look at scientific studies, journal articles, and other medical evidence, I want to include data from various kinds of research, including both laboratory conditions and real-world epidemiology, and from both prior to and during the COVID-19 pandemic. I also want us to apply some common sense and a good bit of our own past experiences. This can be dangerous in a field like medicine, where realities are often counter-intuitive, but if undertaken cautiously this common sense approach can serve as an anchor for the more academic information.

With that in mind, I think we can start by thinking about the advice we give to children when they are sick or have seasonal allergies (if your children are like mine, these efforts are ultimately futile, but struggling against that futility is a time honored parenting tradition). We tell children to place their hands over their mouths when they sneeze or cough. If we are particularly savvy (and can get past the occult theme; looking at you anti-Harry Potter friends), we teach them the Vampire Sneeze/Cough, where we cough into the antecubital fossa (the bend of the elbow) instead of our hands.

It does work much better if you wear a cloak at all times.

Why? Because respiratory viruses are spread through respiratory droplets; mucous and saliva from the respiratory track that contains the virus. In this article we will look at the filtering ability of various types of masks and whether they are actually able to catch the microscopic particles that cause illness, but you don’t need a microscope to measure the number of microns between a toddler’s fingers when she almost but not quite entirely fails to cover her mouth for a cough; it’s a lot.

Now it’s true that these etiquette maneuvers do not actually stop or absorb all of the particles; they catch some and merely redirect others into the surrounding environment. But you knew that. If you live with a sick child, the odds of yourself or another family member getting sick is high regardless of how good they are at vampire coughing. The goal isn’t to stop 100% of the droplets, but to modify the spatial distribution; to make it less likely that you will get sick from someone coughing or sneezing a few feet away or across the room. Even in science some things are intuitive; if you can feel the spray of respiratory droplets on your face when someone coughs near you, you know your chances of getting sick are higher.

This is the same principal we are talking about when it comes to masks. Nobody is saying that if someone has COVID-19 they can just wear a mask, N95 or otherwise, and cough and sneeze without getting anyone sick; studies have show that the particles still escape. But if someone coughs across the room from you, their mask or their elbow, or even better both, interrupts the momentum of the droplets (50 mph for a cough, 100 for a sneeze according to a study in the Journal of Fluid Mechanics) and decreases the chances of the droplets reaching you, giving you time to move away or at least cover your own face, blocking a few more particles. These are components of an overall risk mitigation strategy that involves things like social and physical distancing, frequent hand washing, sitting outside instead of inside, contact tracing of COVID-19 patients, and staying home if you are sick.

Masks aren’t perfect, but nobody is claiming they are.

It’s also important to note that the studies that have shown only very modest benefits of masks, such as the study that produced the graph above, have focused on the spread of droplets through coughing and sneezing; high pressure, high velocity events that force droplets through and around barriers such as masks and sleeves. However, the City of Waco is not asking 100,000 people to wear a mask in case one of those people happens to cough in HEB. We now know that both asymptomatic and presymptomatic COVID-19 transmission do indeed occur, and the mechanism of transmission still seems to be from saliva and respiratory mucous, including respiratory droplets and aerosols, even in the absence of coughing and sneezing. Talking, forcefully exhaling, singing, yawning, spit talking; all of these are lower pressure events where a mask may actually block, rather than redirect, a higher percentage of these small, lower velocity particles. Again, you already believe this intuitively, because you cover your mouth when your breath stinks.

Or you should.

I also think that revisiting our actual real life experience and common sense is particularly important when dealing with medical misinformation, which is often found to be self-contradictory and manifestly illogical within only a few moments consideration and comparison to facts we already know. It rarely takes being a physician or another scientist to figure out that these wild claims on social media aren’t accurate, though I’m sure it helps.


Unmasking Mask Misinformation (sorry)

A friend sent this to me this morning; it was posted on a public forum (“public forum” sounds so much more legitimate than “Facebook comments”) as a response to our city’s new masking policy. I’ve also been sent a longer paragraph format piece that starts “I am OSHA 10&30 certified.” Since they overlap quite a bit, I won’t re-post that one in its entirety, but it’s just full of contradictions (‘surgical masks only filter on the exhale’ yet ‘become useless’ for protecting you if your breath clogs them), false claims (‘N95 masks can’t filter COVID-19’, ‘asymptomatic spread doesn’t occur’), and nonsensical statements (if you wear a mask and get exposed to COVID-19 you become a walking virus dispenser, cloth masks are worse than no barrier at all). It does make one really excellent point though; if you are relying on wearing a mask to fully protect you from getting or spreading COVID-19, that is indeed a false sense of security. We can’t say that often enough; but it just doesn’t follow that masks are worthless or make the problem worse, which is what they repeatedly claim. I’d like to go through the claims above in order, before concluding with some final arguments for masking.


Claims #1 and #2: Masks decrease oxygen intake and increase carbon dioxide retention.

This is something that has been studied extensively, and there is no evidence that simple surgical or cloth face masks will cause hypoxia or any significant decline in oxygen levels. Oxygen molecules are very small and diffuse easily both around and through these types of masks; they are nowhere near the size of viruses, or the much larger respiratory droplets that carry most of the virus that is exhaled. The same is true about Carbon Dioxide, which is only slightly larger.

But you can also consult your own experience here. Many types of people already wear masks for many hours of the day, from surgeons to certain industrial workers, and women in many cultures wear face coverings as a part of their public clothing. Yet we do not consider these persons to be at high risk for either hypoxic (low oxygen) or hypercapnic (high CO2) injury. A big part of the problem is that we have sensationalized the wearing of masks during COVID-19 and have started to treat it like it isn’t a normal part of our experience already, which it absolutely is. Whether it is the above examples, or Halloween or Comic-Con, or my 5 year old spending three weeks straight in his Spider-Man costume and refusing to wear anything else, the wearing of masks is something we all have some degree of experience with and have never really been concerned about until now, when we are suddenly being told they are extremely dangerous, generally by the same people who have been spreading various types of COVID-19 misinformation since mid-March.

But more to the point, you can study this on your own. A battery powered pulse oximeter is very accurate and costs about $12, and you can use one to do a simple experiment that will reassure you, at the very least, that your face mask is not causing your oxygen levels to drop. Check your oxygen level with your mask off, and then wear it for however long you expect to need it when you are out running errands or whatever scenario you are worried about. Then check it again. In general in a healthy adult, readings above 95% are normal and below 90% are concerning. As an example, I’ve been wearing my properly fitting N95 for the last half-hour and my O2 saturation has fallen exactly one percentage point.

I’ll admit, I freaked out for a minute before I realized the labels are upside down.

There is one group of people we should mention here, and that’s people with chronic lung disease such as COPD or Asthma. For people with these conditions, the increased heat and moisture of the air within the mask, and the decreased air flow directly to the nose and mouth, really can create both real and perceived difficulty breathing (and in these conditions, these trigger each other so easily that drawing a distinction between the physiologic respiratory distress and the anxiety-provoked sensation of respiratory distress is almost a false dichotomy; not being able to breath is scary). These are also conditions that predict a higher likelihood of severe illness in COVID-19, which complicates matters. For these individuals who should already be taking every precaution possible for their own safety in the midst of this pandemic, the decision of whether and what kind of mask they should wear when they do have to go out should be a discussion between them and their doctor. For the rest of us, especially those of us who personally care about someone with Asthma or COPD, it’s important that we take every precaution we can; it should go without saying that our “what about someone with a chronic respiratory illness” should only ever be a legitimate question on their behalf, not a rhetorical ‘gotcha’ to turn off our intellectual honesty on this issue and dismiss the benefits of everyone else wearing a mask.


Claims #3 and #4: Masks shut down the immune system and reactive your own viruses.

The third claim, that masks shut down your immune system, is just a reiteration of the above two, and there is absolutely no evidence for it. As we’ve already said, doctors, nurses, and other medical professionals, and especially those involved in surgery, wear masks all the time without any fear of their immune systems being shut down or weakened. And while these types of people are often fearless when confronting deadly situations or illnesses in order to care for their patients, as we have seen throughout this pandemic, they tend to otherwise be fairly health conscious. I still remember being shocked during a group discussion in medical school when we were asked what it was we valued most highly. I was trying to honestly wrestle with whether I valued my faith, my wife, or my daughter most, and how it was even possible to separate those things from one another, when my friend answered “my health,” and several others nodded in agreement. I have no judgement for that person, but the whole idea was very alien to me (and maybe that shows something of my privilege in having lived overall a very healthy life, often despite my personal choices). Maybe this friend would risk the thing he valued highest on behalf of a patient (in fact I think he would); but if there was any evidence that his health was imperiled by wearing a mask, he would be leading the charge against masking (just checked facebook; he isn’t), and probably would have been doing so since medical school.

The fourth claim is one that I first came across in the Plandemic “documentary” last month, and based on the wording it seems to be taken directly from there (or they are both taken from a 3rd, unknown source, which I’ll call “Q”)(I’m now being told that “Q” is already taken). The actual claim is that wearing a mask will activate dormant retroviruses that live in your body. Retroviruses are a family of viruses that replicate by inserting viral DNA into host cells and hijacking cellular machinery, and only a few known species causes disease in humans, including HIV and Human T-Lymphotropic Virus, which can cause certain cancers. This claim is very specific and very conspiracy-theory oriented, but I suspect that this distinction between retroviruses and common viral illnesses like cold and flu is not being made by the people spreading this meme.

The long and short of it is that this just isn’t the way the immune system works. You don’t have a host of dormant viruses sitting in your lungs that, if breathed into a cloth or small space and then breathed in again, will suddenly become active and cause an infection. Do you get sick when you sit in a car? What about when you hold your breath? What if you sleep with your face too close to a pillow? Is there evidence that we see more respiratory infections in people that wear masks regularly? Of course not. In someone who has a functioning immune system, once your immune system has seen and defeated a virus, you cannot give that virus to you; you already have an effective immune response to it. There are a small number of exceptions, like getting shingles through varicella zoster reactivation, but coronaviruses aren’t one of them and there is no evidence that wearing a mask or breathing out and then breathing in the ‘same air’ has anything to do with viral reactivation; there isn’t even a physiologic mechanism that would make this possible.


Claim #5: The virus is too small to be trapped by the masks!

This is where both the misinformation and the answer get a bit more technical, and if you want all of the scientific details, the blog First10em has an amazing article on masking, viral transmission, the 6 feet apart rule (which they call the “2 meter” rule, whatever that means), and the transmission patterns and particle sizes of both droplets and aerosols. The question of whether various types of face masks besides N95’s actually do filter the COVID-19 virus itself is still an unanswered question, but the answer seems to be, to some degree, yes. Studies have shown different types of masks to have varying filtering efficacy even down to to very, very small particles in the range of 300 nanometers or less, in fact right in the range of the virus itself (the SARS-CoV-2 virus is roughly 120 nanometers; an earlier version of this article incorrectly reported the size of the measured particles in this study as 40 times smaller than the virus, which was just due to me getting my conversions wrong. Sorry; pay attention in 8th grade algebra, kids), but other studies have shown that the virus is still able to transmit through (or around) masks, at least to a few inches away and if propelled by a cough. Taken together these studies seem to reiterate what we have been saying all along; masks aren’t perfect, but they do decrease the risk, especially in short-term contact with non-cough, non-sneeze related transmissions like we would see in asymptomatic and presymptomatic cases. Indeed, this is confirmed by a Hong Kong study in 2011 that found that the protection offered against respiratory pathogens by all types of face masks decreased with higher velocities and prolonged exposure.

Again, Oxygen molecules are < 0.5 nm

Regarding this piece of misinformation though, we can summarize the two main errors pretty succinctly; the virus isn’t floating through the air by itself, it’s suspended in respiratory droplets and aerosols; and the masks aren’t supposed to block 100% of the particles on the microscopic level (though that would great), just trap most of them and slow the others down. The mosquito through a chain link fence analogy is silly because mosquitos can fly around barriers volitionally, and because it uses the size of the virus instead of the size of the respiratory particles, which are much larger (1-100 microns, mostly, instead of 0.12 microns). But if you want to use the analogy, it’s more like hitting golf balls through a chain link fence; yes, the gaps are bigger than the golfballs, and some will go through if they are hit really hard; but many will be blocked outright and many others will be slowed down and redirected.


Claim #6: There is no evidence to support masks.

We have already looked at some of the various types of evidence that I believe we all find somewhat convincing. We believe as a culture that masks are least helpful in preventing infections in some situations, such as surgery, and believe they are safe when we wear them for cultural or religious reasons, as part of our jobs, or as part of costumes. We engage in barrier maneuvers (some better than others) to block large respiratory droplets when we cough and sneeze. We know the masks redirect and lessen such droplets even in these high-velocity conditions, and we’ve seen the evidence from physics and fluid dynamics studies that they can filter the smaller aerosols under low-velocity conditions. For me, the last remaining piece of the puzzle is, “does it actually work, really?”

I want to look at two more types of evidence; epidemiology evidence from before the COVID-19 pandemic, and emerging epidemiological data from right now. An Australian study in 2009, well before the COVID-19 Pandemic (but you knew that), found that the wearing of face masks did diminish the transmission of upper respiratory illnesses even among household contacts, but that there were fairly low rates of compliance with masking. If masks were worn more, they could help significantly.

“Adherence to mask use was associated with a significantly reduced risk of ILI-associated (Influenza Like Illness) infection. We concluded that household use of masks is associated with low adherence and is ineffective in controlling seasonal ILI. If adherence were greater, mask use might reduce transmission during a severe influenza pandemic.”

This study and others like it, 10 years prior to the COVID-19 pandemic, should at least put to rest any ideas that wearing masks is a novel recommendation or a government ploy to control yet another aspect of our lives. Masks have been recommended, and shown to work, for preventing respiratory virus transmission for decades; any suspicion of them now likely comes more from the current hyper-politicized, conspiracy saturated climate than from anything else. But the COVID-19 virus is new and acts very differently from other respiratory viruses in so many ways, so what’s to say that masks will be effective for COVID-19?

It is too early in this pandemic to have robust and definite conclusions about which measures helped most and which showed modest or negligible benefits. We know that social distancing helps from evidence in places like Sweden and Norway, and we now seem to be living the results of relaxing our own social distancing measures without other robust mitigation strategies in place. When it comes to masks, we could compare the United States, which is (apparently) very resistant to masks becoming a social norm to places like South Korea where wearing a mask has been the norm since early in the pandemic; but this comparison is complicated by vastly different healthcare systems and populations and by a strong difference in adherence to other mitigation efforts as well, which we Americans have also been consistently defiant of.

Population: 328 Million
Population: 52 Million

I do agree in principal with the approach by one writer to the CDC’s journal, Emerging Infectious Diseases, in comparing Taiwan to Singapore; but again this is not a perfect comparison by any means.

  • Update: It has been pointed out to me that there are now several recently published studies, conducted during the COVID-19 pandemic itself, that have looked at the issue of mask wearing to determine if the benefit is significant. You can find two of them here and here (with thanks to Baylor Epidemiologist Dr. Emily Smith, PhD, who has written an excellent summary of the current evidence for masks). I’m sure many more studies are ongoing. Of course none of these are going to be able to perfectly measure the effectiveness of masking under real life pandemic conditions; if you can imagine a scientific experiment that could, it would probably be unethical and immoral (and logistically impossible), such as taking members of a population and randomizing them to wearing or not wearing masks and then measuring how many become sick from each group. Those types of study designs are entirely off the table, so we analyze epidemiological data; looking at what happened in countries, regions, and cities where masks were adopted early, and what happened in other places after they were adopted later on. It isn’t possible to know how well the mask policies were followed from such data, or to perfectly tease out confounding factors like social distancing measures, the success of contact tracing, and the robustness of testing programs; it wouldn’t be possible to say masks are the most important thing if they are always or nearly always used in conjunction with other mitigation strategies, which is exactly how they should be used. But these studies do conclude that implementing mask policies (and following them!) makes a significant difference in the trajectory of this pandemic, and taken as just one important kind of the multiple kinds of evidence we have looked at, I do think they contribute to a convincing case for wearing masks.

Ultimately, once this turns the corner, we will never be able to say with certainty what the real answer was; whether it was wearing masks that helped the most or the heightened caution in other areas when cases began to climb, whether reopening resulted in a surge here in Texas or if it was our bucking of social distancing all along, whether each of our mitigation measures individually made a difference or not. What we can say for certain is that the American method so far has not been working. By denying the disease’s existence and danger, producing conspiracy theory after conspiracy theory, claiming we beat it prematurely, and fighting tooth and nail against every reasonable recommendation and rule meant to protect ourselves and our neighbors, we have taken a global pandemic and made it largely into an American pandemic, with the highest number of cases and deaths in the world.

There is plenty of evidence that masks are safe, and that they stand a fair chance of helping, especially against asymptomatic and presymptomatic spread. If you are sick, get tested, stay home, and isolate; make sure you get the medical care you need. If you are well and can physically distance yourself from others, then distance yourself from others while finding ways to still care for your community and your own mental and physical health. If you cannot distance because of strong religious or moral convictions or the realities of your job, or due to strong personal preferences, then please wear a mask and wash your hands frequently.

This is just one of the ways we can do better during the rest of this pandemic; myself included.

Dallas Doctor Speaks at Set Texas Free Rally

A friend sent this video my way along with some questions from a family member. The questions were of a specific and limited scope, which I deeply appreciate, and I hope I will have answered them satisfactorily within this post. The video is of Dr. Ivette Lozano, MD, who is general surgery trained and now runs a solo general medicine practice in Dallas, an hour and a half North of where I work; I am not sure whether she also works in surgical and/or hospital settings, as this information is not available from her website and does not come up in the video. She was speaking at the Set Texas Free Rally in Dallas on May 9th. Dr. Lozano has done numerous interviews and television appearances during the COVID-19 crisis and has these collected on her practice website; though I will keep commentary focused mainly on the video that was sent to me, watching her other interviews has been helpful in understanding her experiences and position more clearly, and I will refer to those at certain points as well. I do not feel that it would be appropriate for me to link to her practice website directly from a blog post that seeks to discredit and contradict so many of her claims, but if you wish to see her other interviews they seem to be available on YouTube.

I’d like to point out two things about this video right from the start. First, unlike the personal youtube videos we have looked at so far and and the extensively produced PlanDemic documentary, Dr. Lozano is speaking in a live, outdoor forum without the option of editing or multiple takes. She speaks for 13 minutes and seems to consult her notes very infrequently, if at all. That in itself is an impressive feat. I’ve spoken at this type of gathering a few times as a professional, sometimes on very little notice, and I honestly can’t remember half the stuff I said afterwards; it’s just not the most conducive to an academic discussion. With that in mind, if Dr. Lozano does ere in some finer details or specifics, I think a measure of grace is called for; in such a setting, it would be at least as likely that such an error were due to the challenges of that context and not to design.

The second is that Dr. Lozano states multiple times (and we will examine these instances more closely as we come to them) that she is speaking from her own personal experiences. In common experience this tends to serve as a rebuff to any attempts at correction or argument. I do not mean that this is Dr. Lozano’s intent; I only mean that we need to point this out now to preempt any blanket objection to a thorough evaluation of her claims with such phrases as, “well she is sharing her own experiences, so you can’t argue against that with statistics or outside information. She is just telling her story.” In scientific pursuits, and in her role as a physician, her statement that she is relying only on her own experiences should properly be understood as her ceding that her evidence, while compelling to her personally, is in fact anecdotal; that is, based on a small sample size that has not been studied rigorously and is not likely to represent an entire population. Dr. Lozano, as a clinician and scientist, would no doubt understand this.

Anecdotal evidence is important in medicine. It serves as a jumping off point for examining trends and leading to more rigorous research, and as an anchor for contextualizing results and treatment guidelines. In absence of anything better, we rely on our own limited experiences in treating patients; but the principles of evidence based medicine also dictate that, as scientists, we rely on stronger forms of evidence when they are available. If that evidence seems to contradict what we ourselves have experienced, that is reason to both examine the evidence more carefully, and to reflect on our own clinical experiences with a greater degree of scrutiny and honesty. Most often there are factors at play that our limited experiences and volume of data simply cannot reveal, and once we account for these our own experiences really do harmonize with the evidence after all. In fact, it’s fair to say that, to a large degree, what we call high quality evidence is really just the experiences of many, many physicians and patients aggregated and then evaluated rigorously; we ignore the experiences of many in favor of our own individual narratives only at great peril to ourselves and our patients.

So, as we look at these claims, please do not fall into the trap of thinking that as personal experience her claims are exempt from contestation. That is a legitimate and important way to interact with individuals in a great many contexts, and listening to people’s stories without judgement is a vital part of what I do every day as a physician; but it is not the way either Dr. Lozano or myself have been trained to think of medical data.


00:18 I am currently treating COVID patients in my office.”

I am, too. It is important when we talk about our own anecdotal experiences that we at least give some idea of volume. I have interacted with only a few COVID-19 + patients; our county and city has had a blissfully small burden of disease from this virus and has not yet hit anything like a surge. Dallas, a much larger metropolitan area, has been hit harder, and I would readily believe that Dr. Lozano has seen more COVID-19 patients than I have personally; though she does not here give an indication of the number of cases she has personally treated. Yet, Texas also has had relatively few cases, and so both of our experiences would pale in comparison to those of clinicians in New York, Wuhan China, Italy, Spain, etc. We need to have the humility, as doctors, to recognize that our own small samples cannot lead to definitive clinical data on their own.


00:25 – 1:23 “Let’s start with some simple numbers.”
  • Populations:
    • 330 million in the US
    • 29 million in the State of Texas
    • 2 million people in Dallas
  • Deaths:
    • Dallas: 111

Dr. Lozano: “When you see those numbers it kind of shocks you, that we could stop society for one hundred and eleven deaths.”

Dr. Lozano

So here is my first objection. The Number of deaths in Dallas County, 111 (now 145), has nothing to do with two things. First, it has nothing to do with the populations of either the entire United States or of the State of Texas. If you want to include those numbers, your data set would look something like this:

  • US
    • Population 330 million
    • 89,932 Deaths from COVID-19
  • Texas
    • Population 29 million
    • 1,336 Deaths from COVID-19
  • Dallas
    • Population 2 million
    • 111 Deaths from COVID-19

If you are not going to include the number of deaths (underestimated though they may be) in the US and Texas, why include those populations? I believe it’s simply to make the 111 deaths in Dallas seem small in comparison. I could do this in Waco, too; I could stand up at a rally and say “the population of the US is 330 million, and there are 257 thousand people in McLennan Country. We’ve only had 4 deaths. Are we really going to shut down all of society for 4 deaths?” It sounds pretty silly doesn’t it, to invoke that 330 million people without mentioning the 90 thousand lives lost among them?

Now, maybe it sounds like I am splitting hairs, but this is important; the reason that we shouldn’t invoke population numbers detached from death numbers is because the 111 deaths in Dallas also has nothing to do with shutting down Dallas. Think about that for a moment. Cities, States, and Nations that were not hit early by the pandemic have had the privilege of developing their response based on the impact in other places. Shutting down Dallas wasn’t based on 111 people in Dallas losing their lives to COVID-19; it was based on over 15,000 deaths in New York, 27,000 deaths in England, and 32,000 deaths in Italy. It was based on the recognition of what this virus can do to a city or a region, particularly once the healthcare infrastructure is overwhelmed. In fact, in saying that Dallas was shutdown because of only 111 deaths, she is exactly reversing the logical relationship between those ideas; the reality is that there have likely only been 111 deaths because Dallas was shutdown.

Dr. Lozano goes on, “here is how it is notified to you:”

  • 27,000 Positive Covid Tests (??? but probably Texas)
  • 3,000 Recovered (???)
  • 111 Dead (Dallas)
  • “If 3,000 have recovered, from 127,000 (???) positive tests, that’s 124,000 that have recovered.”

Now it’s clear that Dr. Lozano misspeaks here, either with the 27,000 or the 127,000 above; please remember, she is speaking in a very challenging format and such things happen. However, I honestly cannot tell which is the statistic she intended. Looking back at data from May 9th, Texas had around 37,000 positive COVID-19 cases and 1049 deaths, but listed 19,000 as recovered, not 3,000. Dallas had 111 deaths but to date has only had about 6,000 confirmed cases total, and the US was already in the millions of cases by that time. So, without knowing where her numbers have come from, it’s a bit hard for me to fully examined the claims she is making, but we can safely make at least three observations.

First, she is now directly comparing the number of cases in Texas (the 27,000 above; I cannot imagine where else this number could have come from) to the number of deaths in Dallas only, without mentioning the number of cases in Dallas at all. This is deceitful use of statistics and I sincerely hope it was accidental. Second, her point seems to be that the public is being lied to about the number of cases that are recovered; “27,000 cases, only 3,000 recovered.” But this is not the case; at the time of her speech, official data placed those numbers at 37,000 cases and 19,000 recovered. Third, her final conclusion (here she misspeaks again but her intent is clear) that the number of cases minus the number of deaths equals the number of recoveries is erroneous both because we do not yet know the long term ramifications of the disease, and more to the point, because there are still over a million people with the illness in the US who have not yet recovered. Most of them are at home under close observation and follow-up, but many are fighting for their lives in the ICU and are by no means ‘out of the woods’; some of these people are in the ICU in Texas, and we cannot discount their struggle and the suffering and danger they are still facing. Some will still die, despite the best efforts of their doctors and nurses.


1:23 “I don’t want to bring statistics from other physicians because there is always someone on the Left who wants to contradict me.”

This is the portion of the video where Dr. Lozano begins to speak about her personal experiences, but I want to spend one more moment on this very troubling statement. The politicization of COVID-19 within the medical field is largely a false narrative, and not a particularly coherent one. We’ve talked about this a lot on this blog, on multiple occasions, but basically the conspiracy theorists would like you take any doctors you happen to know and trust, or who share their conspiracy theory, and put them in the “one of the good ones” box; the few honest doctors fighting for the truth. All the rest of us, even if we happen to share your background or faith or even political leanings, are to be put in the “part of the system” box and seen as either infamous conspirators or unwitting patsies. We are, so they argue, inflating death numbers, scamming medicare, and lying to the public in order to… do… something. This part isn’t really clear, you see. Despite the vast scope of different political allegiances, backgrounds, economic views, and personal convictions among doctors, we are all somehow part of a conspiracy to destroy the economy, embarrass Donald Trump, bring about a totalitarian police state, enact socialism, etc. Despite many docs I know getting all of their news from Fox, despite some being close to retirement and watching their 401k’s like hawks, despite many having voted for Trump and planning to again, despite the fact that we are not a monolith. Despite the fact that we have had to work extra hard to take care of our patients in the midst of a pandemic, and the fact that many of us have gotten sick, and some have died, doing so. Despite the fact that, a few minutes later, most conspiracy theorists will point to empty ER’s and closing doctor’s offices in non-surge areas as a sign of the economic injury being done by mitigation measures, their conspiracy theories still call for those doctors struggling the most financially to be a part of a conspiracy to propagate the COVID-19 myth. It’s all rather silly, I’m afraid.

Which is why it is so alarming to see Dr. Lozano adopting it here. What she is saying is that she is only willing to rely on her own anecdotal evidence in talking about and treating COVID-19 because she believes that the experiences of her colleagues and higher quality data from research hospitals around the globe are skewed by a Leftist political agenda. This is a very, very dangerous way to practice medicine. At best, Dr. Lozano knows her audience and is willing to let them believe in these conspiracy theories in spite of her knowledge of the way medicine actually works, and the devotion that the overwhelming majority of doctors have to both veracity and the health of their patients regardless of their own political leanings. At worst, she has come to believe in this perverse and pessimistic view of physicians herself. My fear is that this perspective ultimately leads to practicing ‘lone wolf’ medicine detached from evidence, the insights and experiences of peers, and the commiseration and accountability that come from serving within this ancient and altruistic profession.

But because this Southern, Homeschooled, Eagle Scout, 4-wheeler-riding (is that still a conservative credential?) future-missionary-doctor has seen the compassion, the integrity, and the seemingly endless self-sacrifice of fellow physicians from every walk of life and all parts of political spectrum time and time again, I cannot be so quick to attribute to them nefarious political motivations capable of overwhelming their commitment to their calling and Oath. So when discussing Dr. Lozano’s anecdotal evidence, I will be relying on something more substantial than just my own.


1:48-2:05 Discussion of Symptoms

Here Dr. Lozano is discussing the patients with COVID-19 she has seen in clinic. I only point this out to note two things moving forward; first, she does not give us the number of patients she has actually seen in clinic who have the diagnosis. Second, her description of symptoms is interesting. She describes fever, but only fever at nighttime. She describes cough, but only with deep breaths. These are very specific qualifiers and do not exactly match what is known from observations of millions of cases of COVID-19 around the world. Many patients have cough, but not necessary only with deep breathing. Many patients have fever, but not necessarily only at nighttime. To me this suggests that Dr. Lozano may have seen a relatively small number of COVID-19 patients, because there does not seem to be much variability in the presentations she has encountered. It also illustrates the danger of relying on anecdotal evidence alone; once we have cemented a narrative that says this disease will always act like I have personally seen it act before, we put ourselves at risk of delaying the proper diagnosis or missing it entirely. We must learn from each other.


2:06 “These patients are afraid.”

This is true. One of the most important tasks we’ve had as physicians, and really as an entire healthcare field, has been to speak to the fears of our patients in the face of this very dangerous pandemic and help them navigate their medical and mental health needs with safety and confidence. This is an important part of our conversations with patients on every level, from individual encounters to entire populations. Every patient I see who has been exposed to the virus or who has symptoms that might be consistent with COVID-19 needs both reassurance and anticipatory guidance; they need to know what happens next, how to stay safe and keep their loved ones safe, and when they need to seek additional care. Our clinic system has instituted countless measures both to support our COVID-19 patients and to ensure that our patients know they can be safely seen for their chronic conditions as well, from telemedicine systems being built in a matter of weeks to patients being seen in their vehicles so they don’t have to enter into healthcare spaces, and a thousand small steps that probably go unnoticed but reduce our patients’ potential of being exposed to the virus. As physicians, we must combat fear with our compassion and the trust we have built with our patients; never with minimizing their concerns or spreading misinformation.

But Dr. Lozano then goes a step further. At 2:25 she states that the patients who are coming to see her for COVID-19 symptoms are being turned away from the emergency room. She says they are being sent home if they have a fever and told to quarantine, and that during that time they infect their families. She says that doctors are closing their doors and implementing telemedicine, which she considers a scandal because it does not involve a physical exam. She says near the end of the video that they are having patients ‘see their assistants’ instead, implying that they are having Nurse Practitioners and Physician Assistants take on risks they aren’t willing to themselves (and playing to the undeserved discrimination those professionals face in healthcare).

At 3:17, she says that other doctors are hiding in their fancy homes with their fancy cars in the midst of a pandemic, and the contempt for others in her profession is evident in each syllable she pronounces.

Her implication is that doctors are scared of the virus and are too timid to treat their patients; they are refusing to see people, the ER is turning people away, and they are using telemedicine and other tricks to avoid having to give compassionate care that might put themselves in danger from the virus. And if that’s true, it’s a tragedy; it represents the deepest betrayal of our Oaths and the values we hold in common as physicians.

But thankfully, it’s not true. When I heard her say this I really had to grieve for a moment; grieve for a doctor whose experiences and views have so detached her from the rest of her profession that she could hold, and promote, a view of physicians that is such a stark contrast to the reality. Please take a moment and really, honestly compare her narrative to the stories you are hearing and seeing from doctors all over the world; the doctors who are staying in donated hotel rooms or sleeping in the hospital call room between shifts because they are too frightened of the virus infecting their own families. Notice that they aren’t cancelling or no-showing their shifts; they are still taking care of patients every day, placing themselves in harms way and risking their live for others as they have been called to do, but they are also taking on the sacrifice of isolation themselves in order to protect those they love. Consider the doctors, even very old doctors who have come out of retirement to help and young doctors still in residency, who have gotten sick and died in the line of duty. Her narrative, at least on the physician side, doesn’t match the reality. And as much as I love my fancy car (it’s a motorcycle with a sidecar I bought used my first year out of residency; I’ve wanted one ever since I watched Indiana Jones and the Last Crusade as a kid and I’m immensely proud of it), her actively promoting for her audience the myth that most physicians lead lives of extravagant wealth (sidecar motorcycles not withstanding) is not only disingenuous but extremely mean spirited. Many of us are currently drowning in medical school debt.

We also have a used 2012 Honda Odyssey minivan. Jealous?

But what about the patient side? Are patients really being turned away? Well first of all, it’s not only bad business and bad medicine but actually illegal to be denied treatment for an emergent condition at an emergency room. Moreover, in practice I’ve never even seen it done even for non-life-threatening conditions, and in fact one of the biggest problems with our healthcare system is that this means a great many people get all of their care from the ER because they don’t have access to a primary care doctor (when my residency program was founded 50 years ago, this was one of the problems it was created to address). Again, Dr. Lozano’s narrative seems to be the exact opposite of the real situation. From her comments alone you would think that patients with cough and fever were having the doors barred from entering their clinic or the ER; but in many areas that have been working under the assumption that a COVID-19 surge was imminent, most clinics and hospitals have deferred a great deal of other types of care in order to specifically care for large numbers of people with those exact symptoms. We have worked very hard to ensure that our other patients are still getting close follow-up, and things like telemedicine have been put into place to make sure that my 95 year old patient with COPD and congestive heart failure can still get seen without being exposed to the transmission risks inherent in a clinic waiting room. No, patients with cough and fever are not finding a series of doors slammed in their faces, with Dr. Lozano being their last hope; but that isn’t what she’s actually saying.


4:05 Treatment for COVID-19

I promise we’ll get somewhat political momentarily, at least in the sense of giving governing officials their due while not ascribing to them godlike mastery of all intellectual disciplines, and of honestly reflecting on the merits and limitations of national and state medical associations. But let’s press on for now.

When Dr. Lozano was speaking of the patients being sent home and turned away, it might have sounded, to the casual listener, as though she meant they had been refused care, which has certainly not been the case. She tells us what she really means beginning at 5:126:30, and I’d encourage you to listen carefully again, and then I’ll explain the sequence of events she is eluding to.

The patients she is referring to were seen. They were evaluated. They were not sick enough to be admitted to the hospital. Because there is no specific medication that has been proven (by large scale studies, not individual anecdotal evidence) to be effective in an outpatient setting, these patients were not prescribed specific therapy. They were likely given recommendations for symptomatic treatment, instructions for self isolation, and guidelines for seeking out a higher level of care if their symptoms worsen; though the thoroughness of those discussions often depend on the time available, the practice style of the clinician, and the degree to which the patient is interested.

So far, this has actually been perfectly appropriate care. Please keep in mind that the hospital is not a place you want to be unless you absolutely have to be. Most patients (85%) with symptomatic COVID-19 have a “mild course.” This can be anything from a mild cough to significant flu-like symptoms which can be very uncomfortable, but most patients with the viral syndrome will not need to be hospitalized. Filling up hospitals with patients who do not need to be there is the wrong decision not just for other patients in the hospital, those who might need to be hospitalized later, and for hospital staff, but also for the patient. It puts everyone at risk, including that patient, and it’s irresponsible. Dr. Lozano states that they were ‘sent home to quarantine, exposing their families’ as though this were a scandal. First of all, if these patients were symptomatic, their families had already been exposed. Second, home is where they would be safest and best taken care of unless they actually needed hospital level care. And third, there are no other viable options. Certainly some countries have set up mobile containment hospitals for mildly symptomatic COVID-19 patients to stay in until they are deemed non-contagious. Please ask yourself if that is something Americans would consent to; being told that even though their symptoms are mild, they cannot be trusted to keep from spreading the virus to others and are not allowed to return to their homes. We can’t even get people to wear masks.

Finally, these patients come to Dr. Lozano, who gives them a prescription for hydroxychloroquine and some unspecified antibiotic shots for good measure. It is now clear that way back at 2:25 when Dr. Lozano said these patients weren’t being treated, what she was really saying was that they weren’t being treated exactly the way they wanted. Now, we could go off on a rabbit trail about antibiotic stewardship and doctors prescribing antibiotics, and other medications, unnecessarily for viral conditions because it makes their patients feel that something has been done. It builds loyalty, it gives them confidence in you, it keeps them coming back to you for minor conditions because they know you’re going to give them something for it; it does everything except actually treat the virus. Please keep in mind that in over half the viral misinformation videos we’ve seen, this is exactly what doctors are being accused of, despite the fact that most of us fight very hard against this exact mentality. It is much, much quicker and easier (and more lucrative, under many practice models) to tell a patient that the injection you are giving them will make them feel better than to carefully, patiently explain that their own immune system will defeat the virus, that there are no specific therapies but lots of things you can do to try to feel better in the meantime, and that your duty is to “First Do No Harm” to them, including prescribing unnecessary and potentially dangerous medications. The latter, in addition to taking more time, also feels unsatisfying to both the patient and the doctor; it’s also the right thing to do. If your doctor never refuses a single thing you ask for, you probably need a new doctor.


What about hydroxychloroquine?

You should know that no medication is “considered a candy” or “a vitamin” (except, you know, actual vitamins). All medications have potential side effects and hydroxychloroquine, while relatively safe, should not be used without a specific indication and a careful evaluation of the risks and benefits. No medicine should.

Not Candy.

But even allowing for Dr. Lozano’s waxing a bit eloquent in what comprises the bulk of her arguments in this video, we need to ask some very basic questions about hydroxychloroquine. First, we need to ask whether it works, and second, we need to ask whether her narrative and claims about the medication are true.

Does hydroxychloroquine work?

Because Dr. Judy Mikovits brought up the idea that doctors were being stopped from using hydroxychloroquine in the PlanDemic documentary a few weeks ago, I’ve written about this just recently. In the interest of length I will not reproduce those reflections here. The long and short of it is that the medication showed some promise when it was first used on a small number of patients, and following this it was used widely and we all hoped it would be incredibly effective; but unfortunately subsequent more rigorous trials and widespread physician experience have not shown this to be the case, and now it’s use in COVID-19 has been widely abandoned. For more details, please refer to the section titled “Hydroxychloroquine is a miracle drug” from the blog entry “The Paradoxes of PlanDemic,” or read this article from the New England Journal of Medicine that explains this all in greater detail, and the rationale by which the authors have chosen to stop using the medicine to fight COVID-19.

Update 5/22: Click the image to read a study form the Lance published today.

Claim: Donald Trump taught doctors to use this medicine…

While I’m afraid that I have to consider Dr. Lozano’s claims here to be politically motivated and revisionist, in the interest of fairness I admit that, depending on her individual experiences, what resources she has been using, how she acquires new medical information, and to what degree she was pursuing treatment guidance early in the pandemic, from her own perspective the sequence of events could conceivably appear as she has described them. The French study that originally established the efficacy of hydroxychloroquine for COVID-19 was released in mid march, but there was talk of it being used even prior to this; an article coming out of Wuhan, China was published on March 9th, and by the time of the March 19th press conference where Donald Trump recommended it, all the doctors I know had been talking about it in multiple forums for over a week. I had discussions about it in person and on zoom calls, over text and e-mail, and on social media both on friend’s Facebook walls and in private physician COVID-19 groups. Unless you weren’t paying attention to emerging COVID-19 information (and I think almost all of us were by that time), the president’s mentioning hydroxychloroquine for COVID-19, while certainly contemporary to the discussion, was not breaking news. Though Donald Trump was touting the medication with his usual unmitigated bravado, at the time a lot of us really did feel cautiously hopeful; we really wanted the treatment regimen to be universally effective and live up to the hype as well. We also agreed with Dr. Fauci, who stated that this study was little more than anecdotal, and while promising, shouldn’t be relied on as empirical evidence. This wasn’t a political statement; he was merely bringing to Donald Trump’s enthusiastic endorsement the temper and nuance we would expect from a medical professional. If Fauci’s later being proven right adds fuel to the political fire, it is merely a reflection of how unfortunately politicized this pandemic has become; to medical professionals, the rise and fall of hydroxychloroquine is a normal part of the scientific process, though expedited quite a bit by the pandemic.

But Dr. Lozano goes a step further than even Dr. Mikovits; she really seems to be implying that Donald Trump somehow came across this information on his own. While I understand that is a hallmark of diehard supporters of the president, the desire for him to be the smartest in the room on every subject, the idea that he was personally reviewing medical journal articles and came across this French study independently is really very silly. Of course this information would have been given to him during a briefing by his medical advisors, the same ones who then had to qualify his statements, and the very “bureaucrats standing next to our president” Dr. Lozano later decries for “thinking they know more about medicine than I do.” Notice too this strange juxtaposition; she is willing to stand on her professional pride when confronting Fauci and other advisors to the president with medical backgrounds calling for caution with the medication, calling them ‘bureaucrats’ despite their training; but she is eager to say that the president has taught her how to treat COVID-19.

….while medical societies gave no treatment guidance.

As I’ve said, this French study was published and read and discussed widely in the latter half of March, and many medical associations and news sites offered reflections on it. Treatment regimens were included in the original study, so Dr. Lozano’s saying “you would think I would get some kind of guidance from the American Medical Association” couldn’t refer to needing a hydroxychloroquine dosing schedule, but rather expert opinion on what to do with that already available information. As Dr. Lozano requested, that guidance came out on March 25th. The American Medical Association offered a very measured response, calling for physicians to weigh the evidence carefully and to be ‘just stewards’ of healthcare resources. They reiterated that the French study had been small and only included hospitalized patients, and that medications should always only be prescribed due to an appropriate medical condition. This was in response to reports that some doctors were ordering prescriptions of the medication “for themselves, their families, or their colleagues,” and that some organizations were stockpiling the medication. Indeed, there were reports at the time that some patients with Lupus and Rheumatoid Arthritis were having trouble getting their normal dose of the medication because of this. You can read the AMA’s joint statement with the American Pharmacists Association here; it has since been updated, but a summary of the original from March 25th is also online here.

Claim: Doctors are too scared to use it because it isn’t FDA approved.

The FDA actually issued and Emergency Use Authorization to treat COVID-19 with hydroxychloroquine on March 30th. This is still in effect. The FDA has since issued safety guidelines which also cautioned against its use for COVID-19 outside of the hospital. This is because the medication has many possible side effects including prolonged QT syndrome, which can lead to sudden cardiac death, and because even early evidence only supported use for patients sick enough to be hospitalized, while later, more robust studies have not even supported that. The EUA is still in effect however, which does allow physicians treating extremely ill COVID-19 patients in the hospital to weigh the evidence for themselves.


Why won’t the pharmacy fill these prescriptions?

At 7:36, Dr. Lozano begins the narrative that after her 1st or 2nd or 3rd prescription for hydroxychloroquine, the pharmacist called her to ask for a diagnosis. Dr. Lozano presents this as though it were a conspiracy or scandal, the pharmacist trying to breach patient confidentiality laws. In reality this is very common; knowing the diagnosis is important for the pharmacist for a number of reasons, including counseling the patient appropriately, ensuring that look-alike/sound-alike medicines have not been prescribed on accident (this does happen; I have done it and a smart pharmacist caught the error before the prescription was filled). In fact it is required with certain controlled medications. Your pharmacist is considered to be involved in your care, and sharing your diagnoses with them is not a HIPPA violation if it helps them do their job. Moreover, regardless of Dr. Lozano’s jab that “your job is to put the pills in the bottle,” pharmacists literally go to school for years to study medications; they already know your diagnosis from the medicine alone 99% of the time. No pharmacist is saying, “huh, Mr. Johnson is being prescribed Metformin. I wonder what that could be for?” It’s a diabetes medicine; they know you have diabetes. And that’s fine, because they also abide by patient confidentiality laws and aren’t going to go out and tell people about your diabetes any more than your doctor or nurse would.

With hydroxychloroquine specifically, the pharmacist was likely asking Dr. Lozano for a diagnosis because of the AMA/APhA/ASHP joint statement above, which includes this specific phrasing:

The pharmacist asking for the Diagnosis was wise to do so.

Or maybe it was because of this rule from the Texas State Board of Pharmacy:

If the pharmacist had not asked for a Diagnosis, he would be committing malpractice.

So the pharmacist in this scenario was simply following not only the rules of his state governing board but also the consensus advice of the national organizations that represent his profession. Dr. Lozano states that she got around this by eventually finding a pharmacy that would fill the prescription, and by giving them a diagnosis of hypertension or diabetes instead of COVID-19 (it is unclear from her presentation whether these patients in fact have those diagnoses; presumably not, since her whole point is that she is unwilling to share their medical information with the pharmacy). So this requires us to ask the question; are these rules good? Is it reasonable to tell pharmacists that they shouldn’t or can’t fill prescriptions for this medication unless it is for Lupus, Rheumatoid Arthritis, or Malaria? In other words, should this decision really be up to the individual doctor?

In general, physicians tend to be wary of any rule or law that displaces medical decision making outside of the patient-doctor relationship. Dr. Lozano speaks to this around the 8-9 minute mark. The hope is that the years of careful education and training we receive should be sufficient to instill in us the weight of the responsibility we have to follow the evidence and to treat with a light touch in the absence of strong evidence. I believe it generally is. However, there are over a million physicians in the US alone, and oversight and accountability are necessary. As someone who works in the area of opioid dependence treatment, I strongly believe that top-down measures to curb the prescribing of opioids has helped many people avoid addiction and dependence. In the case of hydroxychloroquine, these decisions were made to prevent stockpiling and overprescribing of the medication that would create a shortage that hurt patients who needed it, including those with conditions such as Lupus, and early on, patients in the hospital who were sick enough to be prescribed it for COVID-19.

But it is possible to imagine scenarios where this medication could have been legitimately prescribed in an outpatient setting, at least early on before more data was available. One could imagine a confluence of circumstances where a patient met or nearly met hospitalization criteria, but could not be hospitalized for some reason; being the sole caregiver for a small child and needing to wait a few days for family to return, for instance, or living in a city where the hospitals were full and they didn’t quite meet criteria for hospitalization during the pandemic, even though they might have under normal circumstances. One could imagine a patient in the midst of a work-up for Lupus, whom their doctor was considering starting on hydroxychloroquine anyway, suddenly being diagnosed with a mild case of COVID-19. Would it be legitimate for this to shift the balance of risk and benefit and justify its use now instead of once the work-up is complete? These situations would be exceedingly rare, but they are possible, and it would indeed be frustrating to be a doctor or patient stuck between these realities and the Pharmacy Board’s rules and be unable to get the medication filled.

But is this the case with Dr. Lozano’s patients? Dr. Lozano gave an interview on Fox News where she shares more details from her experiences with the pharmacy. She states, “Yesterday I wrote 5 prescriptions for hydroxychloroquine… Today was horrible, I had 15 people who needed 15 prescriptions.” I have never been in Dr. Lozano’s clinic; I was not there on the day she gave the interview, and cannot vouch for either the COVID-19 status or the severity of illness of her patients. But the idea of one physician in a solo practice seeing 20 patients in 2 days who have COVID-19, and are sick enough that they should have been hospitalized but weren’t, in a city that has only had 6,000 confirmed cases total, is extremely far-fetched. Rather, this paints the picture of a physician who has chosen to simply give the people what they want, and instead of following the evidence and carefully weighing risks and benefits on a case-by-case basis, chose to cultivate a reputation (and client base; she says she has patients driving in her to see her from Austin and San Antonio) by being the doctor who would prescribe the medicine that was suddenly being talked about all over social media after the president’s press conference. Any doctor who suspended their clinical judgement and prescribed hydroxychloroquine for every cough and fever patient who wanted it in March and April could have done likewise; and that is exactly the kind of prescribing practice that the Texas Pharmacy Board rules and the statement by the AMA were meant to protect against.


But what about Dr. Lozano’s experiences with the medicine? Doesn’t that prove it works?

Please listen to what Dr. Lozano says at 7:15.

“I have patients at Lozano Medical Clinic who are cured of this disease. I have patients that recovered within 48 hours. In fact, the illness that they had was more caused by the stress and the fear of the propaganda that’s being spewed on the news media than by the actual virus.”

Dr. Lozano has told us that she prescribed these patients hydroxychloroquine. She has told us she prescribed them azithromycin as well. She has told us that she gave them ‘a few antibiotic injections’ just for good measure. She states that the FDA can approve you-know-what because she has seen patients get better with this treatment. She now tells us she believes most of their symptoms were from stress.

I also have patients who are cured of the virus; their immune systems did that for them. That’s what usually happens with most viruses, and it happens all the same without potentially dangerous or potentially lethal combinations of unnecessary medications. The number of cases where symptoms are so severe that someone needs a high level of support is particularly high for this virus, which is why we are dealing with a pandemic; but they are still in the minority, and Dr. Lozano has offered zero evidence (and quite a lot of counter-evidence) that these patients would have needed hospitalization without the medications she prescribed.

As a physician, I have better tools for treating stress and fear about the virus; compassion, active listening, empathy, and careful explanations of the medical realities they are facing. As far as I know, none of those can cause sudden cardiac death.


“I think when you do things that are incorrect, you need to be thrown under the bus.”

Dr. Ivette Lozano

At 10:12 Dr. Lozano throws Walgreens Pharmacy under the bus. She says that if you have a prescription for hydroxychloroquine, Walgreens will call and ask you to fill the prescription in their drive-through instead of at the counter inside. An immuomodulator, for patients who have autoimmune diseases. That is sometimes being used to treat a virus, in the middle of a pandemic caused by that virus. Surely anyone can see that this is a reasonable request?

10:40 “If you are taking a prescription for hydroxychloroquine, they will ask you to come in through their driveway. Well you know what: maybe eventually they’ll ask you to wear a yellow star on your shirt.”

Internet memes and Godwin’s Law aside, this is an absurd comparison. Every clinic I know of has taken steps to ensure that all their patients stay safe during this crisis, and for many that means seeing patients with risk factors for COVID-19 complications and patients with symptoms of the virus outside to prevent transmission. For whichever indication this medication was prescribed, picking it up at the drive-through is a reasonable step to keep both you and others safe. Is this what Dr. Lozano’s audience considers “oppression”? Is this comparable to the Holocaust? I understand that many people are legitimately concerned over the balance between safety during a pandemic and preservation of individual rights, but is going through the drive-through at Walgreens really the Rubicon we dare not cross? To quote one Twitter user:

Dr. Lozano then says that she has encouraged all of her patients to get their prescriptions filled elsewhere, and that gives me the opportunity to share my first financial disclosure in several months of arguing against financially motivated medical misinformation; my father manages a CVS (in a different state than where Dr. Lozano and myself practice). And while that doesn’t actually constitute a financial conflict of interest, on some emotional level I’m ok with Dr. Lozano calling out the competition here, the same way I didn’t like K-Mart growing up when dad was managing Wal-Mart stores. Call it tribalism I guess. In practice, the only time I care which pharmacy a patient chooses to use is when I know they will get a more affordable price somewhere else, and that’s when we talk through their pharmacy options more intentionally.


10:57 HIV vs. COVID-19

Dr. Lozano states that she trained in general surgery during a time when there was not a good test for HIV, so they took precautions with every single case and did not discriminate against people if they had the virus. It seems odd to compare a virus like HIV, which is very difficult to be infected by even through contact with blood, to SARS-CoV-2 which is spread by droplets and airborne transmission. Dr. Lozano is right that no patient should be discriminated against because of an illness, infectious or otherwise. She is also right that we should take precautions to keep ourselves, and others, from becoming infected. But this looks different for different type of infections, based on their infectivity, potential severity, and mode of transmission. Refusing to operate on an HIV positive patient because of their diagnosis would be discrimination; asking a patient with COVID-19 to use the drive-through during a pandemic- which we really all ought to be doing anyway if at all possible- is not.


11:22 “This virus is 98% treatable with no medication! For those 2% who are sick, the President of the United States has given us a phenomenal protocol.”

I’m going to pass over the fact that the president has apparently gone from being told about hydroxychloroquine by his advisors, to reading about it in his independent research, to now actually creating the treatment regimen himself. Fine.

The bigger issue with this sentence is the way that Dr. Lozano has distorted these numbers. Without getting into details about the percentage of patients who need hospitalization and the percentage that need to be in the ICU (these numbers have shifted and will continue to shift as we have better and better data and antibody testing, as physicians and epidemiologists have been saying since the start), we can accept and agree with Dr. Lozano’s point that only a relative few patients with COVID-19 will need intense and specific interventions; as we’ve already discussed most will get better on their own.

But it’s important to clarify two things. First, Dr. Lozano never mentions working in a hospital either in her youtube videos or on her website, only seeing patients in her clinic. I think it’s fair to assume she doesn’t see patients in an inpatient setting or treat critically ill patients in the ICU. This means that the small percentage of patients she mentions who are sick enough to need specific treatments and high-levels of care are not the patients she is interacting with. She has presented a narrative that says most patients get better on their own, so go get your hair cut and go shopping and if you happen to get very sick from COVID-19, go see her and she’ll prescribe you hydroxychloroquine. The reality is that the patients she is prescribing hydroxychloroquine for are the patients who would get better on their own; they are part of the “98%,” not the “2%.” They’ve already been evaluated by other doctors and were told, thankfully, that they didn’t need to be in the hospital. The patients who need the high level of care are actually in the ICU, those that made it there, and are fighting for their lives. Many of those who have had the worst cases and needed that level of care have in fact been treated with hydroxychloroquine, and many of those patients did die; this is where the more powerful and reliable data about it’s efficacy comes from, not from a small clinic that has drastically shifted the definition of ‘very sick’ because it never interacts with patients in the hospital and ICU.

And second, that small percentage of patients, for a virus that is this contagious, still represents an astronomical number of people. This is the same misrepresentation that Dr. Erickson spends the majority of his time on during his interview; the idea that if most people get better it means the virus isn’t very dangerous. Early mortality numbers based only on antigen testing have been in the society-ending range of 4%-12%, but we have known these numbers would come down once asymptomatic or minimally symptomatic cases could be accounted for. If this virus has ‘only’ a 1% case fatality rate, it still has the potential to overwhelm our healthcare infrastructures and kill millions without mitigation strategies. The danger is a product of the per-case risk multiplied by the infectivity, and this virus is both very deadly compared to something like the flu, which is scary enough, and also extremely infectious. A non-dangerous virus could not do to New York and Italy what COVID-19 has done.

“It is not dangerous to go to a restaurant, to go get your hair done, to go shopping.”

Well, it might be actually. I realize things are open now. This virus is very dangerous and unfortunately we do not have a “phenomenal treatment protocol” that renders it harmless. Please make safe decisions for yourself, your loved ones, and your community.


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:

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.

Data Analyst Declines to Analyze Data, Part 1: Home Isolation, Medicare Fraud, and The Flu.

I want to begin by acknowledging that the headline to this article is quite snarky. While I try to write about these issues of medical misinformation with some degree of charity towards those I disagree with (and often fail at that), writing titles to posts doesn’t allow for quite so much nuance; I honestly find it to be the most challenging thing about blogging.

Here is a video that was recently shared on my friend’s Facebook timeline. It is mercifully short (less than 5 minutes) and I have included the link for those who would like to watch it in it’s entirety. My friend is an Emergency Physician in New York state, and she was probably on shift when this was shared to her wall. Later on she did leave her own comments, and I have chosen to include some of them, and snippets of our conversation afterward, in this blog post. Let me tell you why.

This was about the guy in the video, not about me.
I’m pretty sure.

I tend to believe that while the people generating these conspiracy theory videos are motivated by desire for some combination of fame, power, or fortune (and this video may well be an exception to that) the people who are sharing them widely on social media and forming opinions based on them are more victims than accomplices. They are being given false information exactly calculated to appeal to their fears, their political leanings, and their preconceptions, and they are deciding to place their trust in these so-called experts because they themselves do not have the background or knowledge base to parse the information on their own. Without a background in statistics, medicine, epidemiology, etc. they feel they have no choice but to trust one “expert” or the other, and all too naturally quiet their own discernment and choose the one that reinforces their own views. The problem is that while one group of experts have devoted their lives to rigorously studying disease and the human body so that they can help those who are suffering, the other group of “experts” are actually only experts in engendering this sort of trust, and not in the areas of knowledge they claim to understand; they are essentially false information experts.

Because of this, I do try to approach these topics with gentleness, recognizing that it is easy to be deceived and hard to sort truth from fiction. I have that privilege because right now the COVID-19 pandemic has really impacted my life quite minimally, compared to the rest of the world. Katie is still homeschooling and I am still going into work. We haven’t hit a surge yet and so while I have seen COVID-19 patients, and we have had some deaths due to the virus in Waco, I am not being called upon, at this time, to work extended hospitalist or emergency room shifts trying to care for patients in an overwhelmed hospital with physically and emotionally exhausted staff and colleagues.

But my friend is working under exactly those circumstances, and if she’s a bit more adamant than I am about how hurtful, how dangerous, and how dehumanizing these types of nonsense and lies are to not only the victims of this terrible virus, but also to the healthcare workers fighting it… well, I think she’s perfectly entitled. Please trust me, if she found these falsehoods shared on her Facebook wall by friends or family members when she came home from a shift where multiple patients died or were admitted to the ICU due to COVID-19, she could be considerably more vociferous if she chose.


I’d like to devote a separate essay to the the main point of his video, which to him constitutes “100% proof” of fraud and a major international conspiracy lead by WHO and the CDC, and apparently involving doctors and healthcare workers across the globe. This revolves mainly around CPT codes, and the “two CPT codes” being used for COVID-19 in order to cook the books “right in front of your eyes.” We are going to go into this in more detail, hopefully sometime in the next 2 days, but first I want to discuss the other issues he raises in the video.

Home Isolation

At the 1:46 mark of the video, Mr. McCarthy says, “Here’s a document from the CDC dated July 2020 (Note: this means that the article is due to be published in July, not that this article is from the future, as helpful as those would be if we could get our hands on them) that clearly states…”

“In addition, our findings suggest that home isolation of persons with suspected COVID-19 might not be a good control strategy (McCarthy: Oh there’s a shocker!). Family members usually do not have personal protective equipment and lack professional training, which easily leads to familial cluster infections.”

He concludes, “meaning it’s making it worse, not better folks!”

This is a direct quote from the study below (image links to full article on CDC website).

His point here seems to be that having people who are actually suspected of having the virus stay medically isolated at home is actually worsening the pandemic. Which is… pretty nuts. We are not even discussing broad based social/physical distancing measures and shelter in place orders here, but actual management of suspected cases. It’s hard to imagine in what way, or compared to what strategy, having these patients isolate at home would make things worse. Would he prefer for patients with suspected COVID-19 just go back to work, despite their cough and fever, and wait for their test results? Does he think that patients wouldn’t be in their homes exposing their families at all if not for doctor’s orders? He doesn’t say, but the implication, in the context of the rest of the video, is that having patients who are actually ill keep themselves at home and away from the general public is yet another tool of the COVID-19 conspiracy… As opposed to being a common-sense step we already take for pretty much every other contagious illness.

It’s hard to know whether Mr. McCarthy is simply confused in thinking that the article’s point is that home isolation is too draconian, or if he is intentionally drawing the wrong conclusion in order to deceive his listeners. Sadly, I think it must be the latter, because the very next sentence of the article reads as follows:

During the outbreak, the government of China strove to the fullest extent possible to isolate all patients with suspected COVID-19 by actions such as constructing mobile cabin hospitals in Wuhan, which ensured that all patients with suspected disease were cared for by professional medical staff and that virus transmission was effectively cut off.

So the opinion of this articles authors is that having suspected COVID-19 patients isolate at home is not nearly extreme enough to prevent spread of this virus, and that patients should be kept in mobile hospitals instead. Considering that his very next point is that hospitals are manipulating the COVID-19 data to make money, we must concluded that his omission of the very next sentence and his substituting his own conclusion, which is the exact opposite of that drawn by the study’s authors, is actually intentional.

Hospitals are miscategorizing people as COVID-19 patients because of the CARES Act.

This claim, which is implicit throughout the video, is explicitly stated at the 2:56 mark:

“All they have to do is use the right code! Why aren’t they using it? Because the average COVID-19 case for medicare or medicaid is between $13,000 and $100,000 right now folks. So by flipping this number to this number (pointing back to the CPT codes), the hospitals are making a tremendous amount of money off of medicare and medicaid… It’s absolutely fraud.”

Now, there’s a lot wrong and just plain silly with his take here. There’s the fact that our healthcare costs in this country are so inflated (largely because of the hospital-insurance company arms race) that those numbers, which he means to be a ‘they are charging how much!?’ moment… really aren’t all that shocking (also, that’s a pretty big range there). There’s the fact that using one COVID-19 code vs. another based on whether a test was positive isn’t going to affect billing or epidemiology data (we are going to go into this in more detail in the next blog post). And there’s the fact that this really does seem like the type of information that, like the last example, actually proves the opposite of his point if it proves anything at all. Many patients with COVID-19 are incredibly, unbelievably sick and require high levels of support and prolonged hospital stays (we have been closely following the story of a man here in town, a friend’s brother, who has only just returned home after over a month in the hospital, including an extended ICU stay), and quoting numbers about the exorbitant expenses associated the disease really shows two things; we need to move away from a for-profit model of healthcare in this country, and this is a very, very bad bug.

But unlike nonsensical theories of 5G towers reprogramming our DNA or defeating COVID-19 by doing a cellular health detox cleanse, most Physicians are not so quick to dismiss the idea that some in hospital administration and corporate medicine might see government provision for COVID-19 treatment, such as that provided in the CARES Act, as an opportunity to profit; or at least to make up for lost revenue from cancelling elective surgeries and decreased admissions leading up to any COVID-19 surge. I have known hospital and clinic administrators I trust implicitly, and I have known hospital administrators who have lied directly to my face; but most probably fall into a very broad category of people who just have different values and convictions around what medicine is supposed to be than I and most other Physicians hold to. At the end of the day, I tend to think it’s a bad idea in general to have the practice of medicine driven by, in so much as it is driven by, people who have studied and been hired to increase profits and market shares rather than people who have taken an oath to do no harm and to aid the suffering. It would be somewhat naive to expect that dynamic to disappear entirely in a pandemic.

But let me be clear; if a handful, or even a large number, of unethical hospital administrators are actually trying to commit fraud to gain access to additional payments related to COVID-19, either by attempting to influence clinician decision making or by actually modifying medical records, those people should be convicted. But even if this were the case, I do not believe for a moment that such activity has any way of significantly changing the hard data we are seeing, for a few reasons.

First and most importantly, the numbers we are seeing do match the experiences of doctors and nurses on the ground. Doctors have a good gauge for what a bad flu season looks like or when a viral GI bug is going around, and generally have a bead what is happening with the health of their communities. It is absurd to believe that doctors and nurses who are suddenly fighting for their own and their patients’ lives against this horrible virus have all been wrapped into some big conspiracy to profit hospital administrators and stock holders. That’s why the ‘hospital administrator cooking the books’ (note to self: new idea for a Les Mis parody song) idea tends to be a final redoubt for conspiracy theorists once they have been confronted by actual doctors and nurses, who in the cultural atmosphere since COVID-19 they no longer feel they can get away with calling liars and conspirators directly to their faces.

But it also doesn’t make any sense to equate medicare or medicaid fraud related to COVID-19 to an inflation of the epidemiology data, because even if EVERY hospital administrator were in on it, they would still have very limited influence on that data. They would not, for instance, be driving to community based and free standing labs to convince lab techs to report positive tests, so they would have a better COVID-19 paper trail if those patients showed up in their ER’s later. They are not going to unaffiliated, clinics and underserved healthcare centers and convincing Physicians, NP’s and PA’s to fudge their evaluations to make COVID-19 look more prevalent. They are not telling ICU and Emergency Room doctors when a patient’s respiratory status is sufficiently dire to require a ventilator (I have actually heard of such cases in the past, and those administrators were promptly reported for practicing medicine without a license), and at any rate if they were they would be ignored. They are certainly not killing people; it is the virus that is doing that.

Just like with pharmaceutical companies, insurers, drug reps, home medical equipment companies, and so, so many other players in the healthcare arena, Physicians have complicated and often antagonistic relationships with hospital administrators. But even if you believed that every single hospital administrator were corrupt and currently working overtime to try to game the COVID-19 situation, there are just so many other people involved in tracking this data. There are epidemiologists and infectious disease doctors, the local public health department, the coroner’s office, local and state government officials of all political influences, and many, many people evaluating this data from every possible angle to see what we might be missing, or what patterns might help us be prepared for what comes next. And finally there are the people living through this pandemic; the doctors and nurses and respiratory therapists, yes, but also the patients, those living and those deceased, and their friends and family and loved ones. These are the people who are robbed of their dignity and their opportunity to grieve and process in peace when people like Daniel McCarthy erroneously claim that COVID-19 is being blown out of proportion to make money for a fairly small group of businessmen.

The flu kills more people anyway.

It’s hard to know exactly what point he’s trying to make by touching on influenza death and hospitalization data toward the end of the video. My hope is that he’s merely pointing out the importance of having reliable data. If so, I would agree with him, although from the rest of the video I don’t think I would trust him to recognize it once we had it. Unfortunately, however, I think he is simply reviving the ‘it’s just another flu’ rallying cry that we’ve heard consistently for months from those ignoring the realities of the COVID-19 situation; if that wasn’t his intent, my apologies to Mr. McCarthy; it’s a good thing for us to talk about here at some point anyway.

I’m honestly so sick to death of this one. It is the end of April and I am sure that this has been explained to Mr. McCarthy several times by now, so I can only assume he has chosen to perpetuate the lie that COVID-19 is ‘basically just like the flu’ because it fits with his narrative, and not out of actual ignorance. I hope I am wrong about that. I won’t go into extensive detail (I have included a link to an article below), but essentially the flu is a partially vaccine-preventable virus that demonstrates seasonal prevalence and has a high rate of mutation. Because of this, epidemiologists have to try to predict which strains of seasonal flu are likely to be prevalent in the coming flu season so that vaccines can be prepared. Some years these are more effective (and more widely accepted) than in other years, and some years the seasonal flu strains are more dangerous or more widespread than other years. This means that seasonal influenza has the potential to be very, very bad in any given year; but also that there is a high degree of variability. 

In addition to flu vaccines, there are several mitigating factors that help keep the flu from overwhelming our hospitals and healthcare infrastructures every Winter. First, flu season is fairly long; usually above 3 months, with a high degree of chronologic and geographic distribution. This means while hospitals are sometimes extremely taxed by the flu, it is rare for them to actually be overwhelmed; though there are certain years and certain locations that come very close. If you consolidated the impact of even a light flu season into a 1 month period, affecting every community in the country at roughly the same time, it would absolutely overwhelm our healthcare systems and people would begin to die not just from the flu but also from our inability to provide care for other conditions while battling it; and this is exactly what COVID-19 does threaten to do (and has done) because of it’s much higher degree of infectivity and, likely, higher degree of asymptomatic or minimally symptomatic spread compared with influenza. 

Second, we know the flu is coming. Each year Physician, Nurses, and other healthcare workers make strategic decisions leading up to flu season. When I have taken leave to work internationally, we have always scheduled that time during the late Spring or Summer, when I knew I would be less needed because we wouldn’t be in the midst of fighting the flu. Staffing decisions and other resource organization is made based on the expectation of a surge, even if the exact timing and parameters of that surge are unknown. With COVID-19, there was no preparation time in those regions that were hit earliest, and the rest of us have been scrambling ever since to ensure that our systems are ready for a surge that is unpredictable because there are no decades of past data to help us now what to expect at our hospital or in our region.

Third, we already how to deal with the flu. While influenza seasons and symptom clusters do vary, the syndrome is very recognizable and we generally have a good idea of what to expect with flu cases, and how they interact with other acute and chronic illnesses. As several quotes I’ve read recently have said, “The flu is an old enemy.” Yes, it is a very, very dangerous enemy, but it is definitely ‘the devil we know’ compared to COVID-19. We have years of research and clinical experience to help us. We know which medications have modest therapeutic benefits and which have none, and what strategies to use when patients present for dangerous complications of the flu, such as post-influenza bacterial pneumonia, or when it causes complications in preexisting lung disease. With COVID-19, new data is still emerging continuously about both the strange spectrum of harm that this virus causes, and the possible treatment approaches; those fighting the virus later in the course of this pandemic really do stand a better chance of both diagnosing it accurately and treating it effectively. 

Finally, the flu itself is already bad enough, and dismissing COVID-19 as ‘basically another flu’ just shows how the people spreading these ideas are already in the habit of dismissing incredibly dangerous infectious illnesses. Already COVID-19 has killed more people in the US than almost any flu season, and yet people are still waving it off as ‘another flu’ the way they were weeks ago when it had ‘only’ killed a few thousand. In the coming days the total number of deaths in the US will surpass the 62,000 mark set by the 2017-2018 flu season, the worst we’ve had since I’ve been a Physician. Once this benchmark is passed, will these conspiracy theorists finally abandon the ‘it’s just like another flu’ argument, or would they like to hold on to it until COVID-19 has actually surpassed the numbers set by the Spanish Flu pandemic in 1918?

https://www.sciencealert.com/the-new-coronavirus-isn-t-like-the-flu-but-they-have-one-big-thing-in-common

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.