6%

One thing that has become predicable throughout the SARS-CoV-2 pandemic is that any story, any recommendation, any development, or any piece of data that can be interpreted as meaning that the danger of COVID-19 has been inflated, misrepresented, or exaggerated by medical experts will be interpreted that way by a large percentage of our population. This is no longer surprising, but honestly it’s also completely understandable. We all hate this pandemic. Whether you are working on the front lines in clinic or in the trenches at the hospital treating COVID-19 every day, whether the virus has harmed or killed a friend or family member, whether your job or business has been affected, or even if you just really miss people, we are all ready for this to be over. The hard path forward involves biomedical research, redoubling mitigation efforts that we are all exhausted of, and at this point, modifying holiday plans and preparing to deal with the quagmire of cascading clinical probabilities that are required to fight the virus in the midst of cold and flu season. But the quicker and easier path to getting rid of this hated virus is undoubtedly to just choose not to believe in it at all. And while this “just don’t believe in it” approach is likely to be about as effective as it has been for any of the other problems I’ve tried it for (taxes, bills, excess carbs), I am sympathetic to the appeal of it. If the pandemic has not affected you directly- or maybe even if it has- it may be very tempting indeed to buy into a video like Plandemic, which tells you that the whole thing is just a government conspiracy, or into the America’s Frontline Doctors‘ video which tells you that there is already an easy and inexpensive cure if you just drive to the see the right doctor. Life can be normal again right now, these sources say; all of your hopes are true and all of your caution and privations can finally come to an end. I’m not saying it’s right, I’m just saying I get it.

But what has been surprising- and consistently surprising, to me at least- is which wild facts people will latch onto to create these false narratives. Before today, I would never have expected this paragraph from the CDC’s weekly updates by select demographic and geographic characteristics to be the next cause of viral misinformation:

Yet here we are.

What is the claim being made?

If I chose to end this blog after today, I would feel I had really come full circle; my very first blog post was about the myth, popular late in March (and persistent even today), that doctors were lying on death certificates to make the virus seem more dangerous than it really was. Today’s myth is that analyzing the diagnostic codes on death certificates –those incorruptible sources of reliable data- reveals that the virus isn’t actually very dangerous at all, and the CDC has just admitted to it. Bypassing the irony that this later misinformation is being circulated by exactly the same people who have been sharing the first for months, we can spend today’s blog post (48 hours late as usual, this time because our internet was out all day yesterday!) analyzing these claims. They seem to have taken two forms.

The first, and more moderate, is to claim (or at least strongly imply) that because 94% of deaths from COVID-19 also had other diagnostic codes listed on the death certificate, it means that people without ‘underlying medical conditions’ are not actually at a very high risk of dying from the virus. And in one sense this is true, even if this new data from the CDC doesn’t actually really have anything to do with that. Your Local Epidemiologist says this better and more succinctly than I can:

And she’s absolutely right; we have been saying this from early in the pandemic. But not just saying it; thinking it and believing it, too. Every decision I make as a physician, from admitting someone for COVID-19 to starting or stopping a medication, referring them to a specialist, or even recommending exercise or lifestyle changes has to take into account their medical history (and a host of other factors). While there are some symptoms we can warn everyone about, the counseling and support we provide for patients seeking evaluation and treatment of COVID-19 has a lot to do with their individual risks from the virus and how it might manifest in their lives based on their age and other medical conditions. This 6% misinformation became viral just yesterday, yet if you asked any doctor last week they would have already told you that the younger and healthier you are the less likely you are to end up in the hospital or die from COVID-19, and the more medical complications you have the more concerned they are about you having the virus. I know because this is exactly what I was saying to people in clinic last week, and the week before that, and the week before that. Yes, many young and otherwise healthy people have died tragically and shockingly from complications of the virus; but this is still a rare occurrence on the whole compared to the number of young, healthy people who have had the virus. When I counsel people at low risk of complications from COVID-19, we of course talk about the signs and symptoms they should watch for that would trigger a trip to the ER, like chest pain and shortness of breath; but I also want to make sure they aren’t sitting at home, anxiously wondering when the virus is ‘going to get them’. I want them self-isolating; I don’t want them to be afraid. But this relative reassurance towards the young and healthy is actually undercut ever so slightly when you combine headlines like these with the actual data being reported from the CDC, which I’ve included below.

When you look at the other diagnostic codes listed in the table above, you will notice that codes like E78.2 and I10 are listed; high cholesterol and high blood pressure, respectively, both conditions I’ve been diagnosed with in the past (and probably still have, if I would ever go get a check-up. Doctors really do make the worst patients). At 35 and having never spent a night in the hospital as a patient in my life, nobody would call me high risk for complications of COVID-19. In fact, if I contracted COVID-19 and died of it this week, two things would happen. First, my blog would probably get a lot more hits for a couple of days (and this paragraph in particular would seem very bitterly ironic). But second, I would be held up as an example of how being young and in relatively good health is not a perfect guarantee of safety from the virus. Yet I would be a part of the 94%, not the 6%.

The reality is that in saying “94% of COVID-19 deaths had underlying conditions,” these stories are adding nothing to and are in fact dumbing down the more sophisticated knowledge we already have, and share with our patients daily, of the most important risk factors and conditions that predispose someone to COVID-19 being a likely threat to them. They are meant to lure you into a false sense of security, because it’s so easy to think they mean somebody else besides you (even if you do in fact have some of those diagnoses, like I do) and a relatively small group of people. But when I look at the chart, I realize that even I fall into that group with “2 or 3 underlying medical conditions” that they are saying 94% of the COVID-19 deaths occurred in; in fact, most Americans do. And when a statistic includes me, privileged to be in pretty good health as I am, but also my patient battling metastatic kidney cancer and my patient suffering from both CHF and COPD, maybe it just isn’t a very useful statistic in the first place.

But the more dishonest and blatantly ridiculous claim, which has absolutely no justification, is to say that only the 6% of deaths with just COVID-19 listed on the death certificate actually count as COVID-19 deaths. Take this one Facebook poster who has been widely shared, who had the gall to take this to the next step and “calculate” that only 9,210 people had “actually died from Covid.” Probably because she was willing to put a number on the deaths, this post has been shared 21,000 times on Facebook; but it’s hard to believe that someone with a doctorate degree, any doctorate degree, could have such little grasp on basic statistics.

No, No, No.

This post entirely misrepresents everything within our complex understanding of medicine regarding the impact of medical comorbidities, the myriad causes and steps leading to death in COVID-19 or any other illness, and even the very process of completing a death certificate. In her estimation, Dr. Hesse is saying that a diagnostic code on the death certificate other than COVID-19, literally any other code, is sufficient evidence that the patient did not die from COVID-19. This is not only preposterous and dishonest but also just plain silly. We are going to explore these issues more thoroughly in the next section, but briefly, just look at the chart above and begin googling ICD-10 diagnostic codes for yourself to test the logic of her interpretation. Yes, I can absolutely believe that some of the patients whose death certificates reflect both COVID-19 and also diagnosis code C71, Malignant neoplasm of brain, may actually have died from the brain cancer and were only found to have the virus incidentally. We can’t tell from the data if that did in fact happen, or how many patients might have such a presentation. But with COVID-19 being an acute illness and brain cancer being a chronic illness, the disease and treatment of which also predisposes you to infectious illnesses, it is at least as reasonable to assume that the majority of patients who died from “COVID-19 and brain cancer” actually died from COVID-19, which they were more vulnerable to because of their pre-existing brain cancer.

But Dr. Hesse’s assertion that only the 9,210 “COVID-19 only” deaths should count also has to stand up to scenarios like, say, any hypothetical patient who was certified as dying with COVID-19 and R09.3, Abnormal sputum, or COVID-19 and N20.0, Kidney stones. Again, we can’t tell from this data whether any such patients with only those codes exists; but neither can Dr. Hesse, and for her argument to be valid, each and every possible diagnostic code included in the chart above would, if added to a COVID-19 death certificate, nullify COVID-19 as a primary or contributing cause of death. That is what she is saying, and it is obviously ridiculous. What this error betrays is a complete misunderstanding, whether intentional or accidental I know not, of how death certificates are completed and the information they are meant to capture. Even though it means a longer essay, I do think it’s worth taking the time to revisit this again.


What information do we include in a death certificate?

Once you have been trained to complete death certificates (and have actually done it), this “6%” argument is not even momentarily tempting or convincing. I know what you are thinking; “but TJ, we haven’t been trained to complete death certificates, so you are asking us to trust you with this area of specialized knowledge we don’t have access to.” Well good news reader, the Texas Department of Health and Human Services, DSHS, has got you covered. If you want to understand this 6% statistic from the CDC, I highly recommend that you watch from 1:44 to 3:08 of this video.

Sorry, the secret tutorial video they released after COVID-19 is password protected.
Also, that was a joke.

Obviously each state will have its own version of this software, but they are all intended to convey the same information; the death certificate is not a high-stakes multiple choice interrogation asking the doctor, “What disease caused the patient’s death? Was it COVID-19 or heart failure? ANSWER THE QUESTION!” Rather it is an opportunity to distill the sequence of events leading to the patient’s death, recorded in greater detail in the medical record, into a structured narrative that explains how they died. When a doctor includes coronary artery disease on the death certificate, they are not making a political statement or a value judgement, but rather an honest reflection of the part this disease played in the patient’s death based on their medical knowledge and their intimate understanding of the progression of illness as the patient’s treating physician. And it is exactly the same with COVID-19. Moreover, this is not something that the physician derives a financial benefit from or an opportunity to defend the medical care the patient received (in fact, I have listed iatrogenic injury on the death certificate when I felt that my own mistake or that of another medical professional contributed in some way to the death of the patient), but rather something that is important for public health information and, in various ways, important to the family of the deceased.

Briefly, I’d like us to complete a medical certification for a death certificate together, again using my hypothetical death from COVID-19 as an example. In this scenario, let’s say that I get sick with cough and loss of taste and smell this week and am diagnosed with COVID-19. Around day 10 of my symptoms I begin to experience chest pain and shortness of breath, and I go to the ER. There I am found to be hypoxic and my chest x-ray shows bilateral peripheral consolidation consistent with ARDS. they begin to treat me with dexamethasone, remdesivir, and oxygen. Over the next few days my respiratory distress increases and, even allowing some permissive hypoxia in order to avoid intubation, the doctors simply cannot keep my oxygen level within safe parameters; they make the difficult decision to intubate me and put me on a ventilator. I am ventilated in prone positioning using the latest and best evidence-based ARDS/COVID-19 ventilation strategies from the genius doctors over at EmCrit and PulmCrit. Unfortunately, I continue to become progressively, severely hypoxic, and eventually suffer cardiopulmonary arrest. Resuscitation is attempted but ultimately efforts to revive me prove futile; the lungs are not compliant, effective ventilation still cannot be achieved, and return of spontaneous circulation is impossible. I’d make a joke about making the life insurance check out to my wife, etc. at this point, but honestly when I reflect on how many people have died from this sequence of events over the past six months, it’s pretty sobering. I’ve made myself sad just now thinking about all of the families that have lost a mother, father, sibling or grandparent in exactly this way.

Once I’ve died, the doctor treating me will have to record it in a death certificate; we can use the Texas system, since it’s what I’m familiar with.

Here in Part I we list the immediate cause of death. In my case, it’s going to be cardiac arrest. Because this is technically the immediate cause of death in every death except those caused by brain death, some doctors would leave this out. Since resuscitation efforts were made and the arrest was a distinct medical event, I would probably include it, but an argument could be made either way. Next we need to describe the events that led to this. I’m not going to include respiratory arrest because I would feel it was a bit redundant, and besides, I was already not breathing on my own when the cardiac arrest happened since I was on a ventilator. Instead, I would say the arrest was due to respiratory failure. The respiratory failure was due to ARDS, Adult Respiratory Distress Syndrome, and you could make a case here for including viral pneumonia as well. Finally, the ultimate cause of this cascade of complications is my infection with COVID-19.

Next I would need to list any other contributing factors in Part II, and here is where the quandary usually comes in, because now I have to decide whether my high blood pressure and high cholesterol belongs in Part II, “other significant conditions contributing to death but not resulting in the underlying cause,” or in Part I further down in the chain of events. In this case it’s easy; my high blood pressure is a significant medical issue and made me at higher risk from the virus, so it belongs in Part II; but it didn’t cause me to get COVID-19, so it doesn’t belong in Part I. My chronic right shoulder pain didn’t contribute at all and gets left off the death certificate. These decisions aren’t always easy; sometimes a condition did lead directly to death in chain of events that are causative narratively even if not pathophysiologically; for instance a patient who is hospitalized for a hip fracture and then develops sepsis from a central line. The hip fracture didn’t cause the infection that kill them, but it was a direct part of chain of events. But what about the vertigo that caused the fall that caused the hip fracture; does that belong in Part I or Part II? I have a physician friend who works in hospice care who completes death certificates almost every day (I have completed maybe a dozen); he says this is typically the hardest decision point when it comes to completing a death certificate, deciding what was really a cause and what was ‘only’ a contributing factor. Still, it’s straight forward enough in my hypothetical case, and we can finalize my death certificate as follows:

Cause of Death – Part I:
IMMEDIATE CAUSE
a. Cardiac Arrest.
DUE TO
b. Respiratory Failure.
DUE TO
c. Adult Respiratory Distress Syndrome.
DUE TO
d. COVID-19.

Cause of Death – Part II
-Hypertension, Hyperlipidemia

So, for young, relatively healthy me who died from the most stereotyped and straightforward case of severe COVID-19 I can conceive of, we have 5 other diagnostic codes listed on the death certificate between direct cause conditions and contributing conditions. Contrast that to what a Texas death certification with only the diagnostic code for COVID-19 -the only types of death certificates Dr. Hesse believes count as COVID-19 deaths- would have to look like:

Cause of Death – Part I:
IMMEDIATE CAUSE
a. COVID-19
DUE TO
b. ________________________
DUE TO
c. ________________________
DUE TO
d. ________________________

Cause of Death – Part II
________________________

My friend, the hospice doctor, has completed over 500 death certificates (a conservative estimate) since finishing residency a few years ago. He says he has included just one diagnostic code alone maybe twice. What Dr. Hesse sees as the ‘real’ COVID-19 deaths, these 9,210 death certificates without any other documented diagnoses, I see as an anomaly; I am forced to ask myself how that many death certificates were complete in what I consider to be such an incomplete and insufficient manner. I have two theories, aside from some doctors simply not giving the proper attention to the task that they should have or not understanding the importance of completing the death certificate thoroughly. One is that some of the doctors who have been taking care of patients in this pandemic simply might not be familiar with how to complete a death certificate. This pandemic has brought doctors out of retirement and graduated 4th year medical students months early to shore up the frontlines; surely some just haven’t had even the 5 minutes of training from the video above and don’t know how to complete the forms properly; frankly it’s a low priority in their training right now. But second, some of the death certificates for COVID-19 patients have been completed by doctors who were incredibly overwhelmed. When we consider places like New York City, where doctors and nurses were dropping from exhaustion during shifts and barely had time to document at all, and were seeing multiple deaths per shift, each and every shift for weeks, it is reasonable to expect that some of those doctors no longer felt that taking the extra time to document a complete death certificate series of events was a priority. I can’t argue with them; it wouldn’t be. As important as the death certificate is to the patient’s family and for public health purposes, it is a low priority in a crisis when your time would otherwise be spent taking care of living patients or trying to shore up your own physical and mental reserves. If this is the case, the doctors who typed “COVID-19” and submitted the death certificates probably had no idea that such an action would contribute to even more dangerous medical misinformation threatening to extend the pandemic a few months later; a lesson in unintended consequences.


So what do all of these other codes mean?

There are many ways to interpret the diagnostic codes listed in the comorbidities table from the CDC’s latest update. We could spend hours in speculation, wild surmises, or careful parsing and analysis (if you’re a nerd) to try to recreate the narratives of the deaths represented by this data. The amount of analyzing, explaining, and even guesswork we could devote to this is endless. But briefly, I’d like to explain how to understand the majority of these diagnostic codes and the diseases, conditions, or symptoms they represent by considering them in three large categories.

Other ways of describing COVID-19.
The first category that these “other diagnostic codes” fit into is simply other ways of describing the symptoms and complications of COVID-19 itself. If I treated you in the hospital for a CVA (cerebrovascular accident; a stroke), but I also added on diagnosis codes for right arm paralysis and slurred speech, you wouldn’t review the medical record and say, “see, I wasn’t treated for stroke after all! They were treating me for right arm paralysis and slurred speech and just added that ‘stroke’ code on because Dr. Webb probably gets some sort of kickback for it.” The paralysis and the slurred speech delineate more specifically which stroke symptoms you experienced; their inclusion creates a more complete record of your presentation and treatment. In fact, it isn’t at all uncommon to have multiple diagnostic codes that actually say the same thing, due to different doctors and different departments interacting with your medical chart and, again, for the sake of completeness. If I have already added “slurred speech” to your chart, the neurologist later adding ‘expressive aphasia’ doesn’t actually add anything to your medical record (except a little reminder that she’s smarter than me); but it might be more appropriate to document it this way for the referral to speech therapy she is ordering for after your discharge, or to have this diagnostic code associated with the MRI. The synonymous diagnostic codes are repetitive, but it doesn’t necessarily follow that they are redundant

Now apply this logic to death certificates and COVID-19. We’ve already discussed that most doctors would like to be as complete and thorough as possible with death certificates and that it is somewhat odd to list only one diagnostic code without providing a fuller narrative. When we see diagnostic codes like J96 (respiratory failure; 54,803 cases), R09.2 and I46 (respiratory and cardiac arrest, 3,282 and 20,210 cases respectively), and J12.9 (viral pneumonia, unknown number of cases, but contained within the “Influenza and Pneumonia” group), all the doctor is doing is using additional diagnostic codes to clarify the events affecting the patient’s lungs that led to death. In fact, it would not be inappropriate to include all four of these codes for many COVID-19 deaths, because the natural history of viral pneumonia due to COVID-19 leading to respiratory failure and eventual arrest is unfortunately far too common. The same applies to codes like A40 and A41, Sepsis (14,053), which is not even a diagnosis in itself but a syndrome describing the body’s systemic reaction to infection, and many of the “all other conditions” codes like R09.1, pleuritic chest pain and R09.0, hypoxemia.

But the most obvious example is J80, Adult Respiratory Distress Syndrome (21,899 cases). This is literally the severe respiratory syndrome caused by COVID-19, yet people like Dr. Hesse who claim to have evaluated this data carefully did not include these deaths in their “real” COVID-19 death count. To be clear, if a patient’s death certificate listed only COVID-19 and ARDS, these medical misinformation hucksters wouldn’t count them; that patient died of ARDS, they would say, not COVID-19. It’s like saying someone didn’t die from falling off a plane without a parachute, they died from the landing. It’s the bad dad joke of medical misinformation and the clearest piece of evidence we have that those originating this narrative are either extremely unqualified to interpret this information… Or else are not in earnest with their conclusions, but instead are pushing misinformation intentionally from what motivations and purposes I cannot say. 

Conditions that really do make COVID-19 more dangerous.
Much of the work I have seen refuting the “6%” misinformation so far has focused on the concept of comorbid conditions or medical comorbidities. Simply stated, these are diseases or conditions that make us more susceptible to other disease processes or more likely to have complications from them. Some of these diseases are also extremely dangerous in themselves, and others are primarily dangerous because of their role in predisposing to other conditions. A good example of the former is Congestive Heart Failure (I50, 10,562 cases). This is an extremely dangerous, chronic disease that has a fairly low 5 year survivability from the date of diagnosis (average of 62%, but as low as 48%, in African American men because of healthcare disparities). You can absolutely die of complications from heart failure, but it also increases your risk for many other diseases and infections. It is both a primary cause of death and a comorbidity, and without a more detailed dataset or an intimate understanding of each case, we cannot possibly say how many of the 10,562 people who died with both COVID-19 and heart failure died from heart failure complicated by COVID-19, from COVID-19 which they were more vulnerable to because of heart failure, or from a more complex clinical picture that involved heart failure, COVID-19, and other contributing factors. But is this information going to change anything for us? The medical misinformation spreaders want you to believe that all 10,562 of the people who died with both heart failure and COVID-19 died at the time they would have from their heart failure with or without a viral pandemic. They want you to believe this based on nothing other than the fact that it fits a more comfortable narrative; but it flies in the face of what we are hearing from doctors, nurses, family members, and patients of those with heart failure about the way that COVID-19 affects those who are already suffering from these types of chronic illnesses.

Other examples in this category include renal failure (N17-N19, 13,693 cases), COPD and other chronic respiratory disease (J40-J47, 13,780 cases), and quite a few of the “other conditions and causes” listed, such as N04 (Nephrotic Syndrome), L93 (Systemic Lupus), and of course B20 (HIV), just to name a few. The people spreading this misinformation are putting the people with these illnesses at greater risk, specifically, by either pretending that COVID-19 is not a threat to them (the “only 6% count” crowd) or by seeming to claim, callously, that caution as a society isn’t warranted on their behalf (the “94% had comorbidities” crowd).

But within this category we also include diseases that are not likely to kill you on their own, and which would have almost certainly been included on the death certificate due to the physician’s conviction that they made the patient more susceptible and less able to resist the complications of their COVID-19 infection. These include Obesity (E65-E68, 5,614 cases), Alzheimer’s disease (5,608 cases), and of course other types of dementia (F01 and F03, 18,497 cases). Do we really believe that a patient with COVID-19 and obesity listed as their causes of death have died from obesity, and that their having COVID-19 was a coincidence? That is not something that happens. Dementia in particular is an interesting conundrum, because with COVID-19 harming so many people in nursing homes it is potentially not only a physical risk factor, which it most certainly is, but also an epidemiological risk factor; many doctors might include a patient’s reason for living in an assisted living facility, such as dementia or disability, within the death certificate as part of the narrative of how the patient came to be exposed to COVID-19, the same way we might list arthritis on the death certificate for a patient who suffered a heart attack during physical therapy. Again, these are not competing diagnoses that draw responsibility for the death away from COVID-19, but rather a fuller picture (that is, as full as can be told with diagnostic codes alone outside of the full medical record) of the patient’s story leading up to their death.

Finally, a few categories of disease deserve some extra discussion, and those are diseases that could cause death all on their own but almost certainly didn’t for the patients reflected in these death certificates. Hypertension (I10-I15, 35,272 cases) is incredibly common and usually leads to longterm organ damage rather than acute crises, but can present with severely elevated pressures that lead to stroke or another vascular event. However, this would typically be indicated with the diagnosis code I16, hypertensive crisis or I16.1, hypertensive emergency, which are specifically not included in the diagnostic codes for the hypertension group in this table. It is possible that this is just a common coding error on death certificates, but I doubt it; if the physician believed that the severity of the patient’s hypertensive crisis led directly to their death, they would likely take pains to emphasize this on the death certificate; applying a code for essential or secondary hypertension instead suggests that they regarded it as a comorbidity or at most a contributing factor. Diabetes (E10-E14, 25,936 case) is another example. Diabetic Ketoacidosis (DKA) is a severe metabolic disorder that often requires ICU level care; but this is primarily due to how labor intensive it is to treat, and the mortality rate remains low. These 25,936 people who had both COVID-19 and diabetes did not die from DKA, which accounts for less than 2,500 deaths annually. Instead, both diabetes and hypertension, just like dementia and obesity, are comorbid conditions that make the patient more susceptible to and likely to experience worse outcomes from other diseases, and as such their role in this list of additional diagnostic codes on COVID-19 death certificates is the same as their role in death certificates for patients who die from stroke, heart disease, and influenza; yet no-one is claiming that because a patient had high blood pressure and diabetes, their death from the flu didn’t count.

Conditions that might have nothing to do with COVID-19 and might have actually caused the patient’s death (maybe)
Finally, we have conditions that, based on the diagnosis code alone, we know to be incredibly dangerous and also to be common causes of death. Some of these, like certain cancers (C00-C97, 7,415 cases plus some of the ‘all other conditions’ group) we can treat similarly to heart failure or COPD; they may predispose you to COVID-19 or raise the risk that your COVID-19 course of illness will be severe, or they may be immediately dangerous in and of themselves and be worsened by COVID-19 or not. If someone wants to ask how many of the thousands of deaths that included a cancer diagnosis were actually caused or hastened by COVID-19, and how many just happened have the virus during the days leading up to to death from a terminal malignancy, I think it’s a fair enough question; though from what I’ve heard from friends who provide hospital and hospice care, the former does seem to be very common. In the latter cases, if such cases are at all common, the additional suffering from COVID-19 must be felt in other ways; in the barriers it places to those individuals being surrounded by family and friends as much as possible during their final days. 

We could legitimately ask the same question for some other diagnoses on the list; heart attacks and cardiac arrhythmias (18,103 and 9,812 cases respectively), pulmonary embolism (I26, contained in the 8,743 “other disease of the circulatory system”), and strokes (I60-I69, 7,653 cases) are all very deadly on their own. However, unlike with cancer, which has no known or proposed causal relationship with COVID-19 aside from immunocompromise, the virus is known to cause a hypercoagulable state that has caused all of the above pathologies. How many of the deaths that involved these diagnostic codes were due to these conditions and how many were in turn due to COVID-19 is known only to the doctors, nurses, and family members that were involved in their care. Attempts to make absolute statements that these deaths simply were not caused by COVID-19 (despite the doctor writing the death certificate feeling they the virus did in fact contribute to the death) because another dangerous disease was also involved are based entirely on a desire to minimize the danger of the virus, and not on any interpretation or analysis that can be legitimately conducted from this set of data.

My friend, an ER Doc in New York

The final set of diagnostic codes we need to look at are the 5,133 included in COVID-19 death certificates under the category “Intentional and unintentional injury, poisoning and other events.” We don’t know which codes specifically show up in these death certificates, but much like the other ‘other’ catch-all categories it contains diagnoses ranging from S00.37XA, Other superficial bite of nose (a diagnosed I received today courtesy of my 16 month old), to X95.9, Assault by firearm. What is going on here? Much like the “other” diagnostic codes we talked about above, there may be any number of reasons that some of these codes might be on a COVID-19 death certificate. Some may be complications that arose in the hospital, such as SO6.9, Intracranial injury, when a COVID-19 patient experienced a syncopal episode and hit their head. Some may be part of a historical narrative, for instance a patient who experienced a prolonged hospitalization following a V03.10XA, Motor vehicle collision injuring a pedestrian, which ultimately ended when they died from respiratory failure due to COVID-19 contracted in the hospital. Again, without access to the actual death certificates, medical records, and medical staff who treated these patients we simply do not know what circumstances or patient history necessitated the physician to include both COVID-19 specific diagnostic codes and codes for accidents or intentional and accidental injuries in the same death certificate; but it absolutely does not stretch the bounds of credulity to believe that such circumstances do indeed occur.

Nevertheless, I want to cede this point to the conspiracy theorists, if only for just a moment. What if we do “admit” (as ridiculous as it is, and with apologies to the families of the individual people whom these death certificates represent) that each and every death certificate listing one or more of these accidental and non-accidental injuries represents a patient who died from some horrible accident, with COVID-19 just tacked on but clinically silent? You see, since the beginning of the pandemic the conspiracy theorists have been telling us, with no evidence, that “if somebody gets hit by a car they are calling it a COVID-19 death” and “if someone gets shot, they call it COVID-19 to inflate the numbers.” This data, from actual death certificates, now shows that the maximum possible number of such falsified death certificates tacking on COVID-19 to an accidental death is 5,133; compared to 183,000 deaths from COVID-19 and an estimated 80,000 total deaths from accidents in that same time frame. And again, that’s assuming that no other possible explanation exists for those “other accidental and non-accidental injuries” contributing to a person’s death from COVID-19.


Conclusion

Many of the diagnostic codes listed don’t fit easily into just one of the above categories, because we just don’t know enough about the history of the people whose battles with and deaths from COVID-19 are represented here. We don’t know, from this data set, whether the physician completing the death certificate was indicating a new stroke as a primary cause of death, or an stroke that lead to a rehab stay where the patient contracted COVID-19. We don’t know whether diabetes was listed because it was poorly controlled and played a major role in the hospitalization, or whether it was well controlled and was only included because that physician knew that diabetes is a risk factor for the patient’s unfortunate bad outcome from COVID-19 infection. We also have no idea what to do with codes that are so benign in themselves that they don’t really seem to have a place on a death certificate at all, yet the physician clearly regarded as an important part of the patient’s history leading up to their death.

But what we do know, with certainty, is that this new data released from the CDC does not mean. If you’ll spend just a few minutes really looking at the data, at the ages and the conditions mentioned, you will realized that it cannot mean that 94% of the people who have died from COVID-19 were incredibly sick, incredibly frail, and incredibly old people with many other diseases who would have died soon anyway; that argument is as bankrupt in its analysis of this data set as it is ugly in its callousness. That is not what the CDC means when they tell us that 94% of death certificates listed ‘more than one diagnostic code’ or contributing factor, as we’ve clearly demonstrated above. And even if it were (and it’s not), it would not somehow mean that the lives lost to COVID-19 were less valuable; those who see this false idea that 172,000 of the 183,000 people who have died from COVID-19 were sick already as a compelling reason to stop mitigation efforts need to carefully consider whether their only motivation for taking caution has been their own personal health and safety this entire time… And then try to understand why that has not been the sole or primary motive for the rest of us; that the safety of those around us, including the medically vulnerable, is actually sufficient reason for some inconvenience and even sacrifice on my part.

And we also know with certainty that no real scientist, statistician, epidemiologist, or physician, and certainly no one who actually treats patients on their death beds and then completes death certificates to capture the complex and detailed medical events of their final days would ever believe the idea that the 6% of death certificates with only COVID-19 listed as a cause of death represents the “real” death told of this horrible virus; at least not without some herculean effort of intellectual dishonesty and self-deception.

Please keep comparing COVID-19 to Human Trafficking (Part 2).


Trigger warning for human trafficking, rape and sexual assault, sexual abuse of children, and exploitation.


The big question we didn’t address yesterday (well, two days ago now) is whether the people making these comparisons between COVID-19 and cancer or diabetes are doing so because they truly care about those medical problems, like the nurses and doctors who treat them and the patients and their family members who are affected by them every day do, or just because they happen to find them convenient comparisons for minimizing or dismissing concerns about the pandemic. And while using a lifelong illness that causes real suffering like stroke or cancer for rhetorical purposes is a bit calloused, I can’t say I find it truly morally repugnant the way I do when the same thing is done, if indeed it has been done, with human trafficking and modern day slavery. Recently, I have started seeing a few different memes/images shared on social media making just such a comparison; but I believe they have very different degrees of merit and, I’m afraid, might be coming from very different places in terms of degree of actual sincere concern about the very real problem of modern day slavery.

Human trafficking is a truly evil industry. Some of the people who have shared these memes have quoted conservative estimates of 25 million slaves worldwide today; I believe the ILO estimates that are closer to 40.3 million, though even that was back in 2016 and the number is likely to be even higher now. This includes 5 million people, 99% of whom are women and girls, who are victims of sex trafficking and forced sexual exploitation. In addition to being robbed of their freedom and dignity, the men and women affected by modern day slavery suffer extensive medical and psychological problems that can last a lifetime, and many are subjected to nearly constant physical, sexual, and psychological violence, torture, and dehumanization. It is one of the worst offenses against human beings occurring today, and its cost in human lives and suffering is incalculable. In one sense, there can be no comparison between human trafficking and COVID-19, because even the suffering from a respiratory virus that claims your life would be preferable to most of us compared to what is endured by victims of modern day slavery.

I first heard about modern day slavery from my friend Michelle Palmer, co-founder of the blog Tuesday Justice, back in 2008, my first year of medical school. That next year we became involved in grassroots organizations in Denver involved in raising awareness about human trafficking and modern slavery both in the United States and internationally. In medical school I hosted film screenings, attended academic conferences on human trafficking and training with the FBI and GEMS on commercial sexual exploitation of children (CSEC), and once even sat next to the author of The Vagina Monologues on a committee focused on professional collaboration to fight human trafficking in the city and state. When we moved to Waco I got involved with Unbound and eventually became one of their medical professional trainers. Over the last few years myself and one of my clinic partners have trained hundreds of physicians, nurses, other healthcare professionals, and Texas medical students to use their calling in medicine to recognize the signs of human trafficking and help address the unique medical and support needs of survivors, in addition to treating survivors of human trafficking and modern day slavery in our own clinic.

Last week, that partner and I both spent a significant number of hours in full PPE, in the 90-100 degree heat, evaluating, testing, and counseling patients for COVID-19. In 2 weeks, I’m going to lead a group of family medicine residents in a discussion of human trafficking cases; I will be working in the COVID-19 clinic that morning and that afternoon. I recognize that all of this sounds dangerously akin to self promotion, but the reality is that given my privileged position as a doctor and the scope of the problem, I feel that I’ve personally done very little towards combating either COVID-19 over the past 7 months or human trafficking over the past decade. That’s not my point. My point is that there is not a competition of awareness, focus, advocacy, or effort between the fights against these two assaults on our fellow Image-Bearers of God. The people who are fighting human trafficking are often the very same people fighting COVID-19.

And I humbly submit that memes which suggest otherwise may, in fact, be made by people who care about neither.


The Bad

I wanted to start with this one because I believe it’s somewhere in the middle in terms of both dismissiveness about COVID-19 and creating a false opposition between COVID-19 and Human Trafficking advocacy. The meme makes two claims; first a statistics claim about the relative risk of human trafficking and COVID-19, and the second a claim about the increased danger to children posed by masks because it perpetuates trafficking. Let’s look at both.

Though the numbers don’t usually matter much in posts like this one, I always like to know where they come from if possible. I went to the original source, an Instagram user who, apparently, works to promote “vaccine education, toxin free living, and government corruption.” I love it when people have eclectic interests.

At least she’s upfront about it.

Unfortunately, she doesn’t list where her numbers come from or how she ended up with this ratio of 66,667 children sold to human traffickers for every one child that dies of COVID-19, and I’m going to admit that it seems a bit high even to me, someone who leans towards more liberal estimates of human trafficking. The biggest problem with her numbers is that nobody actually knows how many children and adults are bought, sold, and enslaved through human trafficking each year; it’s an illegal, hidden, underground industry and the best we can do is estimate. It’s also very easy to misunderstand what the numbers actually mean; for instance, when experts say that an estimated 200,000-300,000 minors in the US are victimized through commercial sex trafficking each year, this is based on a much smaller number of actual reports, data from homeless youth and runaways, the personal narratives of adult sex workers who entered the life as children or adolescents, internet ads through websites like craigslist and backpage, and a variety of other data sources. Unfortunately, the vast majority of children who are being exploited in this way are not known. If we used this estimate (300,000) of US CSEC victims, divided by her 66,667, it would give us just 5 children in the US to die of COVID-19; since this is nowhere close, this clearly cannot be the figure she is referring to.

The experts I trust estimate that there are about 10 million child victims of human trafficking in the world today ( this number does not include the tens of millions of child brides across the globe, nor young or old adults who have been enslaved ever since they were children), and I think this must be the number of she is thinking of; nothing else even gets us close. Working backwards, this would give us an estimate of 150 children (10 million/66,667) who have died from COVID-19 worldwide. This is probably closer to the number of children in the US that have died from the virus; the best estimates that I can put together would put that number at around 100 (it’s tricky since the best data sources I can find don’t distinguish specific ages within the 15-24 yo age group; I don’t know how many from that age group were older adolescents and how many were actually young adults). We could look at this data from every possible angle (I typed a whole other paragraph on hypothetical calculations and assumptions we could make here, but deleted it; it doesn’t add to the discussion), but ultimately we are going to come out with an estimate that is certainly more than 150 but somewhere less than 1,000 child and adolescents deaths from COVID-19 infection worldwide.

So the best guess we can make is that the original author of this meme is comparing the total number of child slaves worldwide to some estimate she has found of the total number of child COVID-19 deaths that is, at least, on the right order of magnitude. There are at least five big problems with this “calculation” of a child being 66,667 times more likely to be sold to traffickers than to die of COVID-19.

First, the 10 million figure is an estimate of current child slaves, not new child trafficking victims; the idea of ‘being sold by traffickers’ paints the situations of enslaved people around the world as a monolith and ignores the debt bondage enslaving millions of families (which is still strongly associated with physical, psychological, and sexual abuse), which is by far the most common scenario for a child slave today. It also glosses over the many forms of control and exploitation included in human trafficking that don’t involve ‘being sold to a trafficker’, which we’ll talk more about in the next section. Sensationalist language hearkening back to ‘Taken’ is not at all helpful in understanding the scope of human trafficking and modern slavery.
Second, it’s very much an apples to oranges comparison since the 10 million estimate is a cumulative total built up over many years, and the number of children dying from COVID-19 is a total from just a few months of a pandemic; it is a comparison of prevalence to incidence, two very different epidemiological concepts. The total number of children trapped in slavery and the total number of children sold into slavery since February are clearly not synonymous, but the author of this meme has treated them as the same thing; this renders her figure, 66,667 to 1, utterly meaningless, since she isn’t even comparing the things she claims she is, let alone statistics that have a logical basis for comparison.
Third, this really is a straw-man. The discussion of whether or not to re-open schools is important, and the conversations I have every day with parents concerned about the risk of their children being harmed by COVID-19 are addressing very real anxiety. We talked about this with last week’s America’s Frontline Doctors video and will be trying to address it more fully in the coming week. But epidemiologists and physicians have at no point argued that COVID-19 was now the greatest threat to children worldwide; in fact we’ve come home from each and every shift incredibly thankful that this isn’t like the Spanish Flu pandemic of 1918, when children were disproportionately affected and killed by the virus. If it were, I’d probably be living in a tent behind our fence instead just changing on the patio and dodging my children on the way to a shower as soon as I come home. Nobody is saying that children dying from COVID-19 is the heart of the pandemic, and memes like this that want to put the number of child COVID-19 deaths ‘in perspective’ are ignoring the fact that child deaths have not been the main motivator for any of our mitigation efforts.
Fourth, and most importantly, the comparison doesn’t matter. Saying that one thing is terrible and dangerous and needs to be fought against doesn’t mean other problems aren’t important. Anyone can do this trick with any two terrible problems. You can say that human trafficking isn’t important because a child is 15 times more likely to be a victim of child abuse within the their own home, or that childhood cancer doesn’t matter because children are 6 times more likely to die from accidents. Just because two things are deadly doesn’t necessitate a comparison of their badness; we can be against both. The cynical side of me says that the only reason to use human trafficking, unless you are really trying to raise awareness about it, is because advocacy for victims of human trafficking confers an immediate moral high ground, and for some reason that is something that COVID-19 deniers feel they must have. They find human trafficking convenient because it paints them as compassionate and ethical and those fighting or concerned about COVID-19 as though they were ignoring this huge human trafficking problem. We wouldn’t expect them to set-up COVID-19 against something more morally benign that harms children, for instance swimming pools or hurricanes. I’d like you to stop and think about that for a moment; think about the fact that some people have decided that their personal crusade against COVID-19 justifies using human trafficking to score rhetorical points; that they have chosen to exploit the plight of human trafficking victims, some of the most exploited people in the history of the world, for their own ends.

But I’ve been wrong before.

Fifth, though it’s not as direct a correlation as with heart disease and immunocompromising conditions like cancer, there is a potential synergy between human trafficking and COVID-19, and it has nothing to do with masks. COVID-19 has, mercifully, killed relatively very few children, but it has left some children without one or both parents, and many more without one or more grandparents; adults who, when they are safe people themselves, confer the safety, security, and support networks that are protective against human trafficking. Despite our fears as parents (I am writing this sitting across from my 8 year old who is working on her math homework) (check that; supposed to be working on her math homework), most children who are victimized through human trafficking are not ‘taken’ from their front yards or from a big crowded event; they are preyed upon by traffickers who look for social vulnerabilities; want of support, care, and love; and circumstances where children and adolescents can be controlled. The logical conclusion of any of the memes or videos or posts that call us to lessen our focus on COVID-19 prevention, regardless of motive, is more deaths from COVID-19 among adults and elders- that is, parents and grandparents- and thus more children at risk for human trafficking in the years to come.

I also said that we would talk about the claim that having children wear masks makes them easier targets for human traffickers. Besides having, as far as I know, no verification for this claim, it also relies on sensationalized concepts of human trafficking and ‘oh that makes sense’ thinking; you are supposed to envision a child being walked along the street by human traffickers with family or friends passing within a few feet and not recognizing them because they are wearing a mask. This ignores the reality of trafficking victims’ experiences and the real methods of control used by traffickers; a problem it shares, though far less gratuitously, with the memes we will look at next.


The Ugly

As bad as it is to essentially make up statistics, and as bad as it is to artificially pit against each other two things that harm children as though you had to choose between them, and as though being vocally against one meant you were in support of or deaf to the other (“You are against a fake virus, while I am against human trafficking”), there is an even more exploitative type of meme going around the internet that takes these same goals and cranks the appeal to visceral emotion up to 11. After careful consideration I have decided not to share these images on my blog; I am sharing heavily redacted versions below, trusting you will recognize the type of macro I am talking about here.

“Let’s spend 4 paragraphs figuring out where that statistic came from” said no one ever

For those of you who have been mercifully spared from seeing the originals of these macros, or the many others circulating right now, they typically show one of three types of images in paired with text minimizing COVID-19 or juxtaposing it to human trafficking; a young child with tears in their eyes and a large hand over their mouth, a terrified child with a shadowy figure standing behind them, or a small girl bound with ropes, often in a basement or darkened room. For those who have seen and shared these images, I want to ask you to do something; go delete them (or change privacy settings; you can choose whether or not to delete them in a few paragraphs) before we move forward.

These images are deeply troubling and problematic for so many reasons that its actually hard to know where to start. “Minor” issues first, as we build towards the very worst and most troubling aspects of these images.

Bad statistics/misinformation:
Trying to get people to accept false numbers or misleading statistics by appealing to emotion rather than logic is a common propaganda tactic and we don’t need it in the fight against human trafficking. The problem is big enough on its own without hyperinflating the scope of it. We talked about the ‘66,667x more likely’ above, but the other number we commonly see is 800,000; 800,000 children are reported missing each year, and the implication is that they become victims of human trafficking. The reality is that most children being trafficked in sex slavery are not reported missing because they are being trafficked by family members or are in vulnerable situations where they would not be considered ‘missing’. Most child sex trafficking victims have not been kidnapped. Moreover, that 800,000 represents mostly missing children who were found very quickly; this is the number from a 2002 study for all children who were reported missing, and includes children who have runaway or gotten lost and family abductions during custody disputes; only 115 of these were what we think of as ‘kidnapping’. Missing children, family and non-family abductions, and all forms of child abuse are serious and important issues, and they all intersect with human trafficking and CSEC to some degree; but using statistics from one problem interchangeably with that of another, or using the most dramatic possible number you can find without careful explanation or honest reflection is not helpful.

Implying silence/neglect of human trafficking issues:
Comment accompanying the second image above reads “time to change the conversation.” This can be taken one of two ways; either ‘it’s time to start talking about human trafficking’, or ‘it’s time to stop talking about COVID-19′. I suggest the real goal of this meme is the latter, because unless you’ve been living under a rock for the past 10 years, we have been talking about human trafficking. To quote a friend who has a degree in modern slavery studies and has worked in this field, even if there are often problems with the organizations that only work to raise awareness of human trafficking without offering other support services or or contributing to the work in other more tangible ways, “they have at least done a good job at that.” Whenever I give lectures on human trafficking and modern day slavery, I always begin the same way; by asking for a show of hands of how many people have heard of this problem before and feel they know something about it. There has been a substantial difference in the response to that question over the past decade. One of the great things about volunteering in this field is that it is one of the few issues where people from all walks of life and ends of the political spectrum find a lot of common ground; we all agree that human trafficking is wrong. Some of us believe that pornography is a major contributing factor (more on that later), while others don’t. Some believe that legalizing prostitution is an important step in fighting it, while others don’t. Some believe that essentially all efforts to confront human trafficking should be secular while others believe that the Church has an important role to play. But despite these differences, there is more common ground to be had here than in the fight against almost any other societal ill. And that has made for fertile ground for grassroots awareness work; telling someone about human trafficking isn’t likely to start a debate or argument. 12 years ago we made shirts that said “slavery still exists” and “27 million slaves: ask me more.” Today the awareness focus has shifted to trying to help people understand modern slavery better and, often, combatting the sensationalist and misleading stereotypes that still persist. COVID-19 has not diminished the conversation around human trafficking, and images like these set it back rather than advancing it.

There is one extremely important point that needs to be made in this section, and I think here is the place to make it. Maybe you are new to human trafficking advocacy; maybe a meme like this is the first you’ve heard of it, and you naturally felt compelled to share. And if that’s the case I want to say two things. First, is that when we are talking about why these memes are problematic and my belief that some of them were made with bad intent, I by no means mean that I believe the people who have shared them have bad motives in doing so; I know for a fact that hasn’t been the case with the people who I’ve seen share the images above. I remember the sense of urgency I felt the first time I heard about children being used as soldiers by the LRA in Uganda; I rushed to my dorm and turned off the Halo game my roommates were playing to try to force them to watch the documentary (it didn’t go well) because I couldn’t believe no one was talking about this. If you are just learning about human trafficking and modern day slavery now, it probably feels the same, and the idea that some awareness efforts aren’t helpful because the images they show or the numbers they quote aren’t quite right must seem a bit strange or overly particular. My goal here is to help you understand why they are problematic, as someone who has been where you are but has since been learning about this for years, and to help you find better resources for raising awareness, like the ones I am sharing in this blog post. And the second thing I want to say is welcome, we are glad you are here; the fight against human trafficking needs you. And the first thing we need from you is to learn more, which is work that none of us can ever actually move on from. I recommend you start with Tuesday Justice’s Primer on Modern Slavery, and then read Kevin Bale’s Disposable People.

Racist overtones:
One of the recurrent visual themes we’ve seen throughout these social media images is the presence of both a child victim and an adult abuser, and the contrast between them. The child is small, the adult large. The child is terrified, the adult commanding and ominous. And often, the child is light skinned, the adult dark skinned. I don’t have exhaustive knowledge of the human trafficking memes that have been shared recently and can’t tell you what percentage of the time this is the dynamic presented. I also can’t tell you if this is done with lighting effects or if the photographer actually recruited white children and POC men for these photoshoots, or which of those options would make it worse; frankly the idea that children were asked to pose for these photos in the first place is troubling enough. But I don’t think these choices are accidental. The history of characterizing black men as hypersexual beasts and violent rapists in order to play into white majority fears of their children and young women being abused stretches back hundreds of years to the very beginning of our nation, and it has been a common theme in lynchings throughout American history. Malcolm Foley, Baylor University Special Advisor to the President for Equity and Campus Engagement and expert on the Church’s response to lynching in America, and my pastor, spoke about this briefly in his interview with Christianity Today following the death of Ahmaud Arbery. He in turn recommends you read Southern Horrors by Ida B. Wells, which addresses this topic in great detail.

“There is hardly a town in the South which has not an instance of the kind which is well known, and hence the assertion is reiterated that ‘nobody in the South believes the old thread bare lie that negro men rape white women.’ Hence there is a growing demand among Afro-Americans that the guilt or innocence of parties accused of rape be fully established. They know the men of the section of the country who refuse this are not so desirous of punishing rapists as they pretend. The utterances of the leading white men show that with them it is not the crime but the class. Bishop Fitzgerald has become an apologist for lynchers of the rapists of white women only. Governor Tillman, of South Carolina, in the month of June, standing under the tree in Barnwell, S.C., on which eight Afro-Americans were hung last year, declared that he would lead a mob to lynch a negro who raped a white woman. So say the pulpits, officials and newspapers of the South. But when the victim is a colored woman it is different.”

Ida B. Wells, Southern Horrors

If playing into sensationalism and parental fears has little to no place in the fight against human trafficking, there is even less justification for drawing on deeply rooted generational racism. By portraying abusers as men of color and victims as predominantly white children, these images are trying to recruit some of the ugliest and most harmful racist ideas buried in the heart of our society in order to fight human trafficking; but the fight against human trafficking doesn’t want or need those racist stereotypes. Moreover, these images are portraying a scenario that is not representative at all of the reality of race within human trafficking, a crime that disproportionately affects children of color, and reinforces stereotypes that themselves go hand-in-hand with racially motivated sexual abuse of trafficking victims. I hope you’ll read the article I’ve just linked from Love 146; it’s very short and shares the stories of three survivors whose race was a selling point their traffickers used to advertise them for sexual exploitation; please take a minute and read their words.

Misrepresenting human trafficking victims:
These images are also damaging and potentially dangerous because they so deeply misrepresent the real situations of victims of human trafficking. Though chains, ropes, cages and locked doors have been used to hold child and adult victims of human trafficking, they are not the most common methods. The techniques that traffickers use to control their victims are varied and sophisticated. Traffickers use shame, fear, and physical closeness in perverse combinations to make victims feel that they are the only person in the world that can be relied on or trusted. Many times they are family members or parents of the child being exploited, and use that relationship to maintain control. Other times they move victims to another city and strip them of their phones, ID’s, and social support networks to make the world outside the trafficker’s control feel even more dangerous and foreign. They use drug addiction, financial entrapment, and poor living conditions to create absolute dependence on the trafficker as a provider. They use psychological torture and manipulation to instill in their victims a sense that they are omniscient and omnipotent; they know everyone, they have contacts with the police, there is nowhere that the trafficking victim can run where they won’t find them. They use threats of violence credible and not; if you leave, I’ll kill your family, I’ll recruit your sister into the life in your place. They forge trauma bonds that make recidivism incredibly high and prosecution against traffickers extremely difficult. These methods, and many we haven’t touched on at all, make chains, ropes, cages, and locked doors unnecessary for controlling victims.

So why does it matter if these images paint a misleading picture of how victims of human trafficking are controlled and exploited? First, because it makes it more difficult for people to notice and report human trafficking when it occurs, something these memes claim to want to promote, if they are only ever looking for physical signs of restraint and enslavement. The work of grassroots advocacy and awareness organizations involves dispelling these myths so that people can really begin to understand the complex, nuanced, and insidious forms of control that are used, and learn to spot them in their interactions with victims of trafficking. When we train medical personnel to detect trafficking, we talk about the presence of a controller, sexualized language and patient narratives that normalize sexual abuse and violence, asking judgement free questions, and understanding the adverse medical findings associated with trafficking; looking for a cage or a rope is going to miss most cases of human trafficking, and all of the cases that could be detected in a medical setting. And second, because the misconception of trafficking control methods being limited to only physical forms of restraint like the ones in these images contributes to shame and victim blaming towards survivors. When we promote the idea that all trafficking victims and modern slaves are bound by ropes or chains, we are also stating the contrapositive; if you aren’t bound by ropes or chains, you aren’t really a trafficking victim. Adolescents are arrested for “prostitution,” a crime that can’t logically exist (children cannot consent to sex; “child prostitution” is always rape), and are frequently further victimized by law enforcement. They are rejected by families and loved ones because their serial victimization and the control methods they have suffered are seen as evidence of poor moral character. Society asks incredulously, “why didn’t you just leave?”, and we tell ourselves narratives that “I would have run away if it had happened to me,” without ever trying to understand what they had to endure. It even contributes to trafficking victims’ difficulty in recognizing their own abuse, because they may believe the cultural narratives that the incomprehensible torment they have endured as serial victims of rape and psychological torture don’t count unless they were handcuffed, caged, or tied-up at all times.

Sensationalizing the sexual abuse of children:
This is the hardest one to write about, and also the reason this post is now over 24 hours late. In my opinion it’s the biggest problem with the images above. Recently the Texas Medical Board began requiring that all licensed physicians complete training in human trafficking, and the Department of State Health Services (DSHS) released standards that those trainings should adhere to. Though the training we conduct had only one major revision because of this, we used it as an opportunity to update the entire presentation and ensure it was something that protected the dignity of human trafficking victims and survivors to the highest degree possible. The one revision; removing an image of two teenage girls standing on a street corner at night. And the reason we removed that image was because of this new training standard:

I mean, it’s the first one!

I’m including this training standard because I want you to understand that my objection to these memes and my request that you take them down if you’ve shared them, and kindly call them out when you see others sharing them, isn’t based on personal distaste or a negative visceral reaction (which is exactly the type of reaction they are meant to provoke). These are agreed upon standards and the idea of these images being harmful is accepted among those who fight against human trafficking every day; it’s just hard to articulate exactly why. We call these types of images sensationalized because we can’t quite call them sexualized; there is nothing sexual about a child experiencing fear and torment. Yet the image is meant to arouse disgust because we know that, to traffickers and johns and others who sexually assault children and adolescents, these are sexual images; in fact, I think you could rightly call them pornography. These images of children with adult hands covering their mouths, or bound and terrified with dark figures standing behind them, clearly send the message, “This child is about to be sexually assaulted.” I don’t know of anything that has less place in the fight against human trafficking than images that, if seen by one of the millions of men and women who have survived sexual assault or the ordeals of abuse through modern day slavery, would potentially traumatize them further and bring to mind those violations. These images are exploitive; they take the worst, most hopeless and fear-filled moments of the lives of real people and reproduce them for use as promotional materials. The fact that what the creators hope to promote is awareness is a mitigating factor, certainly; if these images were used for literally any other purpose we would chase the people creating these memes out of town, society, and history; we would call the FBI on them and put them on social media blast. But the ends do not justify the means, and we do not need simulated pornographic images depicting the moments before a rape or the psychological suffering of a child to convince people that this is an important issue. We need survivors’ stories. We need to understand the factors that contributed to their targeting, their control, and eventually to their empowerment and escape. We need to help young men and adult men understand that “non-consensual sex” is always rape and that desire for sexual interaction with the helpless and those who cannot consent is a serious mental health condition that needs immediate treatment, not a fetish or kink that can be safely indulged in as long as the victims are far enough away. We need to understand the complex networks of organized and non-organized elements that make up the human trafficking industry. We need to fight human trafficking by uniting across political and religious lines against the exploitation of children and the sexualization of innocence, not by dabbling in it as these memes do.


The Good

I think it’s important to note that not all memes that compare and contrast human trafficking to COVID-19 are necessarily problematic. The meme above is clearly different, while though it is using COVID-19 to grab your attention it is not trying to diminish the seriousness or reality of the pandemic. Further, it links to the Polaris Project, a reliable source of human trafficking information and resources, which also operates the National Human Trafficking Hotline, a free resource that anyone can call if they themselves need help or support or to report or ask advice about a potential human trafficking situation. Some of the verbiage, like “I wonder if … people would start paying attention?”, isn’t what I would choose and maybe falls under the idea of treating human trafficking like a neglected topic, which we talked about earlier… But this is very minor and may just be an issue of generational differences in meme tone and vocabulary.

This meme also shares data instead of sensationalized images and false statistics, and doesn’t try to play on fears, racist stereotypes, or false narratives about human trafficking. Finally, it comes from a source that is beyond question focused on helping women rather than minimizing COVID-19 concerns; the Montgomery County Women’s Center in Conroe, Texas, which provides sexual assault support services including legal support, crisis intervention, counseling, and advocacy. A quick search of their social media shows that they have indeed taken COVID-19 seriously and have modified their delivery of services and planned programming to keep their staff and clients safe from the virus; once again showing that any dichotomy between caring about COVID-19 and caring about victims of sexual violence is a false one.


How COVID-19 is like Human Trafficking and Modern Day Slavery

I know that by this point the title of this post, “Please keep comparing COVID-19 to Human Trafficking,” must feel like sarcasm or a particularly flimsy misdirect; but I promise you I really mean it. For me personally there are lots of similarities, not the least of which are the real harm and destruction I have seen them both bring to the lives of human beings created in the image of God, and the work I have accepted of helping provide accurate information to replace the misunderstandings about them that lead to deep seated fears. But there are a few other ways I think the comparison between these two pandemics is actually apt, if made responsibly:

There is lots of misinformation out there.
I would hope this post is proof enough that there is misinformation on both human trafficking and COVID-19 circulating widely. I said before that the role of grassroots awareness efforts on human trafficking has shifted from telling people that slavery still exists to helping people understand what modern day slavery is really like. This is invaluable work that is done best when informed and led by survivors or human trafficking, helping those of us in support sectors and the public in general understand the nuanced and complex nature of their experiences. Just like we try to do on this blog with COVID-19 videos and other medical misinformation, organizations like Unbound, Polaris Project, and Free the Slaves carefully break down the myths, popular stereotypes, and outright lies surrounding human trafficking and then tell the real stories of survivors and victims and the real story of human trafficking and modern day slavery. This aids in awareness, victim recognition, survivor support, laws that support survivors, and a culture that treats human trafficking victims as survivors instead of criminals. Without accurate, reliable data, this work is surrounded by a fog of biases and assumptions that inhibits the work of aiding survivors; we need to tell honest stories about human trafficking because when we share trafficking misinformation, it helps the traffickers instead.

You can make both problems worse without realizing it.
We’ve talked before about the danger of asymptomatic transmission of COVID-19, and studies which have shown (though the results are open to some interpretation) that the 48 hours prior to the onset of symptoms might actually be the most contagious period of time during an infection. As someone who has done pretty good but not perfect at social distancing throughout the pandemic, I find this especially concerning; all of us need to fight the false sense of security that comes with feeling healthy at the moment, thinking about our potential exposures and at-risk contacts even when we don’t think we are sick. That’s different from living in fear; living with a healthy respect for what this virus can do to us or our loved ones is wise, not fearful. But in addition to spreading this virus directly, we can make the pandemic worse with our other actions; sharing misinformation on the internet, failing to vet our sources when we share new or emerging information, supporting policies or politicians that minimize the very real danger of the virus, and fighting against non-nefarious common-well-being policies like wearing masks in public spaces. All of this increases the risks from the virus in much more subtle ways by creating a culture that minimizes personal responsibility and obfuscates the reasonable mitigation measures we can all take.

And almost the exact set of actions have a corollary in unwittingly supporting human trafficking. You probably contributed to human trafficking (as I did) today when you purchased products that had slave labor upstream in their supply chain. Some companies are better about monitoring their supply chain for slave labor than others, and there are groups that keep independent report cards for everything from the fashion industry to your local grocery store. But while buying blue jeans, chocolate, or a new smartphone may support labor trafficking and slavery in the supply chain throughout the world, there is one auxiliary consumer industry that supports sex trafficking specifically; pornography. These two industries are indelibly linked. A culture of widespread pornography use and addiction contributes to dehumanization of and violence towards women, and fetishizes demeaning sexual interactions, sexual violence, and rape, and it feeds the demand for sex trafficking from the consumer side. But the connection runs even deeper than that, because if you have consumed pornography you have not only supported the sex trafficking industry financially but have most likely participated in the sexual exploitation of trafficking victims as well. Many pornography websites, including the largest and most visited pornography website in the world (link is to an advocacy group video about the website, not the website itself, obviously), rely mostly or entirely on user uploaded content and do not have sufficient screening criteria in place to prevent the uploading and viewing of content showing the sexual abuse of children or adolescents, or content showing non-simulated rape and sexual torture. In fact, videos are often tagged with words like “teen”, “young girl,” or “innocent” in the title, yet are still streamed from their website without additional vetting or any requirement to prove that the women in the videos are actually consenting adults. This is not a theoretical risk; the sexual abuse of teenage girls and even children being streamed from these sites has been well documented. And once these videos are available on the internet, they can be next to impossible to have removed, as we have heard from survivors who have battled to have videos of their own rape taken down from these websites.

You can fight both right now.
As a physician, I’m here to tell you that you can fight COVID-19 right now in the comfort of your own home (by, you know, staying there). Wear a mask when you leave the house, physical distance while building up your social circle, reaching out to neighbors, loved ones, and friends remotely to see how they are doing 6 months into this pandemic and if there’s anything they need. Help fight against medical misinformation that contributes to unsafe, pro-COVID behaviors and attitudes. And you can fight human trafficking right now as well. Start reading with one of the resources above and keep reading and educating yourself about this important topic that isn’t going to go away even once COVID-19 is a distant memory. Look into the ways that your clothing, your food, and your other purchasing choices might help or hurt the plight of slaves around the world. If you’ve read this post and have decided it’s finally time to stop using pornography, go to a website like Fight the New Drug to get more information, support, and resources, and find an accountability partner to download an app like Ever Accountable and quit porn alongside you. Finally, consider donating to an organization like International Justice Mission that actively works to intervene in situations of slavery around the world, and then sticks around to provide the legal and support services to guarantee that survivors aren’t re-victimized by their traffickers.

So no, there isn’t a fight between awareness of human trafficking and focus on COVID-19, and the people who want you to believe there is may well care about neither one of them; but we are in the fight of our lives against both, and since you do care, we could sure use your help.

Stop comparing COVID-19 to Car Accidents (Part 1).

I first saw this graph on Facebook last month; at the time I was writing extensively about asymptomatic cases, death statistics, herd immunity, and other topics and didn’t have much margin to spare for it. Besides, multiple people have written extensively and well about this topic over the last several months as these silly comparisons between COVID-19 deaths and car accidents, heart disease, cancer, and any number of other causes of human death and suffering have been rampant.

But yesterday evening, when falling asleep at 7 PM exhausted and slightly delirious from what I thought might be COVID-19 but turned out to be from not drinking enough water while working at our outside COVID-19 clinic in 95 degree heat, which is not technically a COVID-19 related illness (and would not be recorded as one regardless of what the conspiracy theorists tell you), I came across a meme along the same lines and felt it was time to say something about these fallacious comparisons. I’m going to start with traffic accidents and heart disease today, for the sake of thoroughness, but tomorrow I’ll try to address the memes that really got my blood boiling; the ones comparing COVID-19 to human trafficking and modern day slavery.


Contagious vs. Non-Contagious Illnesses

You have no doubt seen some version of this argument before now. It usually has a very simple formula, which we will try to tackle one by one:

  1. Compare COVID-19 deaths to another leading cause of death.
  2. Ask why the other cause of death isn’t being talked about/doesn’t shutdown the economy/isn’t a national issue.
  3. Imply or outright state it’s because the media/doctors/the powers that be want you to be afraid for some nefarious purpose.

(In all fairness, the authors of the article above seemed to be writing it just to raise awareness about programs to help teens drive safer; the headline comparing it to COVID-19, while typical of the format this argument has taken across the internet, is seemingly just to garner clicks in this case)

We’ve seen charts like the one above, showing the “incredibly small number of deaths” from COVID-19 compared to real killers like heart disease and stroke. “See, it isn’t even as bad as the flu!” We’ve seen statistics that are next to meaningless, like “COVID-19 will only make up 5% of deaths in the US this year,” which is supposed to sound to laypeople like COVID-19 isn’t that big of a deal, but is actually a terrifying thing to hear as a physician. We’ve been asked, knowingly, why we didn’t “shut-down the economy” for H1N1 in 2009… Maybe because nobody was trying to undermine the president’s chances of re-election? We’ve been asked why we don’t social distance because of car accidents, and then been told the answer; because COVID-19 is all about creating fear.

During the SARS-CoV-2 pandemic we’ve seen physicians, epidemiologists, laypeople, politicians, and misinformation hucksters compare COVID-19 to the common cold, influenza, measles, ebola, HIV, SARS and MERS, and the Spanish Flu pandemic of 1918. While these comparisons have often been made with false statistics or poor understanding of epidemiology and thus led to incorrect, often diametrically misleading conclusions, the comparisons themselves are indeed apt. SARS-CoV-2 is a contagious, viral illness, just like those other diseases, and the danger it poses depends on how contagious it is, how deadly each individual case is, and the long-lasting sequelae it causes, just like those other illnesses.

But the comparisons in the chart above are not all apt, because most are not contagious diseases, and fighting them requires entirely different monitoring, treatment, and prevention principles compared to viruses like measles, ebola, or COVID-19. Yes, preventing diabetes would be easier if we, as a society, decided to rearrange our lives and our community norms to focus on physical activity and healthy eating, eliminate food desserts (or is it deserts? both contribute to diabetes so I’m going to leave it as-is), provide nutrition education as core curriculum in our high schools, and take any number of other steps to become a healthier nation with better and more equitable access to healthy choices overall. But those changes take a lot of time to implement. While there are plenty of ways to help in such efforts, such as shopping at grocery stores intentionally built in food deserts, places like Waco’s Jubilee Food Market, there’s very little that you can do, right here in the middle of your afternoon, to prevent someone you are coming into casual contact with from developing diabetes or heart disease today. As passionate as you are about fighting heart disease and diabetes, you can’t go to a coffee shop and start yelling about metabolic syndrome to try to raise awareness; they kick you out for stuff like that. But you can do things today to prevent the spread of COVID-19, like wearing a mask and social distancing, and a big societal push in that direction makes sense for COVID-19, where for chronic illnesses with modifiable risk factors it makes more sense to focus on sustained, long-term efforts over generations than urgent, short-term pushes.

Me at Pinewood Roasters, trying to warn people about chronic illnesses.

Moreover, diseases like diabetes and coronary artery disease don’t typically kill you all at one time. As we’ve discussed multiple times before, these chronic diseases increase your risk of multiple other ailments, including your risk of a severe case of COVID-19. Saying we shouldn’t worry about COVID-19 because ‘look how bad heart disease is’ is a bit like saying the people on the Titanic shouldn’t worry about the iceberg, because it’s really the water that ultimately killed most of them. There’s a synergy between COVID-19 and heart disease, lung disease, diabetes, and other chronic health conditions, and you aren’t doing congestive heart failure patients any favors by trying to shift the focus off of COVID-19 transmission and slowing the spread of the pandemic; that kind of approach is only going to increase the number of deaths from both conditions.


“Why don’t we shut down the economy for ________?”

But the other reason these comparisons fail is because, to the degree that the approach to treating and preventing them is similar, the responses of the media and doctors to these causes of death has been similar to that of COVID-19. Various people who share these statistics say things like, “we don’t shut down the economy over diabetes,” “we don’t close schools because of car accidents,” and “we don’t social distance and stop going to bars because of liver disease” (I made that last one up because it was the most ironic possible instance of that line of argument). Dr. Phil made this exact same argument on Fox News back in April.

But none of this is actually true, is it? One of the reasons that school gets cancelled on days with severe snow storms (or in Texas, days where someone might have seen some white stuff falling from the sky when it was the wrong season for Crepe Myrtles) is because severe ice on the roads would increase the risks inherent in traveling back and forth to schools; we cancel school precisely because there is an increased risk, above that at normal times, of people dying in car accidents. We also have tons of laws related to traffic safety, including speed limits and traffic signals, without which we could no doubt get to work quicker and be more productive, and laws about texting while driving without which doctors, at the very least, could be much more productive during our commutes. We have all of these rules and regulations in place because the danger has been recognized.

Becoming the Sorcerer Supreme occurs in less than 1 in 14 million cases of physician texting-while-driving accidents. Don’t do it.

We also have laws about cigarette advertising and smoking inside restaurants and places of business, laws regarding industrial and toxic exposures, laws about medical leave for chronic, progressive illnesses like cancer, and laws about sick leave and not being fired because of medical issues. It’s true that these laws often provide depressingly little protection for employees, but they are in place and it’s erroneous to say that we don’t “allow” these medical issues to affect ‘the economy’ or ‘our freedoms’. The one key difference is that none of these approaches are proactive the way that masking, social distancing, and strategic closings are in a viral pandemic. Things like scheduled exercise breaks and company-sponsored healthy meals, are proactive ways to fight heart disease and diabetes and would definitely boost the economy if adopted widely, but they are difficult to implement and need a high degree of buy-in from both businesses and employees; they are going to require cultural changes that take time, something we don’t have a lot of in the midst of a viral pandemic. Yet the economic costs of these diseases is so great that if we could somehow drastically reduce deaths and hospitalizations from them by strategically shutting down non-essential businesses and engaging in social distancing and mask wearing for a discrete period of time, it would be an obvious win for the economy, even aside from the question of the inestimable value of those human lives. But while heart disease doesn’t work that way, contagious illnesses like COVID-19 do, and the idea that any of the measures we have adopted have been ‘overreactions’ that we ‘wouldn’t do for any other disease’ belies the fact that we definitely would if we had similar options to fight those diseases (or I hope we would; I’m probably letting my naive optimism show a little too much here).

But even apart from questions of economics, diseases like cancer, diabetes, and coronary artery disease are important topics that are talked about constantly in the news, and that millions of people like me devote literally every day of their full time jobs to fighting, preventing, diagnosing, treating, and counseling people about. COVID-19 is causing a pandemic, and it’s understandable to feel some frustration that it has sometimes seemed like the only thing the news has been reporting on; but we shouldn’t pretend that sensationalization of medical topics is new or that the media has never spent significant energy and focus on these other diseases. When something negatively effects peoples’ lives to an extreme degree, like COVID-19 and these other diseases do, people are going to be read and write about it; but unlike COVID-19, the interest is more or less sustained over the years. This isn’t just true for the news; it’s true for us, too; just look at this graph of searches from Google Trends. We are always thinking about these issues, as a society, at a pretty steady rate; COVID-19 is new and very dangerous, and so we are thinking about it now all at the same time.

I am uncertain of how many of the searches for “heart attack” are related to the Demi Lovato song.

COVID-19 is just as incredibly dangerous as the leading causes of death.

But the final and most important issue here, and maybe the one I should have started with, is that these statistics are lies, at least when you are seeing them shared on social media now. That graph above showing COVID-19 deaths compared to cancer and heart disease is from March, when ‘only’ a few thousand people had died from COVID-19 and the US had yet to hit any regional surges. It compares cases at the beginning of the pandemic to deaths from other causes for the entire year. But by the second week in April COVID-19 had become the leading cause of death, in deaths per day, and stayed there throughout all of April and half of May. Since then it has continued to jockey for position with cancer and heart disease (while disproportionately affecting people already battling these diseases), and is now on the rise again.

Also from April 2020

If we want to compare apples to apples, we could wait to compare the number of deaths once COVID-19 had an appreciable impact; the 2nd graph below shows COVID-19 deaths compared to other causes of death today. If we wanted to compare same-sized apples, we could look at deaths from COVID-19 since the first death was reported in the US on February 29th; the 3rd graph below shows deaths from COVID-19 compared to an equivalent time period, 154 days (and for the 2017 flu and 2009 H1N1, the slightly shorter period encompassing their entire flu seasons).

Ask yourself why people are sharing only the top graph on facebook, 4 months and 160,000 deaths later

Looking at the 2nd graph, COVID-19 has already surpassed stroke, drug overdose, and the very deadly Seasonal Flu of 2017-2018, and there is zero chance that it won’t also surpass accidents and chronic respiratory diseases soon. But unlike the flu, COVID-19 did not begin to disappear in the late Spring and early Summer, and we are once again seeing a surge in deaths from the virus as we enter August. If we look at the 3rd graph, there is reason to believe that COVID-19 will settle in as the 3rd leading cause of death in 2020; but it has already dwarfed all other causes except heart disease and cancer. Even this graph undersells the true impact of the virus, since the proportion of deaths occurring in February and March was very low. If we were to look at the number of deaths in the 120 days since COVID-19 deaths began to rise at the end of March, the picture would be even more bleak; but posting more and more alarming graphs by limiting the time frame to the most dangerous months of the pandemic so far, in order to show how dangerous COVID-19 really is, feels a little too much like manipulating the data in the virus’s favor; and COVID-19 doesn’t need or deserve any help from us.

So these comparisons are problematic because they ask us to believe that our society doesn’t already devote enormous resources to these other problems and that they don’t have incredible impacts on the economy, and because they are comparing very different causes of suffering, disease, and death that have to be combatted very differently. And they are deceptive because they are deliberately using old data from early in the pandemic (using old data when you know new data is available is also called lying) and discounting whatever time period of the pandemic doesn’t support their narrative. But I think the most frustrating thing for someone like me who spends hours every day talking about and thinking about diabetes and heart disease, has devoted extra time and effort to gaining proficiency with methods of treating drug dependence and preventing drug overdose, and has spent hundreds of hours working in emergency rooms and treating people following accidents and motor vehicle collisions, is that people often seem to be sharing these comparisons not because they actually care about these other important medical issues, but because they don’t mind using them to reinforce their COVID-19 denialism and conspiracy theories… and then dropping them again once they are no longer useful or convenient. But because I’ve lost my lisinopril bottle again and apparently want to see how high I can get my blood pressure this week, we are going to save that discussion for tomorrow when we talk about the comparisons being made between COVID-19 and Human Trafficking.

Medical Misinformation Meme Monday

At some point in this sort of voluntary, part-time work, you have to face the fact that people can produce misinformation, honest misunderstandings, and conspiracy theories far more rapidly than you can write about them, and that it is literally, physically impossible to keep up. For me, this realization came around the first week of April. At times like that I am thankful for people like Dr. Mikhail Varshavski (“Dr. Mike”) and Dr. Zubin Damania (“ZDoggMD”) who are doing this work consistently on Youtube and their own websites, and for people like Dr. Emily Smith, Your Friendly Neighborhood Epidemiologist, and the anonymous Your Local Epidemiologist, who for all I know might also be Dr. Emily Smith (I’m just saying, have you ever seen them together in the same room at the same time? Probably not. Because quarantine). If you have a question about a piece of misinformation or something that’s unclear about COVID-19 that I haven’t addressed on this blog, or (as seems more likely) that I’ve addressed in such a wordy and convoluted way that you are actually worse off than you were before my ‘explanation’, chances are one of these folks has got your back. There must be many people out there doing this type work that I am missing; please feel free to link to their sites in the comments.

With so many pieces of misinformation floating around out there and so little time to write 3,000-5,000 word blog posts, today’s post is just an attempt to debulk the malignant tumor of COVID-19 misinformation. The rules are simple:

  1. Memes only.
  2. Each meme gets one paragraph only (paragraph length unspecified)(and it still counts as one paragraph if it is interrupted by pictures or videos).
  3. The crazier or less sincere the meme, the snarkier the response.

COVID-19 Medical Information.

We’ll start out with a light one. I’ve seen this posted with the comment “Coronavirus is a cold.” It’s hard to derive any sort of conclusions from just that. Does the meme intend to convey that the entire worldwide pandemic is a hoax? Are they are trying to say that literally all of the deaths and suffering have somehow been fabricated? If I posted this meme with the comment “wow, look how much we’ve learned about Coronaviruses in the last 3 decades,” it would completely change the meaning; but the meme as written is clearly designed to imply that the pandemic has been faked because coronaviruses only cause colds. I think there’s at least three legitimate ways we could debunk this idea, and I can’t really decide between them, so we’ll do all three. First, we could do some basic education on medical history. ARDS, Acute Respiratory Distress Syndrome, was first described in 1967, just one year before Coronaviruses were classified; but the first Coronavirus that was known to cause ARDS was SARS in 2003. Obviously it wouldn’t have been known in 1989 that Coronaviruses would emerge that caused such severe respiratory complications, and thinking of them as a virus that typically only causes a common cold was perfectly reasonable. If you want a thorough explanation of the history of coronaviruses and ARDS, I recommend this article, which could have been written as debunking of this meme: A Brief History of Human Coronaviruses by Shawna Williams. It contains an excellent visual timeline, which I’ve included only a fragment of here.

The second approach I think is valid is to point out how silly it would be to fake a pandemic using a virus that is known to cause only a common cold. It seems like faking infections, hospitalizations, chronic complications, and deaths in every single country in the world and having doctors, nurses, respiratory therapists, researchers, and millions of non-medical people pretending to be patients, would take an awful lot of effort; maybe it would have been worth devoting some of that untold energy and seemingly infinite resources to attributing your fake pandemic to a pathogen that couldn’t be disproved by by pulling up any old text book from before 2003. This is what makes me think that the meme was knowingly deceptive on the part of the original creator, because it’s so hard to believe that somebody actually found this in a 30 year old text book and said to themselves “aha! got ’em!” The third and final point we could make is to just point back at the meme itself, just eight lines up:

This textbook page doesn’t list cervical cancer as a disease linked to the Papovaviruses family, which under the classification scheme used at that time included human papillomavirus; HPV. Maybe it’s a good thing that medical knowledge and research has continued to progress since 1989?


This is one of my favorites, and was actually shared to my Facebook wall by my mom (I should clarify; she shared it because she also thought it was ridiculous and knew I would enjoy it). Something like this almost has to be written facetiously, right? But for the sake of thoroughness, let’s clarify a few points here. First of all, the reason the collection is done in the nasopharynx really isn’t that complicated; that’s where the virus is more densely populated, compared to other locations that could be swabbed, and going deeper in increases the chances of picking up the virus on the swab. I know it’s uncomfortable; I’ve had it done three times now, and the second time was especially awful. Despite what people may think, doctors and nurses don’t like causing pain, and we wouldn’t use it if we felt like there were other reliable options. But so far studies comparing the sensitivity and specificity of Nasopharyngeal swabbing to other swab techniques and locations have been mixed in terms of how determining how necessary the Nasopharyngeal swab actually is. Some have shown that it clearly gives us the most reliable way to tell if you have the virus or not, and others have shown that other swab locations might be just as good. But until something like a definitive answer emerges, doesn’t it make sense for your doctor’s office to use the technique that everyone agrees is as accurate as possible? This is all pretty obvious, but doesn’t answer the question of ‘if the virus is so contagious, why wouldn’t a less invasive test work?’ The other part of this meme seems to call into question that the virus is contagious if we have to do such an uncomfortable test to detect it, and the answer here is simple too; when we test for the virus, unlike when you get infected with the virus, we don’t have the virus’s help. You see, your body is a good breeding ground for certain viruses, who use your own cellular machinery to reproduce and, when they reach a certain point (viral load), begin to cause disease. This takes time; the incubation period (how long it takes the virus to reproduce enough to cause illness) of COVID-19 is 2 to 14 days; the COVID-19 test we use in our clinic comes back in 15 minutes. That’s because the tests we use aren’t trying to let the virus go through multiple reproduction cycles until it has proliferated enough to be detected; this is a good way of testing for pathogens called a culture, but it takes longer. The rapid tests rely on detecting some part of the virus, such as its DNA or specific proteins, and the more of the virus that is collected for the test, the more likely it is for the test to be accurate. In other words, the test may require more of the virus to be reliably accurate than the virus requires of itself to make you sick. Finally, the part about the microchip is really, really silly, and if you believe it there probably isn’t much I could say to change your mind; but if it helps here are two videos; the first showing exactly what our swabs look like, and the second showing me getting the Nasopharyngeal swab done at one of our clinics.

I realize some microchips are smaller than what my phone’s camera can pick up, but I’m not buying a digital microscope to appease conspiracy theorists.
This was swab #1 of 3 since April, and I’m worried the microchips are starting to build-up in there.

Two signs that your meme is bad:

  1. Your main point can be summed up as, “people with certain medical conditions deserve to die.”
  2. You add a picture of Morgan Freeman and I still don’t read it in his voice.

There’s not much to do with this one. Sometimes high blood pressure, diabetes, and obesity are significantly attributable to personal decisions, and sometimes not. It’s always, and I mean always, much more complicated than people know from the outside, and managing these conditions both as a doctor and as a patient is hard, frustrating, and often feels like an uphill battle. Sometimes people can exercise, and sometimes they can’t. Yes, smoking is bad for you, and I spend a lot of time trying to help people quit (by the way, one of the most effective and least utilized methods for quitting is getting a smoking cessation coach. You can get one for free at https://www.yesquit.org, and they can even help set you up with free nicotine patches or other medications), and you should quit, but we know it isn’t easy. The idea that anybody should be shamed or punished for a medical condition, let-alone medical conditions that are only partly modifiable with behavioral changes, is obscene. Shame on you to whoever made this meme and to anyone who shared it, and on Morgan Freeman for endorsing it.

Before I get angry e-mails, that last part was a joke; I realize that Morgan Freeman has no idea this meme exists. But isn’t there something disturbing about both this and the next meme exploiting the images of Black men- one for his gravitas, acting talent and air of wisdom, and the other for his strength, hard work and physical prowess- to minimize a pandemic that is disproportionately killing Black and minority men and women?


I’m going to just admit now, figuring out the origin of this picture took me longer to research than almost any medical question I’ve addressed on the blog so far. At first glance I had no idea what was going on here, but I braved the internet so that you don’t have to, and here’s what I came up with. According to my research, the image depicts champion body builder Blessing Awodibu, known both for his multiple body building titles and his various comedic Youtube videos, flexing next to “Daddy Long Neck”, a social media personality and musician who has Marfan Syndrome, a connective tissue disease. The two did a sketch together on Youtube back in December of 2018 where they arm wrestle, and this image appears to have been taken at the same time. We’ve already addressed this idea that by taking precautions to avoid COVID-19 you are somehow coddling you immune system into a state of weakness back when we compared your immune system to a Death Star, and on a few other occasions early on in the blog, so I won’t rehash it here. Suffice to say that while exercising is of course a healthy habit, none of the things listed by Awodibu are going to protect someone from COVID-19, and I’m fairly grossed out by the fact that whoever made this doesn’t wash their hands before eating.

Really, this meme is just the jock version of this nerdy Star Wars meme I made back in April.

There’s also a good bit of irony here, since in the original Youtube sketch Daddy Long Neck actually won the arm-wrestling match, prompting Blessing Awodibu to ask “which protein do you use?” This would imply that the immune system in the meme that is wearing a mask, using hand sanitizer, and doing curbside pickup for groceries is less likely to get sick from COVID-19, so I guess I do agree with this meme after all.


COVID-19 Statistics (Yay!)

I’ve included a few statistics memes that were sent to me recently, and this first one is the most straightforward of the bunch. Unlike the others, which make a few important intentional or accidental statistics errors, this one is clearly written by someone who has no grasp of statistics at all. Let’s look at the three statistics it gives:

  1. 0.94% of Americans have contracted the virus.
    This is actually a really terrifying statistic, because if it were true, it would mean that the now 143,000 deaths (up over 10,000 since this meme was made last week) are just the tip of the iceberg; that we’ve had that many people die and over 99% of the population hasn’t even had the virus yet. Fortunately, this meme is only accounting for confirmed cases, and does not take into account any of the antibody testing and studies that have helped us get a better estimate of the number of asymptomatic and minimally symptomatic people who have already been infected with SARS-CoV-2 without realizing it. Even in areas that have already survived a surge of cases, these numbers have not been anywhere near high enough to confer herd immunity, and we definitely aren’t out of the woods yet; but if only 0.06% of people have even had COVID-19 at this point, we would be on track to blow even the most dire models from March or April completely out of the water.
  2. The survival rate is 95.72%.
    We talked about this a lot back in the posts about the Dr. Erickson/Bakersfield Urgent Care Doctors video. The easiest way to make a really alarming statistic seem mild is to just present the inverse. A “95.72% survival rate” sounds like a good thing, because survival is good and 95% is a ‘high’ number; “see, the good thing has a high number! It’s not that bad!” But this is exactly the same as saying that COVID-19 has a mortality rate of 4.3%, instead of the still scary but much less catastrophic 0.5% to 1.3% most doctors I know would be willing to accept. A mortality rate of 4.3% is terrifying for a virus that is this contagious, and flipping it to “95.7 survival” makes it exactly 0% better.

    So the first two statistics by themselves actually constitute a form of misinformation about the virus we’ve seen only rarely, in that it makes this already terrible pandemic seem even more dangerous than it actually is. Which is what makes the final statistic so baffling.
  3. Only 0.04% of Americans have died, so the survival rate is 99.96%.
    This is why you don’t make memes as a group project; it’s obvious that the person who wrote the last part hadn’t looked at the rest of the presentation, since the line immediately before this claimed a survival rate of 95.72%. What they’ve done here is divided the number of deaths by the entire population whether they’ve had the virus or not, very similar to what Dr. Erickson did in his video when looking at deaths early in the pandemic (“millions of cases, very little death”). But that’s not what a “survival rate” is at all, because you are basically making the claim that hundreds of millions of people have ‘survived’ something they haven’t been exposed to yet. I can think of exactly one type of scenario where it would be helpful to calculate a “survival rate” based on the entire population instead of just the people actually effected (i.e. the people who have survived), and that would be after an extreme mass casualty event. For example, in the 1997 movie The Lost World: Jurassic Park, a T-Rex makes it from Isla Sorna to San Diego to rescue his baby by… Swimming? Stowing away on a boat? That movie was so crazy I can’t remember. He weaves a path of destruction across the city until… something happens to stop him, I think. Anyway, in a situation like that, it would be reasonable to calculate a survival rate for the entire city once the dust settles; but using the current number of deaths compared to the US population to calculate what percentage of Americans have “survived” COVID-19 right now is like calculating the T-Rex survival rate for San Diego while it’s still running behind you on Harbor Drive.
Dinosaurs aren’t that dangerous; most San Diegans weren’t even on that bus.

I like this meme for three reasons: 1. It starts and ends reasonably, 2. It comes from my home state, and 3. It is the best statistics example I’ve seen yet of comparing apples to oranges, only in this case somebody has painted an orange red and glued a stem to the top to try to pass it off as an apple. Let’s break it down a bit:

“Here are some numbers that are confusing to me.”

This is a great start, and honestly if all misinformation could start out this way instead of “READ THIS BEFORE FACEBOOK DELETES IT” we would be a lot better off.

Covid-19: 3,399 deaths/88,691 cases = 4% of the people with cases have died.

This is actually a great way to phrase this, because it emphasizes a few points that we can’t be too precise about. Louisiana has had 88,691 confirmed cases (now 95,002), but we can’t be sure how many people have had the virus without getting sick and getting tested, so saying that 3,399 of the people with confirmed cases have died, to get a case fatality rate of 4% is precisely correct. It also uses the present perfect tense instead of the past tense, a nod of recognition that this pandemic is not over. For people in Louisiana with confirmed cases of COVID-19, 4% have died up to this point; many are still fighting for their lives, many are recovering, and many more are being diagnosed as we speak; this number is dynamic.

Flu: 1,400 deaths/14,000 cases = 10% of the people with cases died.
Notice the past tense? Because the 2018-2019 flu season is over now? Masterful. But unfortunately, here’s where it all goes off the rails, because Louisiana did not have 14,000 cases of flu last year; it had 14,000 hospitalizations for flu. And that completely changes the meaning of the statistic, because now you are comparing the very sickest flu patients with the most dangerous risk factors to all confirmed COVID-19 cases and getting a number on the same order of magnitude. That makes COVID-19 insanely scary. And we don’t yet know how many hospitalizations for COVID-19 this pandemic is going to have, or how many deaths, because we are still in the middle of the pandemic. We’ve talked about the problems inherent in comparing flu and COVID-19 before, and we’ll cover some of them again below; but if we want to compare something at least in the same fruit family, there are studies that have looked at the number of deaths compared to hospitalizations in Louisiana hospitals from COVID-19, just as this meme does for the flu. One study from the New England Journal of Medicine, which also looks at the increased burden of COVID-19 on African Americans due to chronic health disparities, found a hospital death rate of 24%, compared to the 10% for the flu in the meme above.

So, I don’t understand why we haven’t been wearing masks already?
This meme is so precise in every other respect, and the mistake between 2017-2018 flu cases and flu hospitalizations is so glaring, that I can’t help but believe it was intentional. I find that really disappointing, because otherwise I really like this one, and I definitely agree with the final point. Why haven’t we been wearing masks before now? 15,000 to 60,000 deaths from flu each season may not be COVID-19 pandemic levels, but it still represents a lot of human pain, suffering, and grief, and wearing masks during flu season would cut down flu transmission a lot. Here’s hoping that our experience with COVID-19 will teach us some useful transmission control skills as a society going forward, just as SARS did for Taiwan in 2003.


We can move due West to my new home state, Texas, to see another meme explaining to us, contrary to what every doctor and epidemiologist has been saying for months, why COVID-19 just isn’t very dangerous compared to the flu. In a perfect world, it would be enough to explain that this is a fake, and move on with our lives. This is not a table published or endorsed by the Texas Department of Health and Human Services. There are a few ways to tell. First, it looks fake.

And second, DSHS said it wasn’t from them.

And really, do we need to say anything else about it? If the meme is a lie in the first place, do we need to spend the energy picking through the data? I will never understand the mentality that says, “sure, it was a lie, but I still think it makes some good points!” When you have discovered that something (or someone) is not a truth telling thing, stop going to it for truth.

But let’s look at the numbers, briefly.

Texas Population
Yep.

Seasonal Flu Numbers 2017-2018, 2018-2019
These all check out too, and you can find them here (2017-2018) and here (2018-2019).

Flu Rates, 2017-2018, 2018-2019
We can ignore the negativity and positivity rates, because they really don’t matter for this discussion. The rest of these took me a minute, because I’ve never seen these numbers before, and they didn’t really make sense. You see, the commonly accepted case fatality rate of the flu is 0.1%, and I couldn’t figure out either how or why a meme trying to show that the flu was more dangerous than COVID-19 would cut the death rate of flu by more than half. It took a few minutes (honestly, as many times as I’ve seen this dumb trick played since I started this blog, I’m embarrassed it took that long), but then it hit me; they are dividing the numbers from the top the rows by the population of Texas to get the numbers in the bottom 5 rows. It’s the same nonsensical math they did in the first stats meme we look at in this blog post! Look at the “Seasonal 2018”:

  • They calculate the “infection rate” by dividing the number of positive tests by the population of Texas. 35,339/29,677,668×100=0.11908%. The problem is, that isn’t the number of flu cases, it’s just the number of positive flu tests. I saw scores of flu patients in both of these years, in the state of Texas, but most of them aren’t represented by this data because most didn’t get a flu test. Why? Because it’s primarily a clinical diagnosis and the flu test has a sensitivity of 50-70%. Unless it’s a clinical scenario where having a specific test result is going to change the patient’s treatment, the flu test isn’t useful to me. I often offer it to people who ‘just want to know’, but if they have flu-like symptoms and flu exposure in the middle of flu season, I’ll explain that ‘if this flu test is negative, I’m not going to believe it because you definitely have the flu.’ So that infection rate is an extremely inaccurate, way too low estimate of how many Texas had the flu during the 2017-2018 flu season. Why does that matter? It doesn’t really, for this discussion, except as a hint at the fuzzy math strategy they are going to take with the more vital numbers.
  • They calculate the “death rate” by diving the number of deaths by the population of Texas. 11,917/29,677,668×100=.04015%. Again, that’s not anything. You could compare the death impact of flu to other diseases by comparing the deaths per 100,000 people, or you could compare the case fatality rate by dividing the deaths by the total number of cases; but just diving the number of deaths by the total population conflates these two important numbers and gives us nothing useful at all. But it gets worse.
  • They calculate the “recovery rate” by subtracting the number of deaths from the population and then dividing by the population. (29,677,668-11,917)/29,677,668 x100=99.95985%. So by their own math they are saying that 29,665,751 people in Texas recovered from the flu, including 29,642,329 people that never had it. This is by far the strangest use of the word “recovery” I’ve ever heard. Please, tell a friend that you’ve recovered from measles and when they ask, “when did you have measles?” tell them, “I didn’t; that’s why I said I’ve recovered from it. Duh.” See if you don’t get punched.

So what do they do with the COVID-19 data? Well, pretty much all the same nonsense; claim that tens of millions of people have ‘recovered’ from COVID-19 who haven’t even had it yet, divide the deaths by population instead of by confirmed cases to get a “death rate” of 3,112/29,677,668×100=0.01049% instead of 3,112/250,462×100=1.3%, and produce an infection rate that is utterly meaningless. But the two worse misinformation sins are these: first, they have gravely misunderstood the differences in our testing strategies for flu and COVID-19. In flu we test the sickest patients or the patients for whom a certain test results really guides our clinical judgement, which means we test a relative few of our actual flu patients. In COVID-19, we are testing many patients including people we don’t think have the virus because it is important for contact tracing and other epidemiology measures (and of course because we want to implant as many of those microchips as possible). This means that positive tests vs. deaths is not a useful statistic unless you really understand the testing strategy, because the COVID-19 strategy is going to catch a far higher percentage of the mildly symptomatic COVID-19 cases than we ever would for flu. But the point of this meme, I honestly believe, is to draw your eyes to the four cells right here, to try to trick you into thinking that COVID-19 is orders of magnitude less dangerous than the flu, which couldn’t be further from the truth.

But the second misinformation sin is also the most important, practically speaking, and it’s this; that they made this meme in the middle of the pandemic, and COVID-19 is still killing Texans. Since this meme appeared a week ago, we’ve gone from 250k cases to 332k, and from 3,112 deaths to 4,111. 1,000 lives in less than 10 days. The meme calls flu season a whole year (“10/17-10/18”) and tries to stretch the COVID-19 pandemic in Texas to as long as possible to make them seem comparable; “1/20-7/20”. But in January and February we had zero deaths. By the end of March we had 42, and by the end of April, 782. This has been a Summer pandemic for Texas, and the people who will increase that total by next week are fighting for their lives today. In real life, in a hospital; not on a spreadsheet. I don’t know if COVID-19 will cause more than 10,000 deaths in Texas. I hope it won’t, but it probably will; I can’t see a way around it. The people who are sharing this meme have apparently already determined, right now, that those deaths will not impact their beliefs about this pandemic. Those lives won’t count. Whether it’s because they are nameless and faceless to them, or because they were ‘faked’ by the doctors, or because they heard that somebody who was in a car accident ‘got counted as a COVID death’, they’ve decided that no matter how many human lives are lost in our state, country, or world, it can all be waved away as long as you can find some way to arrange the numbers that makes those lives seem insignificant. Until it affects them personally, which is the very thing the rest of us are all working so hard to keep it from doing.


Political Stuff (Boo!)

I don’t know about international politics, and it’s too late to look it up, but I’m assuming this is wrong; surely somebody somewhere is trying to unseat a president this year. So, ha, got you on a technicality. I wrote last week about the idea that COVID-19 was a big conspiracy to somehow hurt the president, and how that depended not only on not having any knowledge about the pandemic, but also on not knowing much about doctors, because of whom I’ve been subjected to more doctor’s lounge Fox News broadcasts in the last decade than I ever wanted to watch in my lifetime. That’s about as political as I get on this blog, except to say this; dispelling this meme, and the beliefs behind it, should not be my job. It’s the job of our national leaders, and especially the presidential administration, to challenge these lies that are so incredibly dangerous to Americans, instead of tacitly endorsing and even actively promoting them. Every time they refuse, people die as the result.

Stay alive. Stay alive.
I have never seen a patient so hypoxic
They start out with a cough but by day 10 they’re looking toxic.
Our leaders tweet “the doctors are faking this virus”
We shoot back, “stop supporting these lies your job is to inspire us”
Social media’s nothing but conspiracies, politics,
They won’t listen to truth and reason, so everyday more get sick.

My name is TJ Webb and I endorse this message.

I haven’t thoroughly vetted this one, but I really like it.

A rare moment of cynicism: Why are the doctors lying?

Before I started blogging about medical misinformation, my last blog (which lasted for exactly one post) was called “Mad Virtues.” It was based on this quote from G.K. Chesterton: 

“When a religious scheme is shattered it is not merely the vices that are let loose. The vices are, indeed, let loose, and they wander and do damage. But the virtues are let loose also; and the virtues wander more wildly, and the virtues do more terrible damage. The modern world is full of the old Christian virtues gone mad. The virtues have gone mad because they have been isolated from each other and are wandering alone.”

G.K. Chesterton

While my intention was never to deny the existence either of real nefarious intentions in the world or of original sin, my thesis was that most disagreements, and especially the most deeply felt and violent disagreements, were actually due to a clash of deeply but disproportionately held virtues; virtues that had gone mad, and caused terrible damage, because they had been isolated from the other virtues and truths meant to keep them in check.

In general, I believe this is true today, and I believe it applies to the content of this blog. I think that people like Dr. Richard Bartlett or Dr. Ivette Lozano really believe they are doing the right thing by treating all of their patients with budesonide or hydroxychloroquine, and encouraging people around the country to seek out these unproven therapies for mild COVID-19 cases. I think Dr. Dan Erickson and Dr. Artin Massihi really convinced themselves that their erroneous statistics were valid, which allowed them to view the harm that the shutdown was causing to their own business and the economy around them as a greater threat than the virus. I even believe that Dr. Judy Mikovits, with 20 years of fighting the medical field and presumably becoming increasingly entrenched in narratives of far-reaching conspiracies among doctors and scientists, earnestly believes that her Plandemic interview was an opportunity to expose the “truth” about the virus.

In each of my responses to each of these viral misinformation videos, I have tried to assume the best; that the intentions of those making the videos, like those sharing them, were sadly misguided, misinformed, and erroneous, but ultimately sincere. I hope that if I ever fall into unintentional but very public professional error and embarrassment, the same grace would be shown to me. But today I’d like to try something a little different; instead of assuming the best, I’d like to assume the worst; I want to ask what the game plan would be if a doctor were in fact knowingly lying about the virus; what they would stand to gain from such an immoral act.


Are most doctors lying, or just a few?

As soon as we abandon the idea that deeply held differing opinions dramatically shape our perception of events and even our understanding of statistics (in other words, that most of the doctors who are deceiving others are only doing so because they have already deceived themselves first), we are left with only one alternative conclusion; someone is deliberately lying. So who is it? According to a recent tweet that was retweeted by the president, it’s most doctors.

If we follow this theory, we are going to arrive at some uncomfortable but fairly inevitable conclusions. First, it means that I am lying, because on this blog and in my conversations with patients, family, and friends, I’ve consistently been repeating the ‘party line’ that COVID-19 is very dangerous and encouraging people to exercise caution and take it seriously. It means that when I told you in my last blog post that I was worried about a lot of my patients who have pre-existing heart and lung disease, I actually just wrote that because it made me sound like a compassionate doctor. It means when I said at the end of June that I was seeing a steep rise in the number of positive tests at my clinic, I was making that up and just banking on none of the nurses or lab techs I work with reading that and calling me out on it (I don’t have to worry about the other doctors; they are all in on it too). It means that the long nights and early mornings and sacrificed Saturday afternoons it has taken to write this blog on the side of my full-time clinic job has been motivated not by the stated desire to provide clear (if a bit long-winded) refutations and explanations to dangerous medical misinformation, but by a desire to run a convoluted and ineffective interference to people like Love Connection up there tweeting the truth about the virus. And all I can say is, hey, I’m just as shocked as you are. My wife is going to be very upset when she reads Mr. Woolery’s tweet and realizes that the reason I’ve failed to build her that Ana White potting bench for the past month is because I was busy deceiving some very, very small segment of the American public.

It also means my friends from medical school and residency have been lying, not just to the public but also to each other. Since late March I’ve reconnected more frequently and with a wider range of former classmates and co-residents than I have in years as we’ve checked in on one another and provided updates and insights from our own experiences with the virus. I’ve talked with friends working in the ED in New York during their worst weeks of crisis, and with friends working in rural hospitals that have seen hardly any COVID-19 at all. You could fill libraries with the texts, e-mails, and facebook messages that have taken place between doctors in the past 4 months, and not a one of those has been to clarify the latest lies the WHO, CDC, Bill Gates, and Dr. Fauci want us to push this week (not exactly true; that has been said a lot and is actually a pretty tired joke by now. At least, all of my friends are tired of me making it). If those texts and e-mails are ever subpoenaed, the American public is going to learn a lot; but not about any conspiracy.

Crimes against punctuation and grammar, yes. Against humanity though?

And by the way, not all of those conversations are private, although more are now because of social distancing. Even though we aren’t sitting at coffee shops having these discussions, many take place on very public Facebook comment threads instead of private messaging, and a pediatrician friend and I have had more than one of our Google Hangout Dungeons & Dragons sessions derailed by comparing notes about the virus while the rest of our party waited patiently for us to get back to the quest at hand. If you believe that most doctors are lying about the virus, you have to believe that these types of conversations are actually planned and carried out to deceive friends and loved ones who are not doctors. There’s a joke about ‘rolling a deception check’ in there somewhere, but I don’t have the emotional energy to think of it. Every time you see two or more doctors talking about the virus, how dangerous it is, or what they’re doing to fight or prevent it, that’s a staged performance for the benefit of the public.

Nailed it.

So why all of this lying? We have consistently been given two explanations; because we want to hurt the economy (in order to hurt Donald Trump’s chances of re-election), and because we want to make money. You might notice right away that these two motivations almost but not exactly completely contradict each other. I’m sure it is possible to both want to hurt the economy overall and stand to make money yourself (and here I’ll be called naive by friends who believe that this is essentially the go-to strategy of the ultra rich), but for someone earning a wage like a physician it must be somewhat rare; we would really have to spend some time with a fresh cup of coffee and some excel spreadsheets to make sure that the ‘extra money’ we were making would be enough to offset the hit to our 401k’s and Roth IRA’s, not to mention the doctors who actually own stocks. Honestly, I’m surprised the White Coat Investor hasn’t done an article on “5 financial reasons you should trick people into believing in COVID-19 (and 5 reasons you should blow the whistle on this global conspiracy of doctors and scientists now!).”

If we look at them separately, the first one feels like the type of thing that makes sense only if you forget that you actually know some doctors, and makes even less sense the more doctors you know. For me it’s easy to intuitively disbelieve that doctors as a group are out to get Donald Trump because for the past 13 years I’ve had to endure an almost endless stream of Fox News in every doctor’s lounge I’ve been in from here to Denver. But if you only know one doctor and they happen to vote the same way you do, you might think your doctor is ‘one of the few telling the truth.’ If they do think the virus is a pretty big deal, you might think they have nuanced and complex views on the pandemic, which is probably true, or that they are essentially honest but have been ‘tricked’ by the CDC or other doctors or whomever. But if you knew hundreds of doctors, like I do, you would have to face the reality that while there are many you like and trust and a few you don’t, and while they fall all over the political spectrum, you would be hard pressed to pick even a handful that would be willing to participate in anything like a conspiracy, and that as a group they would be even less likely to be duped by a medical conspiracy if there was one.

This guy’s definitely in on it, but I can’t think of anybody else.

Doctors are not a monolith, and we don’t vote as one. In fact, some of the medical specialties that have been most negatively impacted by the pandemic financially, like Surgery and Otolaryngology, and some that have been most intimately involved in COVID-19 treatment, like Pulmonology, Anesthesiology, and Emergency Medicine, are the exact fields that vote Republican at higher than average rates. There’s only so far you can take this information, and it’s probably true that Donald Trump has lost some physicians from his constituency since this data was collected just before the 2016 election; but at the very least it shows that that if COVID-19 were really a conspiracy to hurt the president, there would be thousands of Republican critical care physicians coming forward to reveal this, instead of a handful of urgent care and concierge medicine doctors. I personally know several doctors who are fighting the virus on the frontlines and still plan to vote for Donald Trump in 2020 despite being frustrated with his administration’s response to the pandemic; for them, a virus is not a political issue, even if it is being used as one.

But the second one is actually even more ridiculous. I’ll start with myself again. Of course it doesn’t matter since we’ve already established that I’m lying about everything, but I can tell you that I’ve made exactly zero extra dollars from COVID-19. I am thankful to work in a clinic system where my personal income isn’t determined by the number of patients I see or what type of insurance they have (our work volume is instead driven by the extensive primary care needs of the population we serve), and unless somebody votes to give frontline doctors hazard pay or student loan forgiveness, this pandemic seems extremely unlikely to be some sort of lucrative opportunity for me (I’ve got a pretty good life insurance policy, though, and my med school loans are non-transferrable, so it could end up being fairly profitable for Katie by the end)(grab a screenshot now, because she’s going to make me delete that one as soon as she reads it). I have put in dozens of hours of overtime, mostly back in March and April helping our clinic get ready for whenever the virus finally surged in our area, but this was all gladly done and entirely unpaid, and I certainly wasn’t alone in this. Since then I’ve spent many hours writing this blog, but it would be hard to argue that this is financially motivated either since so far the net earnings of tjwebbmd.com is negative whatever the cost of WordPress Premium is.

But not every doctor has the same type of employment contract that I have, and when we look at other types of business models we discover that my not especially profitable is the very best case scenario for most doctors during COVID-19. Remember that social distancing measures meant thousands of primary clinics cancelled any appointments they felt their patients could safely postpone as soon as COVID-19 cases began to rise in the US; despite the fact that many of them could ill afford to do so. Some of these clinics closed for good, and this unfortunate side effect of the virus, which is going to affect the health of many people for years to come, was actually put forward by COVID-19 conspiracy theorists alongside the idea that most doctors were lying about the pandemic, without any apparent irony. I know doctors that work for larger healthcare systems who were laid-off during the pre-surge months of the pandemic here in central Texas, not to mention surgeons cancelling elective cases and many hospitalists and ER docs working fewer shifts because hospitals volumes were so low (this is outside the scope of the discussion, but we talked about this phenomenon most recently in my response to Dr. Simone Gold and her A Doctor a Day campaign). For most doctors, COVID-19 has been either financially neutral or a financial hardship.

But what about that big $39,000 paycheck hospitals are presumably getting for putting a patient on a ventilator? We’ve dealt with this conspiracy theory before, and you can read all about it on Snopes.com, or you can wait until this weekend when we try to tackle this meme and a whole bunch of others on the blog. But even if you believed this crazy theory that doctors are intubating people who didn’t need it in order to get their hospital a big pay check (instead of, say, actively working to push the limits of non-invasive ventilation for every possible patient, which is what they are actually doing), consider what else you would have to believe to think this somehow explains “most doctors” lying about the virus: 1. The doctors are getting the money instead of the hospital (yeah, right), 2. the other doctors and nurses and healthcare professionals that know the patient’s case are complicit and staying silent in massive numbers, 3. ER docs are admitting patients who don’t need to be in the hospital just so that their critical care counterparts can get put them on ventilators and get those payments (“set ’em up, knock ’em down”), 4. other doctors who are not involved in the hospital care at all and cannot possibly get a cut of that money are lying about the pandemic and letting their practices get closed so that another doctor in town can make money intubating patients unnecessarily, and 5. they are doing all of this despite their Oaths to do no harm, years of devotion to caring for people, a very real chance of getting caught, and, for about half, the fact that the whole conspiracy is designed to hurt a president they voted for in the first place.

That’s a lot. I’m not saying it’s impossible, but $39,000 seems like a pretty low-ball figure to betray all of the ideals we hold most dear and participate in some grand plot at the expense of the American people. Maybe come back when you can afford to pay us whatever the insurance companies pay their doctors to deny prior-authorizations all day.


You want a cure?

But what if it’s the other doctors who are lying? What if it’s not doctor after doctor I see on Facebook and Twitter saying ‘stay safe, please wear a mask, please do physical and social distancing in order to keep you and your families safe from the virus’ that are trying to deceive you with this advice because it somehow makes them money (Step 3: ???… Step 4: Profit!), but the handful of doctors writing things like this:

The social media post is about 2 weeks old by now, which I realize is ancient in internet misinformation time. One of the struggles of doing this as a hobby on the side of a full-time job. Regular readers will notice I’ve done something unusual for this blog: I’ve omitted the name of the author I am responding to. This is a fellow Texas physician a few hours north of here (whom I’ve never met), and his name isn’t hard to find; I’ve even mentioned him when referencing this post in prior essays and his post has been viral on social media. But I’ve omitted his name here because, unlike in those other essays, I plan to treat this post as cynically as possible. I’d like to work through this post and ask what we can conclude about this doctor’s practice style, COVID-19 testing and treatment policies, and overall goals in writing this post, and while I believe my worst-case-scenario conclusions are a valid interpretation, I sincerely hope that the real, living and breathing, created in the Image of God person who wrote this is better than he will get credit for in those post. He probably is, and so I’ve erased his name from his post and plan instead to treat the author as a fictitious person.


Dr. Lozano is the doctor who spoke about Hydroxychloroquine at the Set Texas Free Rally way back in mid-May. I wrote a response to her speech at the time and tried to address her use of Hydroxychloroquine in the outpatient setting for minimally symptomatic and even asymptomatic patients. Since the doctor in this post is using it much the same way, I won’t spend as much time on this and will to some degree take it as a given that we agree this is an improper use of the medicine, or at least that you have heard my side of the argument already.


I think this is a really fascinating set of claims, for a couple of reasons. First, as I said in the post responding to Dr. Lozano, numbers matter. This doctor claims at the end of June to have been treating people in the ‘outpatient trenches’ for 2 months, but like the rest of Texas, McKinney began to hit a surge in cases just about a week prior to his post; by the time of the post there had been less than 500 in the entire city, and fully half of those were in June; at the end of May the total confirmed cases in McKinney was 251. He goes on to say that he has treated ‘over 50’, (which, since we are being cynical today, means 51 or 52) patients relatively early in their disease course, trying to catch them 3-6 weeks before they would need the hospital; but with so few cases in April and May, how many of those 50 could possibly have made it to his 6 weeks post treatment yet to ensure they were out of the woods? The time course he lays out for concluding his treatment works and the time course he would have had to observe his patients’ response to his treatment just don’t line up.

But the saving grace for this post’s author on that point is that he could still get credit for most of the patients he treated this way up until about mid June, because the time course from first symptom onset to the rapid deterioration from Acute Respiratory Distress Syndrome in severe cases of COVID-19 is typically between 8 to 12 days. His time course of “starting treatment 3-6 weeks earlier” doesn’t make any sense, because the incubation period of the virus is 2-14 days and the time from symptom onset to clinical deterioration is typically 8-12 days or less; at the very most, a patient with a severe course of COVID-19 may have about 3.5 weeks from the time of their exposure to the point of requiring hospitalization, and that would be an extremely rare occurrence; most commonly it would be about 10 days to 2 weeks.

His citing a time frame of treating people 3-6 weeks before they would need hospitalization suggests one of two things. First, he could be comparing the start of symptoms to the time of death in patients that spent a number of weeks on the ventilator, claiming that hydroxychloroquine might have saved these individuals if they had been started on it 3-6 weeks sooner because he isn’t actually familiar with the hospital-based treatment protocols or clinical trials that used hydroxychloroquine, which certainly did not start the medication in the final days prior to the patient’s death, after they had already spent a couple of weeks in the ICU. Or second, he could be building a narrative that says COVID-19 really presents much earlier and can be detected by someone with special expertise or insight into the virus, which he happens to possess. The problem with this later one is that the incubation period means he reaches a firm time cap, the date of first exposure to the virus, long before he gets to his 3-6 weeks early; by claiming he is treating people 3-6 weeks before they would have been sick enough to need the hospital, he is essentially saying that he’s treating some people before they’ve even been exposed to the virus. If you just now thought, “wait, isn’t ‘treating people before they’ve even been exposed’ the same thing as treating people who are healthy and might not ever be exposed?”… Yes, yes it is.

Fine, he has his time course a bit off; but his overall point is still valid, that maybe the medicine would work if it was started before the patient needed the hospital.” I think this is a common and very understandable stance, and there are so many different ways to approach it it’s hard to know where to start. We could point to the fact that not all hospital patients with COVID-19 who were treated with hydroxychloroquine had the same disease severity when they started the medication; if it were most useful early in the disease course, wouldn’t we have seen the less severe patients and those who were hospitalized earlier in their disease course derive greater benefit from it in all of the studies and the widespread clinical use it had a couple of months ago? Yet no such trends emerged to point us towards even earlier use of the medication. We could point out that it was doctors who started using hydroxychloroquine broadly in the first place based on some early anecdotal evidence and only stopped once more and better data was collected which unfortunately showed it wasn’t beneficial, which is exactly how science is supposed to work, and that both the idea of the president coming up with the treatment from his own research and the medical field abandoning it as soon as he endorsed it just to spite him are complete political fabrications. Here’s me and my friends texting again, this time on the same day President Trump mentioned hydroxychloroquine for the very first time.

Not pictured: My text a couple of hours later saying “whoops, Donald Trump mentioned this in his press conference today, so let’s abandon the drug even if it would have helped our patients. Too bad.”

We could also point to studies that have been done in exactly the clinical scenario in which this doctor is using his treatment plan- self-reported exposure to the virus- using hydroxychloroquine as post-exposure prophylaxis to prevent symptoms, which ultimately showed no benefit: as many patients became symptomatic and were hospitalized in the group taking the medication as in the group taking placebo. But as Dr. Myron S. Cohen, M.D. points out in an editorial about this study, medical research is not entirely free from popular opinion, and there are a great many ongoing trials still being conducted with hydroxychloroquine right now, many of which are focused on treatment very early in the disease course. (Edit: One was published in Annals of Internal Medicine the same day I published this article. It found that Hydroxychloroquine did not substantially reduce symptom severity in outpatients with early, mild COVID-19). If there is a use for it against COVID-19 at any point in the course of illness, we will hopefully know about it soon. But the doctor who wrote this post had no reliable data to suggest that his treatment would be effective; after looking at his own numbers, it’s pretty clear we still have no reliable data.


We talked about this last week when another Texas doctor claimed that inhaled Budesonide was a “silver bullet” against COVID-19 based on only a dozen patients. Right now we think the fatality rate of the virus is somewhere between 0.5% and 1.3%; still 5 to 13 times higher than a very deadly virus called Influenza, but not anywhere near the civilization ending numbers we had to work with before more widespread testing was available (I talk about these numbers more in this post). This means that if you took a random sample of 50 patients with confirmed COVID-19 and actually did absolutely nothing for them (which is not the same as offering anticipatory guidance, providing symptomatic support, carefully discussing emergency room precautions and red flag signs and symptoms, and talking through and arranging follow-up care) and 50 of them were alive a few weeks later, you would be thankful but you certainly wouldn’t be shocked. If you had 100 patients with the virus and they all lived and none ended up intubated in the ICU, you might call that God’s grace or good luck (or both, depending on your theological leanings), and you’d probably look at the demographics and risk factors of the patients, but you wouldn’t assume that the doctor had done anything extraordinary. Looking at this doctor’s sample of 50 or so patients, the one thing we can definitively say is that these statistics are not amazing. Any number of doctors around the country treating COVID-19 appropriately without unproven medications dosed with a heavy mix of conspiracy theories could give you a similar case series and claim that their particular brand of talking with patients had a “100% success rate.”

It is a little interesting, though hardly amazing, that none of his patients required hospital level care at all, and is enough to want to know more about his subset of patients. But it is exactly here that this doctor first tips his hand a little bit, by giving the details of just one of his patients. He states that he treated a patient who had been discharged from the hospital after 4 days of treatment but still ‘felt terrible’ (as people tend to do when they are ill, and also when they’ve just spent 4 days in the hospital. Heck, I feel awful after 4 days in the hospital as a doctor, much less as a patient). He treated this patient with his unproven drug regimen as well, and includes them as an example of just how effective it is. But please bear in mind that this patient had not been refused admission or callously sent home to die; they had already been treated in the hospital during the worst period of their illness, and deemed healthy enough to continue to recover at home by their hospital doctors. To include this patient not just in your data set but as an example of how effective your therapy is at preventing the illness from worsening is proof in itself that your understanding of how this virus operates is not based on reality and the experiences and insights of your peers who have more experience with it, but on narratives that you have built for yourself because you happen to find them useful. We already suspected this doctor was treating patients before they were exposed to the virus; now we know he is treating them after they were already far along in their recovery as well.


The doctor doesn’t stop there, but he goes on to give a list of other measures he doesn’t agree with, and we need to spend some time here, because this is where we really come to understand his treatment philosophy.

He states that he doesn’t believe in contact tracing, calling it ‘communism’ and stating that he ‘cannot even get the Public Health Dept. on the phone’. This is a bit like saying ‘you can’t fire me, I quite!’ and then asking about your severance package; if he really believes contact tracing is communism, one would wonder why he was calling the Public Health Dept. about contact tracing in the first place. I also don’t understand how contact tracing could possibly be communism, but clearly this is a secondary issue at best.

He also doesn’t believe in quarantine, which while undoubtedly difficult on a broad-scale (other countries have found ways to help their effected citizens deal with quarantine and isolation with adequate social and emotional support measures) is also common sense epidemiology, and in wearing masks, which have plenty of solid evidence (which has only increased since I wrote that blog post). He doesn’t believe in social distancing (I don’t understand what he’s talking about in the parenthesis, but I think it’s about the economy), and he even says he doesn’t believe in testing, citing an insanely inaccurate false negative rate that is only possible, even for the very worst tests, once COVID-19 is at 55%-65% prevalence in the population you are testing; a number we have not seen anywhere in the world at any point during this pandemic. For reference, the highest his county has reached at any point has been a test positivity rate of 16.89%, just 2 days ago. This would give the two tests I use a false negative rate of 4% and 1.3% respectively.

This is really a whole separate set of claims. He is claiming that the methods used by every single country that has seen success in protecting their citizens from the virus don’t work, while an unproven and incredibly politicized medication regimen used by him and one other doctor in a nearby city is the miracle cure. One might advise a more humble approach, claiming that while these strategies might work (as the evidence clearly demonstrates they do), they would be rendered unnecessary by his treatment strategy; but he boldly claims both, even to the point of saying that other doctors not using his treatment regimen has lead to 100,000 deaths. If he is wrong about the latter and is widely believed, the virus will spread more quickly; if he is wrong about the former, those who are exposed as a result will be without the miracle cure they were promised.


What if he were lying?

Here’s the cynical part, and the part I find hardest; what if this misinformation, rather than the honest misunderstanding of a doctor with very limited experience with the virus, were a deliberate and calculated deception in order to make money, as so many other doctors have been accused of? Would this, unlike advising social distancing at the expensive of your own clinic’s bottom line or cancelling lucrative elective surgical cases, be an effective financial strategy?

Let’s review. In this post, this doctor:

Advises against wearing masks, social distancing, and quarantine. If he’s lying, this would increase the number of COVID-19 cases during a time of otherwise decreased medical visits, thus creating more sickness and more patient visits in general.

States he doesn’t believe in testing. This eliminates a natural barrier to receiving ‘targeted’ treatment, because it places the diagnostic decision making entirely in the subjective realm, all based on phony statistics about the COVID-19 tests. This means that a number of his patients will receive treatment without even having the virus in the first place, which will inflate his “amazing” treatment statistics. This is great, because he also states that he…

Claims he is treating 3-6 weeks earlier than other doctors. This means he is relying on some unique way of diagnosing the illness that is entirely original to him, that would lead to a diagnosis weeks before a patient would end up in the hospital; in other words, it won’t even matter if you have recognized symptoms of or exposures to COVID-19, he is able to diagnose you well ahead of any normal doctor. Combined with a promise that he won’t rely on test results for the virus, this is tantamount to a promise of specific medications for treatment ahead of time, which is an advertising tactic, not conscientious evidence-based medical practice. It would be like promising antibiotics for your child’s ear infection whether they need it or not, and then claiming that your child would have had an ear infection and that most doctors don’t treat as early as he does because they just don’t know the very early signs, like being fussy, tugging at their ears, and wanting to watch Moana over and over again (hey wait! My toddler does have all of those symptoms!).

Promises “completely safe and incredibly effective” treatment without any credible scientific evidence of its effectiveness. This reinforces his criticism of masks, social distancing, and quarantine for his patients specifically (who wouldn’t need them anyway, since they are now ‘healed’), which increases subsequent cases in their families and friends; the very people his patients are likely to refer to him by word of mouth.

Shares his post on social media. This spreads the word, especially once it goes viral, and not only increases cases as people believe it and use it to justify forgoing mitigation and transmission control measures, but also drives people to his clinic from all over the state and region because he…

Shares his name and says to contact him. Having now promised treatment for a virus that his post is likely to cause more cases of, he now ensures that he will have a higher percentage of the market share of both these new COVID-19 cases and people who don’t have COVID-19 but are seeking pharmaceutical treatment out of fear due to the increasing surge; a surge his post is at the very least contributing to.

In summation, this post is saying don’t do any of the these inconvenient things doctors around the world say will help keep you and your family safe from the virus; just come see me in my clinic and I will diagnose you with COVID-19 whether you have classic symptoms or not, whether you test positive for it or not, and without fail prescribe you these medications that you can’t get from most other doctors.

You don’t need five years of medical school to understand why this should make you cautious.


I have to admit, that felt really dirty. I’ll say it one last time; I actually think this doctor, like so many of those I’ve argued with from a distance on this blog, really believes his post. He has gotten his stats wrong, relied on old and incomplete data on masks, misunderstood what other countries have done to fight the virus, confused contact tracing with communism (ok that one is new), leaned on anecdotal evidence, and I believe in general approached the subject with enough bias and preconceived ideas and little enough actual exposure to the virus that he never had a chance of reaching a different conclusion. In fact, his very limited clinical experiences with ‘treating’ the virus are almost perfectly calculated to provide him the confirmation bias he needs to firmly cement the truth of all of his claims in his mind, and that will only get worse as more patients come to him “early” in their disease course and experience a full recovery, whether they ever had the virus in the first place or not.

I do think this doctor can be wrong, and yes, do damage, without it being nefarious. But it’s clear from social media that there are some people, perhaps many people, who are not comfortable with the majority of physicians drawing one conclusion while a small minority draw the opposite conclusion unless one of those groups is lying. If that’s you, please consider which doctors have the greater financial motivation to build a false narrative- and stand to actually gain from the narrative they are building- and which are willing to tell the truth to keep you safe even if it potentially hurts them financially. That’s already one of the most obvious ethical principals we nevertheless have reinforced for us repeatedly throughout medical school and residency and a decision that a great many of us got used to making years ago anyway, and the idea of a doctor telling his patients “please stay home and stay safe” as he wonders how he’s going to pay the rent on his clinic building is far easier for me to imagine than any of the critical care doctors I’ve met in the last 13 years intubating a patient that they thought didn’t really need to be on a ventilator, much less because it was going to make them some extra money.

What happened to all the deaths that AREN’T from COVID-19?

I’ve seen this meme and the sentiments expressed therein posted around the internet, and from spending some time in ultimately futile arguments with the people sharing them, I am slowly coming to the realization that the “I wonder why” might actually be rhetorical. When I’ve tried to explain “why” so they don’t have to wonder anymore, it seems like maybe they thought they already knew the answer. In fact, shockingly, it seems that rather than a sincere question about medical statistics, they are actually implying that the COVID-19 death rate is being inflated for political or other purposes. So rather than continuing to offer my explanations to people who have sort of already decided they don’t want them, maybe I will offer them to you, who at least might find it a little interesting.

One word to begin with; one possible implication here (which has been stated explicitly elsewhere) is that Physicians are falsely attributing deaths to COVID-19 that are really caused by other diseases, in order to inflate these numbers. You will have to ask the conspiracy theorists for more details. For instance, what agenda are the doctors trying to forward here? If this is an anti-Trump thing, how did the libs manage to convert all of the 60 year old docs I work with that get mad when I turn off Fox News in the doctor’s lounge? If this is to give the current government more emergency powers or something like that, how did they convert the physicians I know who went into medicine to further social justice? We are a pretty diverse group here in doctor land, and if somebody has managed to recruit us all into a nation-wide conspiracy, I’d like to attend that person’s TED Talk. The medical community could use more people like you! The insurance companies, healthcare administrators, and pharmaceutical companies have been callously taking advantage of our compassion, energy, and time for years, and we, our families, and especially our patients are the ones who end up paying for it. So once you are done with your COVID-19 conspiracy please stick around and help us get organized!

To be clear, I have never heard of a doctor lying on a death certificate. It happens all the time on TV shows so it must happen in real life, right? And it probably does, at least sometimes. But if it does, it’s because that individual clinician has failed the integrity test, or more often the cognitive dissonance test, and described the events of the patient’s death in a way that diminishes or obscures their culpability. If that’s the case it really is shameful, and there are failsafes and powerful analytical tools in place (although I honestly believe, not used often enough) to ensure that the events of a patient’s death, especially an unexpected death, are really and thoroughly understood. I will say, most of the Physicians I know are more likely to swing the other way; to take on too much personal responsibility, to assign too much blame to themselves when a patient passes. We carry our dead around with us for years, and very, very often there wasn’t anything that anyone could have done differently. When there was, hopefully we have learned from it; but the pain may last nearly as long as the lesson. But all that to say, the idea of doctors across the nation suddenly embellishing death certificates and medical records to make a virus we HATE seem even more dangerous than it already is seems pretty ridiculous, aside from being just blatantly not true.

Of course, there are people who will be quick, especially when speaking to a Physician personally, to remove this culpability by one degree of separation; maybe it isn’t the doctors themselves but hospital administrators or bureaucrats, or the ‘deep state’ officials at the CDC and WHO, who are falsifying the data. Weary unto death, all I can answer is “fine, maybe.” There’s only so many layers of conspiracy theory I can personally unpack for someone. Listen, you won’t find many people who spend more of their time fighting medical bureaucracy than I do (I’ve written Hamilton rap parodies about it), but please consider the sheer number of people who would have to be in on it; governments across the globe and all across the political spectrum, Trump allies and critics alike, the army of scientists and researchers and analysts at these big organizations, most of whom stand to gain absolutely nothing by falsifying data and who have deep seated personal convictions about the integrity of their work, just like you and I do, and who probably have to be very careful talking about politics around the office because they have diverse and sometimes volatile political leanings, just like your office does. Not to mention the hundreds of thousands of Physicians, Nurse Practitioners, Physician Assistants, Nurses, CNA’s, Respiratory Therapists, and other healthcare workers around the globe who are sharing their personal stories from the hospitals they actually work at every day. I mean, thank you for extending the courtesy to not believe I am personally a dishonest, corrupt conspirator; but pretending that each physician you personally know just happens to be “one of the good ones,” but are ultimately naive and have the wool pulled over our eyes, really isn’t much better.


The real answer to this meme is a lot more straightforward, and quite frankly a lot more worrisome, at least for a Family Medicine Physician like me. You see, these “other” causes of death that this meme is talking about don’t typically cause death all at once, suddenly, all on their own. Most chronic conditions that statisticians point to as “leading causes of death”, like chronic lung disease, diabetes, and even most types of heart disease, won’t cause you to just suddenly die (again, especially certain cardiac conditions are an exception to this). If a person passes away suddenly and has Diabetes listed as a cause of death, you won’t hear their doctor tell the family, “well, you know, sometimes this happens when you have diabetes.” With most chronic diseases, death from that disease is going to be preceded by a sub-acute deterioration and/or an acute exacerbation, often triggered by other acute illnesses, lapses in care, and other factors. In fact, there will usually be multiple cycles of recovery and deterioration before the hospitalization that leads to their passing, depending on the specific medical condition and the patient’s wishes and planning for end of life care as that condition worsens.

In this way, most chronic conditions can, from a mortality standpoint, be thought of as severe medical vulnerabilities; if managed well, it is usually still going to take an event or acute illness of some kind to kill you, but those medical conditions make you that much more vulnerable to those events and illnesses. I have seen older people with congestive heart failure go into acute respiratory distress from pulmonary edema a few hours after eating salty movie theatre popcorn. I have seen poorly controlled diabetics rapidly deteriorate after just a few missed doses of (now unbelievably overpriced) insulin. I have seen cancer patients quickly pass away following a pulmonary embolism, a blood clot that formed in their lungs because the cancer makes their blood hypercoaguable. And of course, we have all seen countless men and women with COPD and CHF pass away from complications of the flu, which a younger person without similar comorbidities might have been able to weather at home. However, unlike other medical vulnerabilities (poverty, lack of transportation, living in a food dessert, marginalized status, etc.), these medical conditions are typically listed in the medical record under distinct diagnostic codes and are listed under the sequence of events in a death certificate. Because of this, it really is possible to track the degree to which these diseases are implicated in death over time. But these diagnostic codes are not mutually exclusive; if a Physician believes that a patient’s Diabetes and Congestive Heart Failure directly contributed to their death from Pneumonia, all of these would be listed both in the patient’s medical chart and in their death certificate. So depending on whether you are examining data for immediate causes of death, contributing causes of death, or underlying causes of death, you are going to get some drastically different data sets. Hypertension and kidney disease, for instance, are much more likely to be contributing factors to death than immediate causes of death.

So, with all of this background information, where are all of the deaths from stroke, heart attacks, and pneumonia? Well, I think there are four likely (and non-mutually-exclusive) answers to this.

1. You might notice that in contravention of the icanhazcheesburger act of 2014, this meme doesn’t actually cite any sources; nor have I seen any data sources that suggest the actual death rate attributable to standard leading causes of death have actually decreased. This may simply be a falsehood, pure and simple. Are you surprised? Welcome to the internet; I’ll help you build a geocities site. I’ve searched for data actually showing that over the last 2 months there has been a drop in all-cause mortality or non-covid-19 related mortality either regionally or nationally, and it just doesn’t seem to exist. If you have it, please send it along; I’d be very happy to sit down and pore over it with you (over zoom). If anything, and here’s where we really get controversial, there’s plenty of evidence that the statistics may actually BE UNDERESTIMATING mortality attributable to COVID-19. But that’s outside the scope of this entirely too long already post.

2. In some ways, we do expect death due to certain conditions to decrease during a pandemic. Social distancing means less travel and thus fewer accidents. Fewer parties and social events generally means fewer deaths from accidental drug overdoses and alcohol. Other more subtle factors are likely at play; less travel also means fewer patients who take a 5 day trip and forget to pack their blood thinner or insulin, and less eating out probably means fewer diet-related episodes of DKA or CHF exacerbations. Of course other causes of death, such as those related to suicide, domestic violence, and child abuse may go up; it’s too early to see all of the ramifications of the drastic measures we have taken to fight this terrible disease. The cost has yet to be counted.

3. The data does show that COVID-19 is “now the leading cause of death in the United States” as one news source put it (google it; I won’t clutter up this post with link after link). Does that mean that deaths from heart disease and chronic lung disease are down? Is that because doctors or administrators or the CDC is “recategorizing” these deaths as COVID-19 deaths? No. A great number of those COVID-19 deaths ARE deaths from heart disease, chronic lung disease, and uncontrolled diabetes, just as a great number of deaths from the flu are ALSO deaths from heart disease, lung disease, and diabetes. These vulnerable patients that have these diseases are the very same people we are trying hardest to defend with social distancing and innovative healthcare delivery and isolating suspected and confirmed COVID-19 patients. Doctors and nurses aren’t ‘wondering why people aren’t dying’ from these diseases anymore; they are seeing them dying from these diseases making them significantly more vulnerable to complications of COVID-19, and desperately trying to protect them. Data that shows the full set of contributing factors will still show these diseases; but you might see the underlying cause of death data be more readily available, because slicing data in a way that minimizes the impact of an actually terribly deadly virus isn’t particularly helpful in the middle of a pandemic. What we want to know is how dangerous is this virus to ALL of our patients, even and especially the ones we worry about already.

4. Finally, regardless of this meme’s failure to give any sort of statistical support, I highly suspect that there are patients who might have been in the hospital right now for their heart failure, their lung disease, or their cancer who aren’t because of the Pandemic. This is due to a lot of factors, but all of them boil down to a necessary but dangerous shift in treatment thresholds and an overwhelmed or potentially overwhelmed medical infrastructure. ER doctors have a higher threshold to admit patients to the hospital because, even more so than at normal times, they are safer from infection at home; the risk-benefit ratio has shifted. Clinic doctors are handling more than ever before over telemedicine and other innovative care options, but that transition in itself is going to mean that things are missed because the routine is disrupted. Where are the hospitalizations and deaths from heart disease and lung disease, from strokes and diabetes? They are there as part of the COVID-19 hospitalizations, certainly; but we are terribly, terribly afraid that they are also at home, with the worsening of their condition going unnoticed, and that by the time this pandemic is over and normal life resumes it will be too late to intervene. All of us are afraid of a second spike in COVID-19 deaths if social distancing measures are discontinued too soon, but we are also concerned about a third spike; a spike of all-cause mortality and morbidity from the disruption this pandemic is causing to our normal modes of treating patients. That’s why we are working around the clock to figure out the best way to take care of the patients under our charge while at the same time preparing for and fighting the battle with COVID-19. Maybe you are tempted to look at this last point and say, ‘see, this means we should open things up and get back to normal life!’ That would be a costly decision in terms of human lives; what good does it do to catch someone’s worsening glycemic control a month early if in doing so you’ve exposed them to a virus that will kill them in 2 weeks? We are having meetings daily and working past midnight to try to figure out how to do both; to care for the chronic diseases and catch the lurking threats early, and yet protect the patient from the known enemy that has already claimed AT LEAST 23,604 lives in the US alone since February 29th. It’s a moving target, but we are still in the middle of this fight, and for the physicians and nurses on the ground politics has nothing to do with it; we are fighting for our patients. That is, for you.

So please, from your facebook friend who also happens to be a doctor, think twice before sharing memes or youtube videos that imply we are all part of some big conspiracy (wittingly or otherwise) to inflate the pandemic and hurt this group or undermine that politician. I promise you we are all far too busy.


Edit: Please forgive typos, I have patient calls to do before bed and won’t re-read this monstrosity.

Edit 2: For anyone who cares, I’ll try to address that youtube video sometime this week. You know the one.

Edit 3: A colleague shared the original article, which would have answered the tweeter’s “I wonder why” if she had bothered to read it. It is written by another MD experiencing the ‘calm before the storm’ of social distancing measures in areas where the peak hasn’t hit yet, just as we are here in Waco. He mainly talks about the concepts I’ve discussed in explanation 4 and 2 above, in that order, and encourages people NOT to delay emergency care for other diseases or conditions out of fear of the virus, which is good advice.

What he does NOT do is imply that someone is alternating cause of death in reports.

You can read it here: https://www.nytimes.com/2020/04/06/well/live/coronavirus-doctors-hospitals-emergency-care-heart-attack-stroke.html?fbclid=IwAR2qO2ip3oihI9-cix00xQaVCPOKjORW4uIcX5GJEJsU9GaUfbJTEI3ore8#click=https://t.co/HOX2Tc5PWt