Letters to the Editor

Introduction

The last few months we have been slogging through a period of medical, economic, social, and personal difficulties related to COVID-19. I have had conversations with many of you in different ways (in person, phone, text, email) and I have been both challenged and blessed to deeply consider the times that I am living in. How am I to process the various reports, opinions, and recommendations? How am I to answer or respond when asked, “What do you think?”.

First, I must apologize for giving many of you very brief, incomplete, poorly thought out, poorly reasoned responses. This is my imperfect attempt to make a better answer to your honest and appreciated questions, comments,
and opinions.

God’s Purpose

We are called to be image bearers of God (Genesis 1:27). God is the great creator who spoke creation into being and brought order where there was none. God continues to bring order and maintain that order through Jesus (Colossians 1:17). It is easy to appreciate the image bearing activity of great artists, composers, writers, poets, sculptors and such. Another way in which we bring creativity into God’s world is by bringing order out of chaos in the mundane things. We see this ordering of creation by teachers guiding students, by children organizing their rooms, by mothers managing a
busy household, by roofers repairing a roof, by preachers proclaiming the word, by bankers organizing assets, and on the list goes.

My daily contribution mostly involves maintaining or rehabilitating the medical/physical order of my patients’ health. I have little to offer the world in regards to painting or sculpting, but I am honored each and every day that someone would engage me in helping them maintain or bring order to
their physical life. Since the day that Adam bit the apple, our spiritual and physical world have fallen into sinful chaos. My pastor is engaged in a very similar process, he is engaged in bringing spiritual order into my life that is often wrecked with sinful misdirection. My pastor has an absolute authority and perfect guide for his teaching, the Word of God. The Word of God speaks in many wonderful and awe-inspiring ways to physicians and patients, yet that is probably best for another paper on another day.
As a medical practitioner informed by science (taking information and applying it to people’s individual circumstances), I must look for authoritative informative sources on pink eye, pneumonia, arthritis, diabetes, heart disease, breast cancer, meningitis, and most recently, COVID-19.

Handling Scientific Information

In Junior High, we first learned the scientific method, 1. Ask a question 2. Background reading 3. Propose a hypothesis 4. Design experiment to test hypothesis 5. Analyze the data 6. Report results. This scientific method gained acceptance in the early 17th century and has been a standard process of leading us out of the subjective and into the objective in the sciences and especially medicine.

The US medical journals began a tradition called peer review in the mid-20th century. Peer review is the process of taking a work of research that is not yet published, removing the author’s name, and sending it to a number of experts in the same field to review the paper. The reviewers will examine and scrutinize the work to determine if enough information was gathered, proper techniques were used, report any perceived bias, review the data analysis techniques, and essentially determine if the research paper demonstrates high quality research that is deserving of publication or not. The reviewers will submit their opinions on the work to the editor of the publication with their recommendation.

Examples of reputable journals that follow this process and publish credible works include The New England Journal of Medicine, The Journal of the American Medical Association, The Lancet, the British Medical Journal, and others. Based on research that is published in journals like these and opinions from expert panels in their respective fields, the medical community has diagnostic, preventative, and treatment guidelines published that we practitioners often lean heavily on.

An example would be the Eighth Joint National guidelines for the management of hypertension in adults. Another would be the practice guidelines published by the Infectious Diseases Society of America. Groups like these and others (CDC, NIH, WHO, ACOG, ACP, USPSTF) take the best information we have, gather input and opinions from a panel of experts in the field, and publish these guidelines.

As a practitioner, I use the guidelines and try to apply them in a reasonable way to my patients. However, I certainly understand that some situations are rather unique and require a thoughtful, individual approach.

About 10-15 years ago, I would have an occasional patient come into my office with pages torn out of a recent Reader’s Digest. It would be some article about a new medicine, supplement, or antidote for their ailment, and they just needed to call a certain phone number to forever secure their health. I actually found these interactions with patients to be engaging and profitable. It allowed me an opportunity to help bring clarity in difficult situations and help them to do things proven to be useful and have appropriate expectations concerning things that are not proven.

Fast forward and you can probably imagine that I rarely review Reader’s Digest articles with patients anymore, but I do review Google searches with patients several times each day. Many patients begin the conversation with “I’m so sorry to bother you with this, but I did search Google and found x, y, and z, what do you think?”. I have the same reaction as I did 15 years ago, I am honored that the patient would request my opinion and assistance in bringing order to their physical life and try to sort out the good and applicable information from the bad or inapplicable information. Sometimes these Google searches are spot on for what the patient has or needs, and sometimes they are being led in the wrong direction. I feel obligated to point my patient in the direction of what we have learned about x, y, and z through high quality research. Off label therapeutic options or alternative treatments may or may not work for their intended purposes, we just do not know and I try to humbly explain this, I’m neither for nor against them but neutral.

A Word about Anecdotal

Anecdotal evidence is an individual or group of individual stories about a treatment or prevention success from some intervention that took place. When I was a child I once had an upset stomach. My grandmother gave me a Sprite and told me to drink a little and burp and I would feel better. Of course, to my knowledge, there is still no research proving that burping a Sprite will help any tummy ache, but my grandmother was acting out on anecdotal evidence. The oral tradition passed down to her by her mother was that if you drink Sprite and burp, then your tummy ache would resolve. Our world is full of anecdotal evidence. If we ask for advice on what helps sore knees and our friend tells us that BENGAY really helped him, then our friend has appealed to anecdotal evidence to recommend BENGAY to us.

Years ago several of my friends began to subscribe to a certain supplement system (that shall remain nameless). The supplement system promised to help a wide variety of ailments. Advertisement video and marketing materials were full of personal stories of success. People had been delivered of their every ailment and never felt more young and energetic. The supplement system was quite expensive, but most of the cost could
be deflected by participating in the multilevel marketing system of the product and you could receive your supplements for little to no cost or even make money by helping people feel young again. Woefully lacking in this company’s disclosures was any high quality research on the clinical effects of their product. Instead of quality research, we were only given anecdotal evidence (personal stories). My friends have all long abandoned the supplement system from years ago that was filled with so many false
promises.

Anecdotal evidence is not all negative. Though I believe anecdotal evidence performs poorly in providing answers to problems or guidelines to physicians, I do believe anecdotal evidence is the beginning of the scientific method. Anecdotal evidence creates the question and eventually the hypothesis. Does Sprite help alleviate pediatric abdominal pain? Once the hypothesis is made, the research can start, and with good methods, repeatable results, great data analysis, and adequate peer review, then this study is ready for full publication and debate as to the merits of Sprite for pediatric abdominal pain.

Corruption

I have often heard many of the following objections “vaccine companies are corrupt”, “big pharma wants to rule the world”, “the government wants us all sick”, “doctors are in bed with the drug companies”, or “the CDC is full of communists and marxists”. To this, I give what is often a very surprising response, I agree.

“The heart is deceitful above all things, and desperately sick; who can understand it?” Jeremiah 17:9, ESV.
“The Lord saw that the wickedness of man was great in the earth, and that every intention of the thoughts of his heart was only evil continually.” Genesis 6:5, ESV.

The corruption of man is both personal and corporate. It does not spare the vaccine company, the big or small pharma, the supplement industry, the vitamin makers, the essential oil companies, the local dentist, the hospital system, the country doctor, the NIH, the WHO, or me or you. In regards to the purpose of this paper, what are we to do? We are to strive towards exposing corruption, preventing it, and walking away from it. We have tools in place that help us in this endeavor for finding good, solid, fruitful
medical guidance. We want transparency of information. We want the methods of research to be detailed (nothing left out), accurate, and peer reviewed. We want guidelines that are generated based on quality research, independent expert opinion, panels that are plural (several experts working towards consensus), free of pharmaceutical or political influences, and humble enough to be updated/amended when new information is discovered.

These activities are the friend of truth in determining what is good and actionable healthcare information. This is a lofty goal on this side of heaven, but it is our starting place and the best system we currently have for fighting corruption and contamination in our health care space. We do not find our answer in poorly researched, highly politicized, unpublished, non-peer reviewed, and solely self promoting “research” that very easily enters our Facebook, email, Twitter, or Youtube inbox. Getting information or “research” into one of these digital inboxes is a very low hurdle compared to getting a paper published by a reputable medical scientific
journal.

COVID-19

If you have endured this paper till now, I congratulate you. I am now prepared to give my opinions in a couple areas about COVID-19 that I have been asked about multiple times and have thus far given answers that I felt were incomplete or not well developed.

My opinion in the past and my opinion now are not exactly the same. My opinions about anything COVID-19 is humbly fluid. This is a novel virus, we do not know what we do not know. Our knowledge is ever evolving. Will I prescribe hydroxychloxychloroquine (HCQ) for the prevention or early outpatient treatment for COVID-19? Today, my answer is no. I really hope HCQ or another therapeutic proves itself effective for prevention and treatment. As of today, research that is considered high quality has failed to demonstrate a benefit from treatment with HCQ, azithromycin, zinc, or any combination thereof. Currently, the CDC, WHO, NIH, FDA and ACP all
recommend against the use of hydroxychloroquine in the outpatient setting. I am not progressive enough as a practitioner to go against such a widespread agreement on this recommendation. If/when these expert groups begin to change their recommendations, place me first in line as a physician who wants a treatment and prevention option for my patients, and I will most certainly offer those prescriptions to my patients.

Do I endorse the use of masks and social distances in combating the virus? My answer today is, sort of. I know, the first impression of this answer is not gratifying, but let me explain. The science about masks and social distancing is not the same as a placebo controlled drug trial. I have to rely more on expert opinion than the results of a head to head study that would be very difficult to conduct. The experts at the CDC, NIH and others, as well as the authorities of most countries across the globe, all recommend the
same thing regarding masks and social distancing. However, I do not see this as a strictly medical/scientific situation or solution. Left to medical prevention, the entire globe needs to live in a bubble for a few months to burn out the COVID-19 virus. With no mechanism to enforce such a world-wide effort, this is obviously impossible.

If masks and social distancing are not going to “rid” the world of the virus, then what is their role and solution. Again, the situation/solution is more than medical, it has an incredible economic and social component as well. The evidence is both objective and subjective, and is overwhelming. GDP is down, jobs have been lost, rents/mortgages are unpaid, schools are closed, marriages are postponed, careers are lost, children are lonely, and seniors are isolated. The cost of the medical prevention of this virus is very high. I
believe the medical/science opinion is not the only valid opinion and should not be the sole determinant of our public policy towards this virus.

I believe the economic and social perspectives must be heard as well. Who is equipped to balance these perspectives and give us a path forward? I believe the answer is in the political realm. Our politicians and governmental authorities need to hear all the perspectives and try to guide us forward in our pandemic response. The authorities need to listen to good science, but they also need to balance that perspective with the other realms. This is where I encourage us to pray for our leaders, pray for the Lord to grant them wisdom, and pray they balance necessary public response with protections of freedom wherever possible.

My personal opinion (remember, this is fluid) is that we want to reduce virus transmission in regions where hospitals are at or near capacity. For example, if you simply count the number of confirmed cases in a college town that has many 18-22 year olds infected, it may not necessarily mean there is a health crisis in that community. In regions/areas that hospitals are overwhelmed, it is time to love our neighbor by reducing transmission so that people can receive hospital treatment during their time of need. In settings where the local/area hospitals are not stretched, I believe people now have enough general knowledge of the virus to determine to what extent they want to wear masks and socially distance.

There are obvious exceptions such as nursing home workers, physicians, and such. For example, many elderly patients must see me as their doctor. I feel I should wear my mask for their sake until this pandemic is comfortably behind us. But if I want to enjoy a meal with friends who do not want to wear masks or socially distance, I believe we should understand the risk and reward of the situation and should be allowed to make our own choice.

The vaccine question is very simple to me. Put me in the camp of people who hope there is a highly effective vaccine that has minimal vaccine related injuries. In other words, I want a vaccine that is a strong net-positive. Today, there is a vaccine undergoing a stage 3 trial involving 30,000 volunteers. 15,000 will receive 2 doses of the vaccine 28 days apart and 15,000 will receive a fake injection 28 days apart. They will be followed closely for covid-19 infection and for vaccine injury. I really hope that this study and others show a substantial protection with little to no injury. I recognize the challenge in making good vaccines and that it may never be realized. I also know that the life of quarantines, social distancing, and masks is not a long-term solution. I believe we need to work collectively towards a policy of equipping the vulnerable and their essential providers, while giving the fully educated and consented public the freedom to self-determine their social, economic, and medical risk and reward.

My Conclusion

This paper has been my imperfect attempt to bring order to my thoughts and conversations regarding how I relate to medical information and how I answer questions related to COVID-19 (and many others). I pray you sense the humility of not knowing everything about everything, and that this is a fluid situation and opinions can and must change over time as we learn and experience more. I hope this paper helps and encourages you in thoughtful engagement about some very difficult questions and situations. Whether you find much to agree with or very little, my prayer is that the Lord
will sanctify us into ever increasing Christlikeness during these strange, difficult, and challenging times.

Clayton Roberts DO
SMSC Family Medicine