Great Barrington and John Snow duel on Covid
Why hasn't the gigantic medical industry been able to find a cure for the virus?
(A version of this essay was published by Open Magazine on Oct 28th at https://openthemagazine.com/columns/an-elusive-therapy/)
It’s a measure of the total confusion that prevails about the Wuhan Coronavirus that two groups of doctors, all with glowing credentials, have come to radically different, indeed 180-degree contradictory, suggestions for us lay people.
This seems to suggest three scenarios, each more alarming than the one before:
The medical establishment doesn’t have a clue.
The profit motive far outweighs the desire to actually cure people.
There is something seriously wrong with Cartesian Science itself.
Does anybody have a clue?
There are many questions that have no answers. How did Vietnam, which shares a border with China, escape with only 35 deaths, and all in August/September? How did much of East Asia, Australasia, and central Africa (see the diagram) manage to have so few cases while Latin America, the US, India, Western Europe and Russia suffer? Nobody knows.
Let us consider the dueling petitions next. One is the Great Barrington Declaration of October 4th was written by public health experts from the three top universities in the world, according to the World Economic Forum: Oxford, Stanford and Harvard. It carries the weight of their combined reputations.
The declaration suggests that the disease be allowed to run its course. According to The Economist magazine, in “When doctors disagree", it proposes that:
“… the contagion be allowed to spread freely among younger and healthier people while measures are taken to protect the most vulnerable from infection. This approach rests on the concept of “herd immunity”, whereby the disease would stop spreading when a sufficient share of the population has become immune as a result of infection”.
Opposing this, a group of doctors wrote on October 14th in the Lancet, a journal considered prestigious despite serious faux-pas, including a recent one in which fraudsters fabricated alleged Coronavirus data, and fooled not only this publication and its sister The New England Journal of Medicine, but also the World Health Organization. See my article “Pious Frauds: How Credential Elites Distort Science”.
These people, equally credentialed, published the John Snow Memorandum, wants governments to do, again according to The Economist:
“… whatever it takes to suppress the spread of SARS-CoV-2… In particular, it calls for continuing restrictions until governments fix their systems to test, trace and isolate infected people.”
The point is that the expensive formal medical establishment and the medical industry is not able to understand the root cause of this pandemic. This is despite being perhaps the world’s largest industry, at some $15 trillion (extrapolated from its roughly 20% share of the $20 trillion US economy alone).
Not only that, but the British Medical Journal is pessimistic about the vaccines in the fray that are supposed to be the knights in shining armor, so to speak: “Will covid-19 vaccines save lives? Current tests aren’t designed to tell us”. Startlingly, it says the studies do not test a) if the vaccines prevent severe infection (hospital admission, ICU or death, or b) if it prevents person-to-person spread.
In other words, these vaccines are being rushed to market for political, not scientific reason. Nobody knows about their possible side effects, either.
Something fundamental is amiss in all this. Despite all the high-tech devices and statistical techniques available, they’re missing some elephant in the room. It’s almost like we’re back in the 19th century, and nobody knew how tubercolosis spread, and all we knew was that it could be fatal. Then someone popularized germ theory. That ‘Aha!’ moment is missing here. Yes, even after all the money poured into medicine.
Cupidity and Medical Fundamentalism
Money, they say, is the root of all evil. When there is all this money to be made, greed takes over. There is the interesting case of the stent versus the Coronary Artery Calcium score in managing heart problems. Cardiac arrests are the largest cause of death in the US.
The most popular treatment is surgery, especially after a mild heart attack. Inserting a stent, a tiny cylindrical metallic device that keeps arteries open and prevents them from clogging up with plaque, costs over $40,000 in the US. Cardiac surgeons make millions of dollars every year. In India, the government has capped stent prices at around Rs. 40,000.
But statistics show that stents are not all that effective. In March 2020, the National Institutes of Health reported that “NIH-funded studies show that stents and surgery are no better than medication, lifestyle changes at reducing cardiac events.”
How about the humble Coronary Artery Calcium (CAC score)? It is a high-speed computerized tomography (CT) scan of the heart, to find the number of calcified remains of plaque in the arteries. It costs under $500 in the US, and around Rs. 5000 in India. It is, statistically, a very good predictor of future heart attacks.
The theory is that soft, waxy deposits in arteries, ie arterial plaque, calcify over time and can narrow the blood vessel and reduce blood flow. The greater the number of such calcium deposits, as measured by the CAC score, the greater the risk of heart attacks. The ideal CAC score is zero, but people often have scores in the thousands.
But prevention is not so interesting; ‘cure’ using stents and surgery is, as it is far more lucrative. Therefore the establishment sneered at CAC testing for years, and it is only recently that it has become more widely accepted, including by insurers.
This is yet another example of the perverse incentives in the medical industry. A doctor who tells a diabetic patient how to prevent the worsening of the disease gets paid nothing. A doctor who cuts off the leg of a patient with advanced diabetes gets reimbursed by insurance.
There was the famous cholesterol-leads-to-heart-attacks dogma, which for 30 years misled doctors and patients into focusing on low-fat foods and on the large-scale use — absolutely billions of dollars’ worth — of cholesterol-lowering drugs called statins. In the end, after Big Pharma profited by billions, it turned out the culprit was actually not cholesterol, but dietary sugar and diabetes.
There’s also a touching faith in that alleged gold standard, Randomized Controlled Trials (RCT). If you don’t do RCTs, your results, including observations are not worth anything: that is the conventional wisdom.
There was a lot of noise about how Hydroxychloroquine usage was quackery, because there weren’t big enough RCTs, even though there was observational and anecdotal evidence of efficacy in early stages.
RCTs were in fact done for Remdesivir, a new anti-viral drug that was seen as the big hope. But they were very disappointing: on October 16th, the WHO reported interim results for its Solidarity trials. Nothing worked:
“… it found that all 4 treatments evaluated (remdesivir, hydroxychloroquine, lopinavir/ritonavir and interferon) had little or no effect on overall mortality, initiation of ventilation and duration of hospital stay in hospitalized patients”.
Yet, surprisingly, on October 22nd, the US Food and Drug Administration approved Remdesivir:
“Today, the U.S. Food and Drug Administration approved the antiviral drug Veklury (remdesivir) for use in adult and pediatric patients 12 years of age and older and weighing at least 40 kilograms (about 88 pounds) for the treatment of COVID-19 requiring hospitalization. Veklury should only be administered in a hospital or in a healthcare setting capable of providing acute care comparable to inpatient hospital care. Veklury is the first treatment for COVID-19 to receive FDA approval.”
Why on earth?
Well, here’s a clue. In India, the patented drug Remdesivir sells for Rs. 30,000 for a course of treatment. Off-patent, generic hydroxycholoroquine 200 mg tablets cost Rs. 6.50, Azithromcyin is also cheap, and so is zinc. A full course of HCQ + Azithromycin + Zinc probably will cost less than Rs. 300. You can connect the dots.
As for RCTs, the “gold standard”, there is a dissenting opinion. I wrote of them as scientifically dubious in the case of the social sciences, but the same argument holds true for the biological sciences: what exactly are the parameters they are ‘controlling’ for? How do they know these are the right parameters? How do they even know how many parameters need to be controlled for?
A wholly medical perspective is provided by a doctor, Norman Doidge, in an August 2020 essay, “Medicine’s Fundamentalists”. He finds RCTs to be dogma:
“The idea that “only RCTs can decide,” is still the defining attitude, though, of what I shall describe as the RCT fundamentalist. By fundamentalist I here mean someone evincing an unwavering attachment to a set of beliefs and a kind of literal mindedness that lacks nuance—and that, in this case, sees the RCT as the sole source of objective truth in medicine (as fundamentalists often see their own core belief). Like many a fundamentalist, this often involves posing as a purveyor of the authoritative position, but in fact their position may not be. As well, the core belief is repeated, like a catechism, at times ad nauseum, and contrasting beliefs are treated like heresies. What the RCT fundamentalist is peddling is not a scientific attitude, but rather forcing a tool, the RCT, which was designed for a particular kind of problem to become the only tool we use. In this case, RCT is best understood as standing not for Randomized Control Trials, but rather “Rigidly Constrained Thinking” (a phrase coined by the statistician David Streiner in the 1990s).”
We see a similar haughty fundamentalism in the way the allopathy establishment simply looks down upon traditional medicine, for instance Ayurveda, and calls it quackery. Alas, all the talk of ‘evidence-based medicine' turns out to be based on statistical artifacts, like RCTs, that stand on even shakier assumptions.
Thus there seem to be layer upon layer of bad faith upon which this whole citadel stands. But that’s not even the worst part of it.
The failure of the Cartesian vanity
There seems to be a serious problem: the Cartesian idea that by dividing a system up into its smallest component part, and then examining the latter in depth, you can deduce everything about the system.
The obvious problem is that it does not take into account the phenomenon of ‘emergent intelligence’: that the whole is greater than the sum of its parts. Among humans, we have heard of ‘the wisdom of crowds’; among animals, uninteresting individuals like ants or bees create surprisingly sophisticated and intelligent systems as a collective. Where does this intelligence come from?
Cartesians have no answer. They couldn’t possibly have an answer, as that is basically a bad question in their frame of reference. But as Galileo Galilei is said to have muttered under his breath, “… and yet it moves”, after being forced to recent heliocentrism. There is such a phenomenon. We observe it all the time. Cartesianism is inadequate. That’s perhaps why we have to bear with such monstrosities as ‘dark energy’ in astrophysics.
In keeping with this line of thought, the entire effort in Covid has been on trying to identify two things: a) how to cure the symptoms that accompany infection, b) how to get rid of a single virus that may have invaded a single cell. The former is standard allopathy, treating neither the disease nor the individual, but the symptom. The latter is probably not enough.
An intriguing article in New Scientist on October 21st, Viruses have busy social lives that we could manipulate to defeat them, wonders if the social lives of viruses (virii?) is the key.
“It may seem odd to say that viruses fraternise when they arguably aren’t even alive, but virologists are discovering just how rich this aspect of their existence is. Far from being lone operators, viruses cooperate and compete with one another; they can be altruists, freeloaders or cheats. These discoveries are rewriting the virus rule book and suggesting novel ways to tackle viral diseases, and that includes the newest one, covid-19, caused by SARS-CoV-2. Understanding these complex and sometimes strange interactions could be the key to getting our own lives back to normal.”
Yes, indeed. If ants can have social lives, why can’t viruses? It’s hard to dismiss them as ‘not alive’, as they do a lot of things living beings do, such as spread their genes, attack, cooperate, evolve, and so on.
The virus may be one step ahead of us, cooperating not only with other viruses of the same species but also with wholly different ones, say the ones that cause chikungunya. What if they exhibit altruistic behavior, sacrificing themselves when needed to support their peers, even of other species? According to Social Evolution Theory, née sociobiology, they could also freeload, exhibit selfish behavior, and all sorts of things that make humans such endearing social animals.
What if viruses hunt in packs? Is there co-infection, meaning two types of viruses simultaneously attacking the same cell may help (or deter) each other: for instance, if you catch a cold, will that either prevent or encourage the Covid virus from attacking you? In fact, a story in the Daily Mail suggests that the common flu has been decimated by Covid in globally: apparently flu cases have plummeted 98% compared to previous years.
An article in the Hindu Businessline says that countries with poor hygiene, poor quality water have lower Covid fatality rates. Presumably, exposure to many bugs builds resilience.
All this suggests that a system approach is needed, rather than the conventional idea of a single death blow to a single pathogen. Is this the paradigm shift that can finally make sense of the Coronavirus? Who knows?
I wrote in April in Open Magazine that science and technology are the gods that have failed us. Six months later, I see no reason to change my mind. The medical establishment and Silicon Valley (where are the contact tracing applications on cell phones?) have both underperformed. And the vaccine is not necessarily going to live up to the hype. We need new heros.
2500 words, 27th Oct 2020