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Rational CoViD-19 Discussion Thread: Science vs. Politics

Political Jazz Fan said:
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So I gave this a "like", but to be honest, I think our media would be jerking around any Pres from any party, trying their best to drive the agenda of socialism, indoctrinate the public, panic the public, eroding public confidence in government generally, and calling for even more government.....

That is, unless the Pres had the foresight to enlist our spy agencies by saturating their leadership with his personal cronies, and then threatening various Press outlets with every possible nuisance he could orchestrate to make damn sure they print his stuff uncritically, just like Obama did during his Presidency.
 
One Brow said:
How about we put it this way: there is as much reliable evidence for the use of HQC in treatment of COVID19 as there is for allowing spiders to run around your face as a treatment for COVID19. Would you support spider therapy being used? Do we evidence spider therapy won't work?
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This again falls back on what evidence you're expecting for a given situation. If you'll recall, the reason we started all this social distancing and lock downs is because we saw what was happening in Italy, and we felt we were 11 days behind them, so we acted. Of course you can say that a lot of the actions taken were "common sense," but they're not necessarily "evidence-based." I‘d give caution with what I mean by that because I believe people conflate the concept of "evidence-based" with ”is it a good idea,“ and if you say something isn't evidence-based, people think you mean it's not a good idea. So me stating that there wasn't a clear "evidence base" regarding different containment interventions for COVID-19 specifically doesn't mean that there aren't some generalizable principles at play. So we followed Italy by shutting things down, but we also followed Italy with different management strategies they (and China) were employing to treat COVID-19 (among them hydroxychloroquine).

I'm not one to appeal to a limited evidence to conclusively prove something, and I'm not here to tell you that hydroxychloroquine has a positive effect on COVID-19 management, but the idea that there's as much evidence for the parody intervention you listed above as there is for hydroxychloroquine for COVID-19 is disingenuously silly, though I’m sure you’re ready to make a long debate for it. You can make whatever you want of the Wuhan study (I'm not inclined to make much of it), but that doesn’t equate to no evidence. A witness to a crime seeing a man from a distance wearing the same hat that the defendant has isn’t a smoking gun, but it’s not no evidence. It can certainly be two hats, but that’s not no evidence. A study showing positive results that is flawed does not equate to being a study showing negative results. But more importantly, what methodology would you expect from a study, and what kind of real-time management latitude would you allow treating physicians on the front lines of a rapidly changing landscape? Moreover, what absolute conclusions have you made regarding the two Chinese studies that enrolled a total of 92 people? More importantly, are those studies asking or answering the pertinent questions regarding COVID-19? You have a virus that has a mortality rate from anywhere under 1% to up to 5%. What are you going to conclude here?

Let's look at a different example, and that would be the use of aspirin for a heart attack. This is a very commonly administered medication for any heart attack or suspected heart attack. How effective is it? If you're going by the number needed to treat (i.e. the number of patients you would have to administer the treatment to in order to have one person get better above placebo), then the number needed to treat to prevent one death is 42. Those may not look like good odds, and they aren't. What kind of sample sizes do you think you'd need in studies in order to determine that? Do you think you could definitely conclude anything with, say, 92 patients (where only 46 actually got the treatment)? On the flip side, there's a huge list of side effects from aspirin. You can go deaf. You can have kidney failure. You can get gastric ulcers. You can bleed and become anemic. You can become acidotic. You could die if the dose is big enough. Simplistically, if you find an internet source of the (real) adverse outcomes of aspirin, can you really weigh that into the equation? No. Why? Because none of those adverse effects are relevant from one dose of aspirin. Likewise, people are reading side-effects of hydroxychloroquine and putting them into an inappropriate context. The duration of taking the medication is short for COVID-19. The biggest relevant issue is QT lengthening, but even then that's still quite theoretical unless combined with an underlying rhythm issue, electrolyte abnormalities, or other medications that prolong the QT interval. And a prolonged QT interval does not mean that there's going to be a cardiac event. Medication monitoring for QT lengthening is usually in the context of chronic use. It does apply acutely if you're pushing QT up too high, but again these are questions best assessed by treating physicians and not politicians or people behind computer screens pushing back on politicians.

But back to the 42 number needed to treat. It's a small chance of benefit. There are about 850,000 people in the US each year who have a heart attack. That's about 2,330 people per day. If all of them are treated with aspirin, you can prevent death of 54 of them, or about 20,000 per year. How much does it cost? Well, if we're going by commercial Bayer cost (the most expensive at about 5 cents per pill), you can treat all 850,000 of those people for $42,500. When we have pretty known risks with something, how much does one tolerate its application until further data can be compiled to either support or refute its use?

I'm very skeptical of new drugs and treatments on the horizon, so much so that if I were to be fairly open about a lot of my views on different interventions that come out, many here would probably assume that my familiarity with science and medicine is superficial because they perceive they are more comfortable with basic sciences through whatever exposure they have. With any new treatment that comes out, there's the same pattern that almost inevitably follows. Initially there's skepticism, but then as the marketing picks up, people get more familiar with it out of curiosity, and whatever unique component there is to whatever drug or intervention, eventually the steam gets going until it reaches a critical mass where everyone is utilizing something and group-think takes over (and publication bias helps squash any dissent within the community), until after a few years people become disenchanted with their clinical experience that the initial hype is able to die down. So, that being said, an easy trap to fall in is to assume that because that’s often the case, you then believe that it’s always the case. So I typically suspend belief and allow each intervention to have its day in court. There may be factors that push one way or the other that necessitate me trying something that I’m skeptical of, but I don’t necessarily proclaim that something can’t do something just because I haven’t yet seen evidence for it.

So then the question is harm. The biggest harm from my view is if this depletes supply of people taking it for other reasons. I believe the safety concerns can be appropriately monitored by a treating physician. Most of the safety concerns being pushed are done so by lay people, or by people in somewhat adjacent medical fields who don’t have as much of a contextual background in understanding liquid scenarios and knowing when certain adverse effects listed in package inserts become concerning or relevant. This is why you could look at something like valproic acid (an anticonvulsant) that is a category X medication in pregnancy (meaning the FDA has classified it with its highest recommendation of being absolutely contraindicated in pregnancy due to neural tube defects), and then on paper see a treating physician actually treating someone with valproic acid in pregnancy. Without any context, any patient or individual with a loved one pregnant on valproic acid could google and get so many websites stating to absolutely not take this in pregnancy to the point that it would not matter what the treating physician says, the perceived overwhelming concensus would say otherwise. Any treating physician in this situation should be familiar enough with the medication to know that the more important question isn’t if the patient is pregnant, but rather where in their pregnancy they are, because if they’re in their second trimester, the period of organogenesis has passed and the more important question is how severe a patient’s epilepsy is, what the other options are for their kind of epilepsy, what their past history is with the medication, and how epilepsy can be managed safely in pregnancy, because having a seizure while pregnant is very harmful, but a situation like this you could never get that actual context when every written source says don’t take valproic acid in pregnancy because it completely lacks nuance. These are not uncommon situations where I am unable to relay pertinent contextual information to a patient because superficially “all these expert sources say otherwise.” And that, again, is where we arrive at having to defer these questions to treating physicians. Everyone is opining on this medication as if they know what the standard level of evidence would be in this kind of situation, but they’ve never been in the business of asking questions of what standard levels of evidence there typically are or should be given any circumstance because this is likely one of the few times this question has arisen because of its popularity in the past couple weeks in media. So of course people will look and say, “wow, this isn’t following a standard!” without having any context to understand what sets the standards to begin with because the only opinion people can form on this are the superficial factual principles that get highlighted in some form of print, and not from actual experience.

Hydroxychloroquine was being discussed quite a bit before Trump mentioned it. I didn’t have an opinion on it then. I still don’t have an opinion on it now. Trump has no idea what he’s talking about. People schilling for him have no idea what they’re talking about. But those facts are obscuring the fact that everyone who’s quickly coalesced around the opposite opinion also has no idea what they’re talking about. Had Trump come out and said it was his gut feeling that this treatment didn’t work and was dangerous, I have a strong suspicion that the national discussion regarding this would be looking very different right now. I don’t think we’d have the same amount of people currently saying this is unsafe nodding their heads saying, “yes, this is dangerous and Trump is right!”
 
As an analog, for over a month there has been discussion about multiple things that have been utilized in China and Europe that include not just hydroxychloroquine but a number of antivirals, zinc, and azithromycin, in addition to caution that people on ACE inhibitors (a type of antihypertensive), NSAIDs, and corticosteroids were doing worse with treatment. 0 evidence for any of it, particularly ACE inhibitors. What should one do with that knowledge? Since there’s no evidence base, just keep treating with ACE inhibitors? None of these other things were talked about, and for good reason — a major political figure didn’t mention them. So the management of these conditions has stayed with treating physicians and has been unencumbered by political influence. Yet there’s no evidence base for it. And that’s not surprising. That evidence will lag. But let’s pretend Trump went along with many treating physicians and said he believes ACE inhibitors are bad in COVID-19? How many overnight experts could be made and how quickly would opinions coalesce to refute this?

“This is dangerous! ACE inhibitors are absolutely essential for people post heart attack to continue with recovery and cardiac remodeling. These people are in danger!”

“People with chronic kidney disease depend on ACE inhibitors to limit their progression to needing dialysis! This is dangerous and uncalled for!”

“My father had a stroke secondary to hypertension and he’s just haphazardly telling people to come off of them!”

Also, I have no doubt that amongst his investment portfolio you will find a drug manufacturer that makes ARBs (a different type of antihypertensive that people are switched to if they can’t tolerate ACE inhibitors), and this would be viewed as a smoking gun of motive.

All of the above is true. But none of the above has any contextual relevance, and any treating physicians would know so. But as soon as you start politicizing this, people somehow feel validated in doing what they have no basis for doing — trying to make the issue a public issue instead of determined by treating physicians.
 
infection said:
Indeed, which is why it’s easier to fall back on the more simplistic “hydroxychloroquine can make you go blind, and there’s no evidence for it helping.”
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If you say so

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infection said:
... but the idea that there's as much evidence for the parody intervention you listed above as there is for hydroxychloroquine for COVID-19 is disingenuously silly, though I’m sure you’re ready to make a long debate for it.
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No, I made the point, you understood the point, that was sufficient.

I read every word of your post. I am grateful you took the time to go through all that, and to teach me some more about how these things work. I'll read it a couple more times to make sure I understand it before I say anything more on the subject. Thank you.
 
One Brow said:
If Trump were a Democrat, he would not have botched the initial response to the virus so badly.
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no, results would be the same. Whether the dude is R or D, it wouldn’t matter whoever is in office they’re there for their bottom line... not for us. No one was going to do what was best for us. They never do.
 
Thee jazz fan said:
no, results would be the same. Whether the dude is R or D, it wouldn’t matter whoever is in office they’re there for their bottom line... not for us. No one was going to do what was best for us. They never do.
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The sooner you idiots realize this and stop voting for these bloated losers the better off this country will be
 
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