What is truth?

How do we evaluate covid-19 truth claims?

Prior to March 2020, I believed my credentials as a physician were sufficient to convince others I had the qualifications and experience and insight to be credible on a topic such as covid-19. I now know those considerations, especially in this crisis, don’t matter. Other physicians disagree with me. Other Christians disagree with me. Family and friends disagree with me. Our tribes have been completely shuffled. The people who do agree with me represent the full spectrum of religion and politics. So, what unites us?

In pondering why people believe what they believe and act how they act in this crisis, I’ve hypothesized five categories:

1)   Those who are truly nefarious (the evil “they”);

2)   Those who are compromised in some way, bribed, or bought off;

3)   Those who have acted in good faith, believing “the system” works;

4)   Those who are suspicious or even know all is not right with “the system” and the prevailing narrative, but lack courage to act;

5)   Those who are convinced all is not right and have the courage to act.

I believe most physicians, Americans, and people in the world are in category 3. I give them the benefit of the doubt. There is an undoubtedly prevailing narrative and they believe it is true. More importantly, they believe it matters that they believe it is true. It matters to keep them, their loved ones, and others safe. Because it so matters, from their point of view, they would assign someone like me to category 1 or 2. If I believe, spread information, or act contrary to the prevailing narrative, I must be acting from selfish or evil intent, or I’m deceived or brainwashed or have lost my grip on reality.

Truth claims demand evaluation and action when they are consequential. The truth claims of the covid-19 crisis literally determine life and death.

As much as I confess hurt over the fact that people who know me, love me, and used to trust me do not believe me, it’s been indispensable to learn that believing me is a profoundly shaky foundation. Belief should not be in persons or personalities but in what is true. But how do we determine what is true?

Samuel Webster’s 1828 dictionary (I purposely went back to an old definition because, in our attempts to dispense with truth, we have distorted language) defined truth as “conformity to fact or reality; exact accordance with that which is, or has been, or shall be.”

The conformity of fact and reality to past, present, and future determines evaluations of truth.

Initial public health guidance for the prevention of SARS-CoV-2 infection was based on established management and prevention principles for known respiratory illnesses such as influenza, Severe Acute Respiratory Syndrome (SARS), and Middle East Respiratory Syndrome (MERS): hand washing, covering coughs and sneezes, and staying home when ill. The elderly, those with co-morbid conditions, and those with compromised immune systems seemed most vulnerable.

The panic and proposed responses in mid-March 2020 did not align with these guidelines or really any past fundamentals of public health, immunology, and infectious disease. Honestly bewildered by new proposals, I searched the medical literature, looking for evidence to support masks, lockdowns, and social distancing, and did not find it. The justification for abandoning past fundamentals, however, was this virus was “new” and “novel,” so it was not safe to act as we had in the past.

I looked, therefore, for present evidence.

Stanford physician and epidemiologist, Dr. John Ioannidis, had written a March 17 article warning against prepare-for-the-worst measures of extreme social distancing and lockdowns in the absence of good data regarding disease prevalence and the adequacy of such measures, referencing a comprehensive review of the research on community mitigation strategies and including an encouraging analysis of the recent Diamond Princess cruise ship cluster of infections. Being a closed population where likely everyone is exposed and tested, a cruise ship is a perfect infectious disease laboratory. Thoughtful analysis, now vindicated, predicted a case fatality rate for covid-19 between 0.05 and 1%, much more reassuring than the World Health Organization’s original 3.4% estimate, and observed elderly adults were at risk for severe disease or death.

That seem week, data analyst Aaron Ginn had written an article “Evidence over Hysteria—COVID-19” that appeared on the website medium.com, gone quickly viral, and was just as quickly taken down. Fellow physicians I shared the article with commented that the analysis was “excellent,” “thorough,” “thoughtful,” and even “reassuring,” but they were concerned it would cause complacency and slow down preparation for the worst-case scenario. One physician commented on Ginn’s political affiliation, as well as negative social media comments, before even having time to read it. After he did read it, he criticized the article for not being peer-reviewed and for the author not being a physician or epidemiologist. Another commented that my subsequent defense of the data analysis was “logical,” but that he’d rather be safe than sorry.

Ionnidis is a well-respected physician and epidemiologist from a prestigious institution. He was discounted as reckless. Ginn is a thoughtful analyst who had taken the time to aggregate and present a large amount of worldwide data and evidence, providing a great service. He was discounted for his politics and his profession, and his analysis was censored. Justification for not following present evidence broke all the rules of usual scientific discourse.

Those of us who relied on past and present evidence, not accepting novel approaches, staked our future on those evaluations. All of us, however, participated in the scientific method, in one large case-control study. Those who proposed novel approaches based on precautionary principle at a particular point in time must examine whether reality has conformed with their hypothesis that they were necessary. Those of us who rejected those approaches, and lived accordingly, provide the control group to their case intervention group. We must also examine whether our hypothesis that these interventions were unnecessary are in keeping with reality.

I live a hybrid life. I specialize in pediatric cardiac anesthesiology so most of my career has been spent taking care of children with congenital heart disease, both domestically and internationally. My pediatric cardiologist husband, Kirk, and I have a Christian non-profit dedicated to international congenital cardiac care. His speaking in a church on our work led to his being called to be the full-time senior pastor of a church in Maui, where we have a food pantry and federally recognized free medical clinic, through which we’ve treated hundreds for covid-19. Since adding the vocation of pastor’s wife and women’s Bible study leader eight years ago, I’ve worked as a general anesthesiologist on Maui, while Kirk and I both still travel regularly to serve in our specialties in mainland children’s and international hospitals. My covid-19 experience involves our church, as well as inpatient, outpatient, adult, pediatric, and even international care.

Anticipating great need from the shuttering of Maui’s tourism-dependent economy by the stay-at-home and 2-week traveler quarantine orders issued in Hawaii toward the end of March, we immediately elected to extend our church food pantry hours from three to seven days per week, receiving clarification from the mayor’s office that our services were deemed “essential” and being transparent we would conduct regular meetings of our volunteers.

Over an initial two-month period, we had over 100 regular volunteers serve over 2,150 clients. As guidelines required for interacting with the public changed, we changed with them. We cleaned our facility daily. Volunteers wore masks and gloves when interacting with the public. Visitors were greeted at the door with hand sanitizer and a touchless thermometer. We moved the chairs in the sanctuary so family groups could sit in compliance with social distancing guidelines as they waited. If any volunteer had any concerning symptoms, they were required to stay home.

Our bi-weekly volunteer meetings started with an update on the pantry and covid-19 science, and then the rest of our behavior was thoughtfully based on past and present public health evidence, as Kirk and I committed to staying abreast of the medical literature. We were never convinced we needed to depart from initial and traditional public health guidelines of hand and respiratory hygiene and staying home when ill. We would sing, pray, celebrate communion, and hear a teaching. Our volunteers shared a meal daily meal together. We took off our masks when we were around each other and didn’t sit socially distanced. We hugged each other. We even hugged food pantry patrons when they specifically requested it. That moved many to tears.

As a way of assessing our effectiveness at limiting the spread of infection, we conducted serum antibody tests on over 100 regular volunteers and their family members in May 2020. Seven people, including me, tested positive, demonstrating previous infection with SARS-CoV-2. All infections were mild. No one was hospitalized. None of our household members, including our spouses, tested positive.

Reassured, we resumed regular worship at the end of May 2020. We cleaned all potentially contaminated surfaces, made hand sanitizer available at the door, did not serve our usual donuts and coffee, and had congregants pick up their own single-service communion cups. Other church gatherings, such as our women’s and men’s Bible studies, and the young adults’ group that met in our home, resumed at that time as well. Because they were in the lowest risk category, I confess that our youth had never stopped gathering.

Following the success of numerous outpatient physicians across the country, we recommended to those who were concerned or at risk for COVID-19 infection who sought our advice to be on a minimum prophylaxis protocol of several over-the-counter medicines. If they became ill, we made sure they had access to a combination of prescription medications.

The delta variant of SARS-CoV-2 arrived in Maui in July 2021. Kirk, who had been traveling on the mainland, was the first to succumb. Self-enforced post-travel quarantine kept him from infecting anyone else and, likely due to prophylaxis and early treatment, his case was mild. I did not get re-infected. My immunity and his early infection were blessings allowing us to care for others as they became ill during this wave. Ultimately, we’ve been involved in early outpatient treatment for hundreds of patients.

Our approach is sequential multi-drug therapy (SMDT), first proposed in May 2020 by epidemiologist and cardiologist Dr. Peter McCullough and his international colleagues, based on the available scientific literature and early clinical experience. The pathophysiologic and pharmacologic rationale for this approach addresses three known processes in SARS-CoV-2 infection and covid-19 illness: 1) viral replication; 2) cytokine storm; and 3) thrombosis. It is not a one-size fits all approach using only certain controversial medications, but a tailored approach using a variety of medicines based on individual patients, their co-morbidities, their presentation, and their stage in the disease process.

Our experience with the alpha or legacy variant of COVID-19 illness was that it was relatively easy to treat, especially if caught early. We quickly and humbly learned that delta was not. We became even stronger advocates for early treatment, as that made a huge difference in people’s course and outcomes. Also, while the alpha variant was harder to transmit, even among household members, delta was incredibly easy to transmit. Once one household got it, we told the rest of the household to presume they would and act accordingly.  Given the fast and different presentation we observed at the beginning of this wave, we did shut down the church and food pantry for a week.

The omicron wave, which came to Maui in December 2021, was milder than the first two variants, but the most easily transmitted. As I can personally attest, re-infection was possible with this wave, but the re-infected had incredibly mild disease and did not transmit it to others. I got infected at a wedding reception where most attendees were vaccinated and/or negatively tested. I had a full household for Christmas (including vaccinated, unvaccinated, recovered, and disease naive) and no one else got infected.

The only patients we’ve treated who have been hospitalized were during the delta wave and were those who sought treatment late or did not comply with treatment regimens. Through communication with those hospitalized (not just in our local hospital but also across the country) and their families, we learned much about usual inpatient covid-19 care. Outpatient treatment regimens were stopped. Only certain medications were given, despite patient and family requests (and even attempted legal intervention). Fluids were given sparingly, even in the face of evidence of dehydration or acute kidney injury. Sedative and narcotic medications were given, which can facilitate recumbent positioning and hypoventilation, and risk worse outcomes.

For the first time in our careers, for this particular disease, we learned not to trust sending our patients to the hospital and did everything we could to prevent it. We put patients on home oxygen as early as possible, if necessary. We tortured them with requiring sleeping sitting up, deep breathing, and regular movement. We made house calls, making assessments and delivering medicines, hydration, food, and supplies. If we had to surrender and send patients to the hospital for any reason, we advocated for discharge as soon as that reason had been addressed. All the patients who were under our care for the full course of their illness survived.

Just as the Diamond Princess cruise ship was a laboratory at the outset of the covid-19 crisis, our church community, and all those we’ve treated, has been a laboratory throughout the whole crisis. Many chose, at great consequence, to trust our leadership and our care. This was not blind faith. They knew our credentials and our character and, as time went on, our outcomes. We also shared our reasoning and our sources of that reasoning. Participation was volitional, not compelled.

We were the non-intervention, or control group, living in contrast to the intervention, or case, group around us. We lived as freely as possible. We masked only when we had to. We did not isolate or social distance. We traveled frequently, both domestically and internationally (allowing us to observe how other countries, such as Iraq and Tanzania, lived and treated patients in this crisis). We availed ourselves of prophylaxis and treatment protocols. Most of us did not get vaccinated. The majority of us did get infected, but that does not distinguish us from others who lived differently. What does distinguish us is that we survived, and even thrived.

Based on this personal case-control study involving hundreds of individuals, my continuing review of the evidence, and my education, training, and experience as a physician, especially during this crisis, these are the truths I claim about our covid-19 response, so help me God:

1)    Containment of spread of infection: Masks, social distancing, and lockdowns are not helpful and, in many ways, harmful;

2)    Treatment: early, sequential, multi-drug therapy is available and effective;

3)    Hospitalization: hospital protocols have actually increased mortality;

4)    Vaccination: the current vaccines using mRNA and adenoviral vector DNA technology are not completely “safe and effective”;

5)    Prophylaxis: there are many ways to protect oneself against infection and/or improve one’s outcome if infected.

The scientific method involves incorporating facts about the past and the present in order to make predictions about the future. As the future becomes present and even past, observed reality forces us to accept or reject initial hypotheses.

If you want to deny what I claim is true about our covid-19 response, you have to deny the reality I’ve lived.