An Honest Discussion

I sat in stunned disbelief as I read the front-page headline article of the News Review, written by Donovan Brink. I had just returned from a week’s vacation and was catching up on local news, only to find myself the focus of it. Mr. Brink quoted a passage written by myself, found on Evergreen Family Medicine’s blogs, where I listed Ivermectin among potential early interventions for Covid.

He then stated I was an advocate of Ivermectin as an alternative to the Pfizer, Moderna, and Johnson & Johnson Covid Vaccines. Where on earth did that come from? That is absolutely false. I, along with Evergreen Family Medicine, have been strong advocates for Covid vaccination. Our organization has probably given more Covid vaccines to Douglas County citizens than any other clinic in Douglas County. I, myself, have received the vaccine.

I have expressed reservations about mandating the vaccine to children and young healthy adults. I have advocated for informed consent and personal choice. Early treatment of Covid disease and preventing the disease by vaccination are not competing concepts. One does not exclude the other.

Mr. Brink had called me to ask for comments. I declined that conversation because I did not trust him to present my words fairly and in context. How do you misquote written text?

It was in the dark of the night that it hit me. I had to visit the trolls. I rarely go on social media. It’s bad for my mental health. And when I finish, I always feel like I need a bath. But I had to know what was flowing down the pipes.

Vicious NR forum comments made it clear the meme presented by Mr. Brink had been accepted as absolute truth. And nobody likes me anymore. One posted a link to report bad physician behavior to the Oregon Board of Medicine, as a courtesy to those trolls who have difficulty typing it themselves. I don’t mind being reviled. I certainly can accept disagreement. I do object to being vilified for positions I do not hold and ideas I have never expressed.

Years ago, I heard an NPR interview of a Jewish Rabbi speaking to growing hostility and polarization in civic discourse. He stated something that stuck with me. It was that in the Judeo-Christian tradition, debate should only begin after one individual listened closely to the other’s statement. He then restated it back to the first, asking “is this what you meant?” Only after the first person agreed the understanding was correct, could ethical debate begin. Otherwise, you were debating a strawman, a confabulation of your own making. However, satisfying you may find that it is not an ethical discussion.

Have you ever wondered how you came to be in a certain place? How did I become Mr. Ivermectin? The common thread in social posts is that I am a proponent for this drug. I’m really not. I don’t feel strongly about it. Certainly not a miracle drug. It might help. There is reason to believe it could. It may not. Time will tell. It is such a small part of what we do. A causal mention in a long list of interventions. The only word among 2,000 that was heard.

I find it curious that in Oregon, we have decriminalized nearly all hard drugs; cocaine, heroin, LSD, Methamphetamine among our citizens. All used without a therapeutic intention other than getting high. But we wish to punish physicians for using Ivermectin off label to treat Covid.

We justify abortion services because of a right to choose and avoidance of back alley dangerous practices. Then we remove patient choice of Ivermectin in the pharmacy and send him to the Veterinarian or feed store to calculate dosing on his own.

So, let me give my new friends a target. Thanks for asking. A list of opinions I actually do hold. If you want to attack me for any of these, feel free. But, if it is not there, you can’t make it up. Just setting the ground rules.

1. If Ivermectin is proven to be of help in treating early Covid, it will be due to its anti-inflammatory, not anti-viral properties. Although in vivo antiviral activity is shown, doses required in humans to achieve this effect are not feasible. Ivermectin does have potent anti-inflammatory properties including inhibition of cytokine production.

2. Ivermectin dosing requirements for inhibiting production of cytokine and other inflammatory mediators will be different from its antiviral or anti parasite action. When Salicylate products are used in rheumatoid diseases, doses between 4000 and 8000 mg/ day may be used (UpToDate). However, when used for cardiovascular or stroke protection, 81 mg daily of aspirin is sufficient.

3. With proper doses and course of therapy, Ivermectin is a safe drug. One of the safest we have. No drug is perfectly safe including vitamins or Tylenol.

4. It is not unusual in medicine to use a drug off label. The practice is legal and common. One in five prescriptions written today is for an off-label use.

5. Merck may develop another medication more effective than Ivermectin with similar properties suppressing the inflammatory response of Covid. If they do, it will be very expensive.

6. Covid Vaccines have unquestionably saved lives. The two mRNA vaccines (Pfizer and Moderna) and the single dose adenovirus-based vaccine (Johnson and Johnson) have proven highly effective against severe illness leading to hospitalization or death. They are largely safe. For older people (over 55), and those with chronic conditions or immune compromise, vaccine benefits are clearly greater than the risks.

7. Protection afforded from Covid vaccine is less than the 95% protection promised. Vaccinated individuals can harbor and transmit the virus. Increasing breakthrough infections are being experienced with the delta variant.

8. Covid adverse effects reporting system data appear to reflect numbers greater than any other vaccine implemented in the United States for mass vaccination. The CDC has not convinced the public that side effects are rare, mild and short term only. Covid illness in children and young adults is generally mild. This impacts many parent’s decision making when considering vaccination for their children.

The thing about a vaccine is you are giving it to healthy people. Consideration of risk is a reasonable thing. Informed consent is integral to choice.

9. Covid decisions are made more difficult by the virus being a moving target. Over time, Douglas County experience will mirror national and international data. Herd immunity to alpha is irrelevant with delta strain virus surge. Delta may change parameters about morbidity and mortality in the younger population. More vaccine breakthrough will be seen. Further variant strains will occur. The virus is here to stay in some form. Strategy should accommodate reality.

10. Immunity acquired through natural exposure is robust and durable. Likely superior to the vaccine. Individuals with demonstration of naturally acquired immune status should not be mandated to receive the vaccine.

Settled science often isn’t. I have found medicine is humbling if you are paying attention. Consensus in medicine has frequently been wrong.

As a junior medical student, I was sitting around a table of students and residents with the Director of the OHSU kidney transplant program. A major treatment modality, widely accepted without question, had just been proven wrong.

“Which just goes to show once again”, the Director stated, “today’s dogma is tomorrow’s dog shit. “

What is said to be the science today does not have the burden of being accepted as true tomorrow.

On my previous blog, I spoke of the need for bureaucrats, epidemiologist and public policy planners working remotely in their offices, looking at statistics and models, to listen to those of us on the front line.

If anybody was listening, I would give this advice.

1. Stop talking in absolutes, where none exist. Acknowledge what you don’t know.

2. Recognize that there has always been healthy disagreement among medical professionals. It’s not a bad thing. Karl Popper, one of the 20th century’s most influential philosophers of science considered that “the growth of knowledge depends entirely on disagreement.”

3. When the citizens decline your well-intended advice, it’s not because they’re stupid. It is because you have a credibility problem.

Tim Powell MD