SINCE THE OUTSET of the pandemic, the question of what treatments are effective has been the subject of quite a bit of online discussion with some, including former US President Donald Trump, advocating for really rather questionable treatments.
For those of us trained and experienced, and teaching others to critically assess the evidence, this popular interest in medicine and science gives us great hope.
We urge caution, however.
Understanding medical research
During medical education, students are taught how to weigh up the evidence when making decisions about how best to treat their patients. The example of the proposed use of ivermectin, invented as a worm dose by the Nobel-prize-winning Donegal man William Campbell, for Covid-19, is fascinating.
The medical-scientific approach to assessing whether or not this is a good idea is to review the published peer-reviewed evidence using a critical framework. To do this at home, I would recommend a framework derived from the evidence-based medicine approach, developed by David Sackett at McMaster University in Canada, or those described at Joanne Briggs Institute. The studies may be found through a Pubmed search, of the indexed medical published peer-reviewed literature.
Having done this, unfortunately, one finds that the quality of the descriptions of the studies of ivermectin for Covid-19 is low or very low. This makes it hard to dismiss the hypothesis that the differences observed in death and disability in those who received ivermectin could all easily be due to random chance factors alone.
Thus in my view, and most other doctors, to date the evidence sadly does not show any real benefit to giving people sick with Covid-19 ivermectin, outside of the context of a well-structured clinical trial.
The picture here one sees in the case of ivermectin is of several small variable clinical studies. This is in massive contrast to the evidence for the use of dexamethasone treatment for Covid-19 which was provided by the well-organised multicentre RECOVERY study in the UK of 6,425 patients described in the New England Journal of Medicine in February 2021.
Since those results came out, dexamethasone rapidly became a standard of care worldwide for people with Covid-19 who are sick enough to need supplemental oxygen.
Why push for ivermectin?
Perhaps it is an abundance of fervent hope over questioning critical reasoning about the evidence on the part of some people, which is understandable from a humanistic and psychological perspective, though does not lead to good decision-making either for one sick person or for whole populations.
Perhaps, for some who have not had the benefit of years of experience in assessing the evidence for the use of a new drug, it is a vast under-appreciation of how biased and wrong the results of poorly conducted clinical studies can be.
Some people might believe that it is fine and optimal to use several untested and unproven medications in a desperate bid to save the life of a patient who is deteriorating.
Unfortunately, this leads to the irrational and dangerous use of multiple medications and is likely to create unpredictable adverse effects from all of the chemicals in the patient’s body. At what point should this practice stop, after 10 or 20 or 100 additional medications?
Perhaps some people have lost trust in our statutory regulatory agencies, like the Health Products Regulatory Authority or the European Medicines Agency. In my view, these agencies over several decades have developed effective processes to determine, based on the evidence, if a medicinal product works, and if it is safe.
Almost all other countries around the world have their own regulatory agency. In addition, HIQA undertakes assessments of the costs and benefits of new and old health technologies and the National Centre for Pharmacoeconomics advises the HSE about which drugs work well enough to pay for with public funds.
Perhaps some people have distrust of professional societies of experts, maybe because those people feel disjointed or alienated from institutions which might strike them as pompous, irrelevant, elitist, exclusive, ritualistic and expensive. This reaction of revolt and distrust may divert them to seek for and support alternative solutions and alternative routes to truth for the problems of our time, like Covid-19 and ivermectin.
Perhaps some people have muddled up what is entertainment on one hand and what is a source of factually reliable news on the other, confusing ‘Mock the week’ with the ‘Sixone News’ by substituting unfiltered, unedited, unattributable Twitter or Facebook content for the carefully investigated, edited work of a responsible news agency that has an established reputation for reliability to defend and maintain, and who cross-checks and triangulates diverse independent accounts and who seeks out and represents a wide range of people’s opinions and views.
Sowing distrust
Perhaps some people who have suffered horribly and insensitively at the hands of others then blame the institutions which supported and protected the perpetrators. This can lead to a generalisation of blame, and a loss of all links to and confidence in all the current structures and institutions in Ireland.
Those in this mindset may wish to tear down those organisations and organised institutional structures in the hope that whatever new cooperative functioning models of power that arise from the ashes of this annihilation would be better for them and their loved ones. This could manifest as their taking positions which are consistently countering those of Irish institutions of power, without putting forward any better alternative models of organisation and control.
Perhaps some people at heart believe in the unquestioned supremacy and truthfulness of the thoughts and ideas going around in their own minds, their unique personal stream of consciousness as a source of truth above all else. Any challenge that they meet to this belief is immediately rejected by them as existentially threatening personal anathema.
Perhaps some people have been persuaded through digital content from abroad to take on a universal conspiratorial understanding of power, which is often promoted by disenchanted out-of-power politically-active individuals or groups who would like to be in power. This viewpoint promotes an attractive simple binary model of the world that we live in, as dominated by a singular secretive all-powerful cabal including those identified as a medical establishment.
Perhaps some people are attracted to the diverse geographic and institutional origins of the support for use of ivermectin, and because of the absence of a large multinational pharmaceutical sponsor of the trials, and thus consider the drug more highly. The drug can be bought from unregulated websites on the internet, which might appeal to some, and which are clearly being promoted for commercial benefits.
Perhaps some have fallen into the old psychological trap of confirmation bias, and look at, weigh more highly, and like more the evidence that they see which supports their own current views. On the other hand in my view and following the philosopher of science, Karl Popper, it is the evidence against a claim which is the most important.
In any case, there are those who advocate and even demand ivermectin treatment. There are currently clinical trials ongoing evaluating its use, which might yet show a benefit, or not, and as of now, we do not know the results of trials that are still ongoing. Until otherwise proven, the vast majority of medical doctors will not recommend it as a treatment for Covid-19.
Prof Sam McConkey is Deputy Dean and Head of the Department of Tropical Medicine and International Health at the RCSI School of Medicine and Health Sciences and President of Infectious Disease Society of Ireland.
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