BLOG POST: Evidence, narratives and failure to adhere to the Hippocratic oath

As COVID19 unfolds and we reflect on the past few months, it's hard to understand or even make sense of some of the decisions that have been taken to ‘save lives’. While no one doubts that saving lives is an important role for everyone in society – the question is how to establish a sense of confidence in the population that the measures introduced will achieve this end without unacceptable collateral damage of currently unquantified dimensions.

A recent article by Prof. Dirk Kotze in The Conversation highlighted the President’s claim that decision making was informed by scientific evidence. In considering what is meant by evidence informed policy making, I was reminded of a popular children’s story book “Just So Stories for Little Children” published in 1902. Each of the “Just so stories” described in whimsical detail how various features of animals came into existence -spots, stripes and more.

The story of The Elephant’s Child describes how the elephant got its trunk. It describes the inquisitive elephant’s child encounter with a crocodile that pulls its short bulbous nose into a long trunk. Since that time, all elephants have been equipped with a long trunk. The story, while fanciful, does illustrate the key features of “just-so” stories that are constructed from a single piece of evidence (the elephants trunk) and then explained using a causal explanation that is a fanciful construct (the pulling crocodile). These two elements - evidence and a narrative that interprets and explains this evidence, are the essence of what is used to establish policy.

An additional point relates to the question of what constitutes evidence. In this context, I am reminded of the comment by Ben Goldacre in his book “Bad Science” who said “..the plural of anecdote is not data.” The point that he was making was that data that need to inform decisions, need to be collected systematically and analysed circumspectly. Furthermore, anecdotes recounted under oath are regarded as evidence by courts of law, but scientists are sceptical of this kind of evidence and prefer to evaluate evidence that is generated via well established experimental methods. These distinctions are often not considered carefully by politicians and journalists who are unaware of the pitfalls that relate to what is regarded as credible evidence, what are anecdotes and how explanatory narratives are used to justify policy.

The current SARS-CoV-2 pandemic and the responses to it need to be viewed in the context of “just-so” stories that use a combination of evidence and narrative to make a compelling story that underpins policies. Sceptical scientists in these circumstances activate their detector for the existence of ‘just-so’ stories masquerading as policy making informed by scientific evidence.

With this in mind, lets explore what may have informed interventions aimed at minimising the effects of COVID -19 in South Africa. Three interventions are worth exploring– banning the sale of cigarettes, banning the sale of alcohol and the introduction of fever screening.

The argument for banning the sales of cigarettes is that since COVID-19 is a respiratory disease and since smoking is known to impact negatively on the health of smokers particularly affecting the lungs, banning the sale of cigarettes will reduce the severity of the disease in those who smoke and may encourage some smokers to drop the habit. This creates a spurious connection between COVID-19 as a respiratory disease and the deleterious effects on health of smoking.

Is this a smoking ‘just so’ story?

The WHO scientific brief of 26 May 2020 finds that there is currently no evidence to either confirm or deny an interaction between the virus and smoking. COVID-19 and smoking both affect the health of individuals but on timescales that are simply not comparable. In essence, smoking can be regarded as a potential co-morbidity factor, but the banning of the sale of cigarettes will have absolutely no influence on the way the pandemic plays out but may have highly deleterious effects on the short term health of individuals precluded from smoking. Furthermore it created an unnecessary loss of tax revenue at precisely the time when collecting this revenue to fund COVID-19 interventions was necessary.

This was a moral crusade masquerading as a health intervention, and an attempt to mould scientific evidence to a preferred policy outcome.

A precisely similar argument can be made for the ban on the sale of alcohol, a “just so” story with even less substance than the ban on the sale of cigarettes. Individuals who argued in favour of the ban cited anecdotal evidence in its support, based on the use of ICU beds, but not on any long term studies that should have been the basis for the policy intervention proposed. The introduction of this ban should have been based on longitudinal studies of the impact of alcohol consumption on use of health facilities and counter balanced by the negative impacts on the economy and the criminalisation of activities that are perfectly legitimate in an open society. Again, this was a moral crusade masquerading as a health intervention.

These two examples demonstrate that policy making based on ‘just-so’ stories undermines the public’s confidence in responses to the pandemic that are related to non-medical interventions to limit the spread of the virus - hand washing, wearing masks, limiting movement of and interactions between people.

Finally, in a well documented article in The Conversation, Fuller and Mitchell explored both the physiology of fever and the utility of using fever screening to identify individuals who may be infected. Their scientific evidence shows that measuring skin surface temperature is not a good proxy for determining core body temperature which is related to fever. Second, they indicate that the history of the use of fever screening, points to it being ineffective in identifying individuals who should be tested and perhaps quarantined. Significant resources are being invested in equipment and human resources with very little in the way of a demonstrably sensible outcome. What is particularly galling about this example is that the people of South Africa are being mislead by poor science into doing something that has little value, in the misguided apprehension that it will allow those who are infected to be identified.

All three of these examples represent policy making that is capricious and unnecessary in the context of dealing with the pandemic and shows a lack of commitment on the part of those making policy to critically examine the impact of interventions that introduce gratuitous limitations of freedoms vs a public good that is at best nebulous.

Finally, I would like to explore another two “just so” stories from the recent past during the ‘crisis’ of another pandemic. The first of these relates to the supposed treatment for AIDS called Virodene. In this case, a toxic laboratory fixative was touted as a potential treatment for AIDS. The ‘scientific explanation’ for its potential efficacy was exactly equivalent to that of bleach proposed by President Trump in the context of COVID-19. What we have failed to recall about the Virodene saga is that it received substantial local funding for clinical trials and patent protection and was supported by the Minister of Health of the time.

Simultaneously, another “just so” story was in circulation propagated by the Department of Health that would not support the provision of anti- retrovirals to pregnant women to prevent mother to child transmission of HIV, on the grounds that these treatments were toxic. Thus a known toxin with no known therapeutic effect was promoted in preference to anti- retroviral treatments with known therapeutic value. The catastrophic lack of any kind of sober evidence-informed basis for this policy making was fortunately reversed in 2003 when the policy of supplying anti-retrovirals was introduced.

The questions that South Africans should be asking now, is why responses to crises of public health have resulted in policy interventions that were not based on any credible scientific evidence? Given the two episodes I have described, one in relation to HIV and the second in relation to SARS-CoV-2, we should be particularly wary of the suggestion of the current Minister of Health that the Health Act should be amended to give the minister powers similar to those of the Disaster Management Act in order to intervene in future health crises. Given the track record of Ministers of Health, and given their lack of respect for the freedoms conferred by the constitution, it would an entirely retrogressive step to allow them to have powers of this nature.

The final point that I would like to make is in relation to the medical profession in general and their apparent lack of concern for the Hippocratic oath that all of them took in some form or another when they graduated. Amnesia about the Hippocratic oath is certainly not a new phenomenon as has been demonstrated in extreme examples such as the medical experiments in Nazi concentration camps and treatment of prisoners of war. Why do I raise this in relation to the current pandemic? I do so because there are elements of human rights abuses which are taking place in hospitals as part of the non-medical responses to COVID-19. These human rights abuses are occurring without apparent reflection or protests by any medical practitioners.

How did we accept that elderly people should be isolated and neglected? Yes, they may be at greater risk of infection and ill health, but they have one life that may or may not be able to be saved and surely the quality of that life is what is most crucial? Is it really acceptable to say that families need to greet them through glass screens and people in their 80’s and 90’s should not be allowed to touch and hold their families who would not be at risk from their elderly relatives? Have we comprehended the reports of death from loneliness, madness from isolation and deep depression from being denied access to those we love most? The deaths in care homes were deeply troubling but these infections largely came from care workers who moved from one care home to another, rather than from family visits. Similarly, individuals who had to be admitted into hospitals for treatment of conditions other than COVID-19 were either denied access to their relatives or given ludicrously short periods of access.

How did we come to accept this madness? How did we allow our society and civilisation to stoop so low. This is not a discussion about balancing the rights of individuals vs the public good, it is about abuse of rights and the removal of agency from individuals who should be given the opportunity to evaluate their own risks. Permitting such interventions with apparent approval will be a lasting stain on the medical profession which should have been much more compassionate in the way that patients are treated particularly as it has become clear who is at risk and who is not.

This insensitivity to the needs of patients appears to stem from the narrative that we are fighting a war against a virus in the quest to save lives, and consequently we have to accept the collateral damage to the elderly and to hospital patients. Indeed in war, the narrative of dissent (based on scientific evidence) is threatened with punitive action and a return to higher levels of lockdown. This is a false characterisation, the interventions should be to limit the spread of the virus not to wage a war and at the same time to treat vulnerable people with the compassion that it is their right to expect.

What we need, is a growing awareness of the twin dangers of ‘just-so’ stories and war analogies, and hopefully a return to truly evidence-informed policy making rather than searching for policy informed ‘evidence’ as the three examples that I presented demonstrate.