On the Primacy of the Physician-Patient Relationship, From an Unlikely Source – The Attorney General of Nebraska

Yves here. For what I assume are reasons of brevity, this post didn’t cover ground about the state of medical practice that has been very well examined at the same site, on how the corporatization of medicine is undermining patient care and doctor-decision making. It isn’t just the prototypical 6 minute appointment. It is also that doctors in large corporate practices, which is pretty much where all of them are, are required to practice cookie-cutter medicine, such as prescribing statins to patients with high cholesterol to reduce their risk of heart disease, when for years studies have shown statins provide a heart health benefit only for those who already have heart disease. More from KLG:

There is no evidence that statins work, if by work we mean really lessening the likelihood of a heart attack. They do lower serum cholesterol, but there is no evidence that serum cholesterol is correlated with heart disease in people who are otherwise normal and healthy. Serum cholesterol is a largely meaningless number. Familial hypercholesterolemia (FH, usually caused by a mutation in the LDL receptor) patients can benefit. There is some evidence of anti-inflammatory activity with statins. But my reading tells me Lipitor and related drugs are/were mostly a scam, but a very lucrative scam for all involved except us.

The site Health Care Renewal has also described how electronic health records (designed by MBAs for billing) degrade care by taking MD attention away from the patient during his assessment to do data entry, putting doctors though pages and pages of material that they need to check off as not applicable, again distracting focus from diagnosis and treatment. We’ve featured many of their posts on this topic, but for one-stop shopping, see: How Electronic Health Records Degrade Care and Endanger Patients.

These assaults on a doctor’s right to treat patients, as opposed to administer MBA-devised protocols, have gone largely under the radar. But the widespread efforts to stop doctors from prescribing Ivermectin as a Covid prophylactic and treatment have been revealing. As readers likely know well, Ivermectin is an approved drug, with one of the best safety profiles of any prescription medication. Many drugs are regularly prescribed off label (as in for uses in addition to the ones authorized by the FDA). As we’ve pointed out, some drugs like Botox are prescribed far more for their off label than their approved use. It’s not often said out loud, but it seems clear that that attack on Ivermectin is based on the assumption that patients are seeking it to avoid getting vaccinated, as opposed to in addition to vaccination. And they further ignore that the hard-core anti-vaxxers won’t get vaccinated, Ivermectin or not.

But the point this post makes is broader: that trying to restrict physicians’ rights out of an apparent desire to restrict what are believed to be substitutes for vaccination has dangerous ramifications for the practice of medicine.

By InformaticsMD. Originally published at Health Care Renewal

I have not written much at this site, or any site, in recent years due to being kept busy supporting litigation regarding bad healthcare information technology as an expert witness.

A recent letter, however, so caught my eye regarding both current events and my past writing about bad health IT, that I decided to write about it.

It is perhaps a poignant reminder of the craziness of the times in which we physicians find ourselves that a well researched letter on the primacy of the doctor-patient relationship, and the non-interference with that relationship by outside forces based on opinions of non-clinicians, half-baked ideas, overzealous government, media hysteria to garner audience share, etc. comes not from the hallowed halls of academia or a prestigious medical journal – but from a state Attorney General, namely, of Nebraska.

The letter, dated Oct. 14, 2021 and entitled “Prescription of Ivermectin or Hydroxychloroquine as Off-Label Medicines for the Prevention or Treatment of Covid-19“, is located at this link:https://ago.nebraska.gov/sites/ago.nebraska.gov/files/docs/opinions/21-017_0.pdf

It was requested by Dannette R. Smith, the Chief Executive Officer of the Nebraska Department of Health and Human Services.

I recommend reading it in its entirety.

In this 48-page letter, arguments regarding sanctioning of Nebraska physicians for their decisions on how to treat their patients with FDA-approved drugs for off-label purposes are discussed in significant detail and with significant literature references.  The letter reaches the conclusion that:

…  Based on the available data, we do not find clear and convincing evidence that a physician who first obtains informed consent and then utilizes ivermectin or hydroxychloroquine for COVID-19 violates the UCA (Nebraska Uniform Credentialing Act). This conclusion is subject to the limits noted throughout this opinion. Foremost among them are that if physicians who prescribe ivermectin or hydroxychloroquine neglect to obtain informed consent, deceive their patients, prescribe excessively high doses, fail to check for contraindications, or engage in other misconduct, they might be subject to discipline, no less than they would be in any other context … Allowing physicians to consider these early treatments will free them to evaluate additional tools that could save lives, keep patients out of the hospital, and provide relief for our already strained healthcare system.

No matter one’s opinion on the specifics of this particular controversy, the primacy of the physician-patient relationship – absent extreme circumstances of malfeasance/malpractice – is a principle that should not now, and should never need a 48 page letter for its justification.

I find the following passage on pg. 36 particularly intriguing relative to my many essays in the past on observations by many parties that healthcare information technology (e.g., EMRs) are unhelpful and even harmful to provision of medical care, and the response from the Medical Informatics “establishment” and HIT industry that those observations are “anecdotal” and meaningless (e.g., see my 2010-2011 posts “Health IT: On Anecdotalism and Totalitarianism” at https://hcrenewal.blogspot.com/2010/09/health-it-on-anecdotalism-and.html and its linked posts, also “The Dangers of Critical Thinking in A Politicized, Irrational Culture” at https://hcrenewal.blogspot.com/2010/09/dangers-of-critical-thinking-in.html and “Australian ED EHR Study: An End to the Line ‘Your Evidence Is Anecdotal, Thus Worthless?‘” at https://hcrenewal.blogspot.com/2011/03/australian-ed-ehr-study-putting-lie-to.html).

… To be sure, these data derive from large-scale observational studies rather than RCTs, and we understand that RCTs are considered the gold standard in medicine. But for at least two reasons, we find these observational studies sufficient for our purposes.

First, our role is not to set a standard for the practice of medicine. Rather, we must simply confirm whether reasonable medical evidence supports the use of hydroxychloroquine as an early COVID-19 treatment, and we determine that a collection of large-scale observational studies suffices for that purpose. Second, a seminal review of the scientific literature has revealed that “on average, there is little evidence for significant effect estimate differences between observational studies and RCTs, regardless of specific observational study design, heterogeneity, or inclusion of studies of pharmacological interventions.” 235 There is thus no basis to cast aside the observational studies demonstrating hydroxychloroquine’s efficacy as an early COVID-19 treatment.

235 Andrew Anglemyer et al., Healthcare outcomes assessed with observational study designs compared with those assessed in randomized trials, Cochrane Database of Systematic Reviews, at 1 (2014), available at https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.MR000034.pub2/epdf/full (last visited Oct. 14, 2021)

I find the second observation in that paragraph about outcomes of observational studies vs. RCTs truly fascinating.

The arguments by the HIT hyper-enthusiasts that observational data from a wide variety of qualified personnel is “anecdotal” and thus invalid (e.g., from physicians such as at my Jan. 2010 post “An Honest Physician Survey on EHR’s” at https://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html as just a small example of the observational data accumulated over many years) and demands that only RCT’s (which are, in fact, nearly impossible to conduct) could validate efficacy and safety risks of EHRs fail under the above.

Observational data by qualified observers needs be taken more seriously in all of biomedicine, and not dismissed with the refrain that “it’s not a RCT.”

If that had happened in the domain of HIT, perhaps I would not now be spending so much time assisting litigation regarding HIT evidentiary obfuscation, HIT-related patient harms, and other litigation issues.

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  1. Eustachedesaintpierre

    I took statins for a few months after my terrifying ordeal due to the old ticker, but then did some research & decided that improving my lifestyle through diet & walking was the better option – although I have stuck with the daily dose of 75mg aspirin.

    I guess BP would love for there to be a situation of only large RCT’s only counting as valid which cost millions that only they & governments could afford, but in the case of Merck’s Molnuparivir there is plenty of concern out there for it’s potential to cause long term mutagenic side effects, such as cancer & birth defects.

    ” The inclusion criteria for the Phase 3 study of molnupiravir required males to refrain from donating sperm and either agree to abstain from sex or use contraception. Females were required to not be pregnant or breastfeeding. Women who were of child-bearing age had to agree to use a highly effective contraceptive method or be abstinent for 28 days from the start of the study intervention. In addition, women of childbearing age must have had a negative highly sensitive pregnancy test within 24 hours before receiving the first dose of medicine “.

    I wonder if the above instructions come with the box so prescibers & users are aware of it, seeing as it seems important. It appears to me that standards for in particular hospital protocols set in stone by management that leave frontline doctors with no choice & flexibility for treatment, are favourable to other forces rather than that of the patient & BP having the power to control all of this is a bad precedent, judging by it’s history as once outlined by Professor Ben Oldacre back in 2011 on how they cook the books.


    1. petal

      Heard through the grapevine this week (from a trusted source) that people going to the local ER are getting really angry because the staff are refusing to prescribe IVM or hydroxychloroquine for covid when the patient brings it up/asks for it. It sounded like a lot of people are asking for those two drugs, and it’s hospital policy to not prescribe it. The person telling me about what was going on was definitely in the “These are Trumper drugs, these people asking for them are stupid & uneducated” group. They even said so out loud whilst telling the story.

    2. howseth

      Statins have been a tricky one for me. Been taking em’ – one or the other type – regularly since 1997 – plaque advanced anyhow. I know that’s true, due to a Calcium (CAC) scan in 1997 – and again 2 years ago.
      Stopped taking them – and my cholesterol shot up crazy high. Maybe, probably, genetics (FH?)

      Yeah, I’ve read much about how ineffective they may be – and I have changed my diet to much lower carbs and stopped eating grains – and yet my body loves making all kinds of cholesterol. My personal doctor recommends them too – though does not insist on it. I suppose it might be considered malpractice if he did not.

      So, I’m back to taking 10mg Crestor generic – on a positive note – I don’t seem to get the muscle aches others claim… and my liver seems to tolerate it well.

        1. flora

          My doc wanted me to go on statins etc when my chol. levels breached the 220 mark. I resisted. (personal anecdote) My doc back then, over 20 years ago, was no doubt following the “current best science” data protocols. Things change. Scientific understanding changes. “The science” is not fixed. etc. “THE” science is always conditional, subject to new data, etc.

        2. howseth

          Maybe, probably, I can get my total cholesterol down to about 270 on the 10 mg Crestor dose I’ve implemented? I’ll have to watch my blood sugar – as that might kick up – as statins are prone to raise. So, it’s a balancing act.
          Don’t woman usually have an advantage in putting off the onset of plaque for longer due to hormones – at least till menopause?
          Heart disease runs in my family – the male side – so I have cause to take action.

          1. Yves Smith Post author

            I hate to tell you but your doctor’s advice is 20 years stale. You can find evidence that this “cholesterol causes plaque” is bunk. Cholesterol is a backup repair mechanism. Inflammation in the arteries is the issue.

            If the gunk theory was valid, you’d see gunk in the smallest arteries and veins first.

            Go see these articles:

            Saturated fat does not clog the arteries: coronary heart disease is a chronic inflammatory condition, the risk of which can be effectively reduced from healthy lifestyle interventions


            A writeup of the study:

            According to Malhotra, Redberg, and Meier, the current approach to managing heart disease echoes the practice of plumbing, but the notion of improving the condition by “unclogging a pipe” has been invalidated by a series of clinical trials. The trials found that when a stent was inserted to widen narrowed arteries, the risk of heart attack or death was not lessened.

            “Decades of emphasis on the primacy of lowering plasma cholesterol, as if this was an end in itself and driving a market of ‘proven to lower cholesterol’ and ‘low fat’ foods and medications, has been misguided,” the panel contends. These misconceptions may stem from “selective reporting of data,” they suggest.


            1. Janie

              Preach it. My doctor recommended statins a few years ago. Age 70s, cholesterol 250, low normal blood pressure, no familial history of clogged arteries. Probably following guidelines for best practices, wasn’t insistent.

            2. howseth

              I wouldn’t disagree – I too have read similar things about those cholesterol infused calcified plaques actually being a repair patch for other problems – and not the real problem – which is chronic inflammation – causing the need for patch(s) – and if a statin helps at all – it is due to it’s anti-inflammatory qualities… far more than it’s cholesterol lowering effect.

              I’m trying to get a handle on inflammation too – as I – reduce my cholesterol level. Implementing diet changes, supplements, exercise – I’m doing it all – and testing.

              1. Eustache de Saint Pierre

                With me anyhow, it was as a 57 years old idiotically doing the equivalent of what occasionally kills young soccer players. I still get nervous when overdoing it a bit, but nothing like it was which lasted for about a year as in feeling that you are up in the sky flying a single engine plane that might just cut out at any second.

                Yesterday I was finally able to compare myself with the Beatles When I’m 64 – not what I expected as a kid on hearing it, when it felt like a million years away, but I’m working hard, still playing a bit & feeling well – so far anyhow.

  2. Susan the other

    So, it’s all in their head that long complicated randomized trials provide better data than direct observation of the effectiveness of a treatment. Ha. QED.

  3. Kris Alman

    I went through my internal medicine residency from 1984-87. We were feted with free lunches by drug reps, who gave us pens, gadgets and other branded items advertising their new drugs. I felt I was immune to their influence.

    Perhaps 5 years later at a conference on antihypertensive treatments, I naively asked the speaker why drug trials didn’t compare newer meds with generics in their studies. She point blankly said that would never happen. Why would pharmaceutical companies take that risk to develop and market a drug that is less effective than a cheaper generic drug?

    That’s when I took a more critical eye toward prescribing new drugs.

    Patents = profits. This is especially true for a biologic, which has longer patent rights than small molecular drugs.

    It used to be that drugs beat placebos by a wide margin. Not so much anymore for many new drugs. https://www.huffpost.com/entry/new-drugs-effectiveness-old-medicines_n_3380347

    Whether it’s pain, mental health, infectious diseases or otherwise, it’s always hard to know whether a treatment is making a clinical difference. For example, the placebo effect can be high (35-40%) in RCTs of treatment resistant depression. But this knowledge isn’t often sufficient for doctors to turn the spigot off when drugs like anti-depressants are started.

    This is a striking observation from this recently published article:
    September 24, 2021
    Magnitude of the Placebo Response Across Treatment Modalities Used for Treatment-Resistant Depression in Adults
    A Systematic Review and Meta-analysis

    Factors that increase the placebo effect appear to include using an open-label, prospective treatment phase and industry sponsorship.

    Certainly, we know there can be harm from treatment, including for infections which could otherwise resolve on their own. Microscopic critters evolve and then our tools are dulled through antibiotic resistance.

    This is clearly not the reason why early treatment is being squelched for Covid with repurposed drugs.

    I heard Jane Goodall speak recently on Marc Maron’s podcast. Dr. Lewis Leakey recruited her to study chimps in the wild specifically because she was female (and more likely to be patient) and she had not gone to college (and been indoctrinated in scientific methodology). She notes that her students often do their field work with pre-conceived ideas that don’t allow them to see the flaws in their hypotheses nor nuances that are occurring in the natural world. (Forgive me if I am not paraphrasing this well.)

    The electronic health record was touted as a rich source of clinical data to mine for secondary use in biomedical research in the bench to bedside approach of translational medicine.

    Why isn’t that happening with repurposed drugs like hydroxychloroquine or ivermectin?

    It’s no wonder that PhRMA has been spinning a changing narrative for the loss of vaccine efficacy. (Never mind there are no efforts to tease out social distancing policies, mass usage, etc.) But it’s abhorrent how agencies like the FDA and CDC have been co-opted and the MSM has politicized this to the point that anyone who questions vaccine efficacy or safety is a Fox-watching, ignorant Trumper, while elite liberals cling to their vaccination cards and eat inside crowded restaurants without masks.

    And it’s absolutely heinous that doctors are portrayed as criminals when they treat Covid patients with off-label safe drugs that could help their patients.

  4. Basil Pesto

    Sometimes, lawyerly thinking can be a usefully deployed, clarifying thing when it’s done without a particular axe to grind (and even sometimes when it is!), so the good doctor oughtn’t be too surprised.

    I was pootling around the Stanford Philosophy Encyclopaedia earlier and after I read this article, thought I’d search ‘Randomized Control Trial’. Turns out there’s a whole section on it under ‘Philosophy of Medicine’. Excerpt:

    No one denies that RCTs are powerful experimental designs—and that their power stems from the ability to control numerous sources of bias and confounding. However, to refer to RCTs as the “gold standard” of evidence suggests that they are more. Specifically, one may be led to assume that RCTs are necessary for reliable causal inference or that RCTs are guaranteed to deliver reliable results. A number of philosophers of medicine have in the past decade or so argued that these stronger claims do not hold to scrutiny.

    In this way, when we see RCTs referred to as ‘the gold standard’ in the popular press, we can conclude that this is not just some matter-of-fact statement of the supreme medical episteme, but a PR coup for the EBMers (there’s more detail at the link, strongly recommended if you’re interested).

    There’s also a bit more at the ‘Philosophy of Biomedicine’ page (biomedicine, it seems to me, loosely being a term that describes the western post-war medical order). I’ve only skimmed these articles but it also looks super interesting, particularly in light of the other issues associated with the pandemic. Some more excerpts, from the ‘epistemology of biomedicine’ section:

    There is a large philosophical literature on evidence-based medicine, with the first monograph appearing in 2002 (Goodman 2002). Most of the literature takes at least a partially skeptical stance on EBM practitioners’ various hardline stances on evidentiary matters: the suitability of clinicians relying primarily on brief synopses that attempt to synthesize massive bodies of evidence (Borgerson 2009); the room for hidden biases in the process of evaluating medical data (Stegenga 2011), and more. EBM has also inspired passionate disputes among clinicians over how to apply its principles (Berwick 2005; Greenhalgh, Snow, Ryan, Rees, & Salisbury 2015). One line of criticism is that its aims are noble, but have been hijacked by bad actors, namely corporations that learned to that by getting involved in the production of randomized control trial evidence they could sway the evidence for the apparent safety and efficacy of their own products (Ioannidis 2016). Philosophy of EBM is given extensive discussion in the entry on Philosophy of Medicine, and as with the rest of this entry, this entry will avoid needless repetition and keep the focus on biomedicine per se.


    EBM’s reliance on randomized control trials as a cornerstone of health data collection doubles down on the general reductionism of biomedicine. Randomized control trials assume that health variables can be observed, manipulated and controlled as largely independent units. Yet, is a well-established problem that we simply don’t know all of the variables that might confound a clinical experiment (Worrall 2007), so randomization can at most hope that the ‘confounders’ (e.g., unknown dietary factors that affect metabolization of a drug) are randomly distributed between the different treatment populations in an experiment. Taking the reductionism a step further, the goal of exactly measuring the differences between Treatment A and Treatment B requires EBM to only look for effects that are precisely measurable in the first place. This limitation is a deeply-rooted problem since even the official list of clinical signs and symptoms of a given disease can diverge from accumulated patient observations, and in cases such as some psychiatric conditions, the symptoms—or lack thereof—are overtly difficult to measure or factor into an assessment of treatment efficacy (e.g., one’s sense of self and/or emotional life) (Kendler 2016).

    Hopefully fellow readers will find this material as interesting as I have so far.

    1. megrim

      Thanks for this! I’ve been thinking a lot about RCTs and EBM lately, and this is totally fascinating information!

    2. Eric Blair

      Very helpful indeed, Basil. Your observations confirm my thoughts when I was recently watching researchers discuss vaccines at a pre-Covid WHO conference where they talked about “added complexity” as if this is a bad thing. So why would complexity be bad? Because it makes it harder to establish a clear cause-effect relationship. You need to control all the variables, and if you can’t, the next best thing is to reduce the variables you look at. Thus medicine (or any other science) is inherently reductionist, ie, specifically not looking at all the factors that could influence a certain result. But our bodies are vastly complex systems, as the world is vastly complex, so complex that science can’t wrap its research arms around it. If only scientist would study a bit more the inherent limits to science rather than pretend that what science finds is all there is. I guess that job is left to the philosophers.

  5. synoia

    I wish I knew what all the Acronyms meant.

    The US’ predilection with acronym riddled writing reduces comprehension. It appear to me to be an extension of the childish behavior of “I know something you don”t know.

    And no, a glossary that needs to be referenced repeatedly is more of a hindrance than a help to comprehension. Removing these burdens to comprehension in modern word processors is a simple editorial task with “search and replace”.

    1. CanCyn

      Indeed. A good price writing should always provide the full meaning of the acronym the first time it is used in order to avoid confusion. For example EBM (Evidence Based Medicine)….

    2. Rick

      Yes, this is a problem for me. Not just the US – NI for Northern Ireland is one I’m still getting used to.

      HIT – heath Information Techmogy.
      EHR – Electronic Health Records.
      EBM – Evidence Based Medicine, as CanCyn noted.

      I agree with the idea that the first time one is used it should be defined. My profession is riddled with TLAs (Three Letter Acronym, a self referential TLA), one time I ran across an acronym I didn’t know and it turned out to be the technology I was using at the time.

      Hopefully nobody will veer off into the (rather dubious) difference between acronyms and initialisms…

      1. Wombat

        EMR – Electronic Medical Record
        EMH – Emergency Medical Hologram
        EMT – Emergency Medical Technician

        the list goes on

    3. Jeremy Grimm

      I strongly agree! Before I retired, I worked at a job where thousands of acronyms were in play, often meaning very different things in slightly different contexts. I have had to wade through enough undefined acronyms for one life!

    4. Brooklin Bridge

      If you think acronyms are bad in American English, try French and particularly French architecture or politics (God help us all), and I imagine networking software if it’s anything like the American networking software acronyms, not to mention software in general. Virtually anything that gets specialized (probably in any language). I completely agree btw; some people seem to have a knack for it, for me, however, wading through acronyms is gnarly going, especially when one’s not familiar with the given context.

  6. Susan the other

    So how complicated can RCTs and EBM get in modern molecular medicine? Specifically how do you eliminate all the genetic variables? When human variability is off the charts? Just figuring out a way to filter those variables down to a manageable study sounds impossible. It argues against any study being “randomized” successfully because it is impossible to randomize something so chaotic to begin with and with silly protocols like blindfolds, with yes-no questionnaires; with simple, cheap blood scans; a smattering of age categories. I’d submit that that isn’t randomizing at all. It doesn’t even need to be considered. In order to really get the broadest legitimate sample you’d have to run all the genetics, maybe eliminate the mutants, and then continue to watch every subject for any changes between the first and last of the trial dates. How can you run a “trial” on the effectiveness of a drug without knowing that stuff? I can see how those results would be more vacuous than simple close observation of a patient.

    1. HotFlash

      Well, as it happens a client of mine is old friends with a guy who is well up at Merck. The old friend told him over dinner a month or so ago that they have computer programs that can predict the effects of a molecule — benefits, side effects, the lot — based on the chemical structure. This includes totally theoretical molecules. So, perhaps the future, maybe even the present, is clinical trial by algorithm — what could possibly go wrong?

      Also, the old friend had only gotten his second shot a couple of weeks prior, and only gotten ‘vaccinated’ at all b/c Merck had explained to him that no vaccine=no job.

      1. Susan the other

        It sounds like progress in the right direction – studying things at the smallest level. But no broad spectrum treatments hopefully because every genome is different. Customized medicine would be a very cool thing.

  7. Sue inSoCal

    This is quite interesting on several levels. The AG is not a physician, and I see quite a bit of hypocrisy here. In this instance, the gist is “let the physician treat the patient as they see fit.” I couldn’t agree more. And it shouldn’t be limited to these drugs, it should be for all treatment. It should be the physician’s call, so this should apply to general medical practice. Women, for example, are scrambling for rights over their bodies which can involve use of an off label drug that has very little risk. It’s fascinating also that, conveniently, a “conflict of interest” issue is raised here, when the country is, imo, a rolling conflict of interest disaster on innumerable levels. Politics politics….


  8. ven

    Isn’t the issue more serious than this?

    The medical establishment (WHO, CDC, NIH, FDA, NHS, medical journals) supported by the media have gone all out against invermectin and hydrochloroquine, in favour of no early treatment at all. And even after hospitalisation these drugs seem to be banned.

    The media either suppresses news about ivermectin’s effectiveness or jumps with the FDA in calling it a horse de-wormer.

    The doctors that are prescribing them have been pursued and threatened by their medical boards. Relatives of patients that are begging for their loved ones to be given ivermectin are being ignored, and even after the hospital has been taken to court, they even appeal!

    This in spite of the fact that both have a safety record demonstrated over multiple years and billions of human doses; and an efficacy that is better than Molnupiravir, which has its own unknown mutagenic safety issues.

    There is a strong case to be made that Uttar Pradesh in India overcame its covid crisis through the prophylactic / early use of Ivermectin.

    The implication is that we could have rapidly managed this covid crisis by early out-patient treatment with a variety of readily available (though unfortunately off-patent) drugs. Without the use of patented vaccines with no long-term safety studies, and unclear efficacy in stopping transmission. And we have mounting evidence of reported side effects of the vaccines in the US and Europe, far in excess of any other vaccine, that are not being further studied and evaluated. That in itself must amount to medical negligence?

    It is obvious what the pharmaceutical industry’s interests are. But what is there to say about a medical establishment that is willing to forcibly suppress treatment options, even if that results in untold deaths?

    We all know the government – defence – media axis in promoting and lying about overseas wars and death tolls. Now we have a government – pharmaceutical – medical – media axis lying about covid treatment options and side-effects / deaths. Given knowledge of the former, it is odd that people resist seeing the latter.

    At what point will outrage sink in, at the unnecessary deaths from suppression of early treatment options?

    1. Basil Pesto

      At what point will outrage sink in, at the unnecessary deaths from suppression of early treatment options?

      It’s the wrong locus of outrage, for me. While arguments can be made either way, it’s still not clear either way, even from the UP case study, how much of an impact they would have on the pandemic in toto.

      Prevention is better than cure. The virus never had to get to this out of control pandemic state. That’s the outrage.

  9. JTMcPhee

    This is not just a “letter,” it is an opinion of the chief legal officer of the states on the meaning and status and application of state law, rendered after what is supposed to be a diligent parsing of statutes, cases and “common law” precedents, in light of the nearly binding nature of an AG opinion. https://ago.nebraska.gov/opinions

    I had some experience as an attorney with the state of Illinois Attorney General in the drafting of such opinions. This is a pretty good example of the craft, and thank goodness Peterson has agreed to tilt at this windmill. AGs are not generally obliged to render such opinions, and there’s a lot of politics and balancing of interests involved in many cases.

    At the other end of the spectrum, we have the “legal opinions” of the minions of the Blob and reactionary players delivered by creatures like John Yoo. https://libertyconservative.com/war-powers-debate-john-yoo-vs-jonathan-turley/

  10. S Silverstein InformaticsMD

    As a physician myself, I am ashamed that so many physicians allowed themselves to be neutered into doing absolutely nothing for patients with covid infections early on, instead sending them home and wishing them good luck.

    It is likely this is unprecedented in the history of modern medicine.

    It took the Attorney General of Nebraska to bring out the truth about the primacy of the physician-patient relationship, physician autonomy and off label drug use of drugs known to be very safe.

    Roy Poses does have many posts on (some summarizing via keywords) the corruption that afflicts the medical domain.

  11. Michael G

    Before I start to be convinced of something, I need BOTH good numbers and a plausible mechanism. Either alone is inconclusive.
    With climate change, for instance, there is clear evidence of the rise in temperature, and a plausible mechanism through CO2 levels.
    Almost anything will kill a parasitic worm or a virus. The key point is specificity. As I understand it, Ivermectin is the most effective of a group of compounds that target glutamate-gated chloride channels in parasitic worms, without doing the same thing in humans. Ivermectin may well have other effects and side effects, but it would be an astonishing coincidence if it had the same specificity against a respiratory virus. I am not really convinced.
    However, as a genuine example of coincidence, William Campbell is a former pupil of my old school and we had the same outstanding biology teacher..

    1. Yves Smith Post author

      I have written repeatedly that Ivermectin is in the advanced stages of several clinical trials outside the US for use against HIV. This is from a microbiology professor who did bench work on HIV treatments back in the day when the medical industry was desperate for any measure to arrest it. Ivermectin is performing very well in every study. That is evidence of antiviral effects….and oddly completely unreported in the US.

    2. saywhat?

      but it would be an astonishing coincidence if it had the same specificity against a respiratory virus.

      Logically, “an astonishing coincidence” is not necessary; just that Ivermectin kills SOME (perhaps many, not just one) viruses including Sars Cov -2 without harming the human body.

      And as Yves notes, Ivermectin is apparently effective against HIV.

      So no coincidence is required beyond Ivermectin kills some, perhaps many, viruses safely in addition to killing worms and it’s hardly a coincidence that a medicine might have multiple uses, is it?

    3. Michael G

      I need to know WHY. If you don’t have a mechanism, the risk is far higher that the nice-looking data are one of many possible statistical artifacts. If, by chance, Ivermectin does have a secondary target, I would expect there to be other molecules that were far more specific against that target.
      Ivermectin may be a magic bullet, but I am not convinced one way or the other. If the statistics stand up, then there will be a plausible mechanism. Also there will be a reason why other drugs are not effective by the same mechanism. When we have statistics and a mechanism, I will be convinced.
      Looking back over 80 years, I realize that I have spent my whole life being told with complete authority things that were not true. After evangelicals in Northern Ireland, the first big lie I remember was the overthrow of democratic government in Iran, all the way through to neoliberal economics and Brexit…
      Asking for numbers plus mechanism is the best defence that I have found

      1. Yves Smith Post author

        Oh, come on. No one knows how aspirin works.

        And if you aren’t a molecular biologist, you can’t tell if you are being given a valid explanation or buzzword-filled blather. I can give you chapter, book and verse of plausible-sounding medical theories, starting with “saturated fats cause cholesterol” that are now known to be bunk.

      2. KLG

        WHY? Because it works during the early days of a SARS-CoV-2 infection, according to thousands of physicians across the world. As Yves points out, for a long time we did not know how aspirin works even though white willow bark extract, which is rich in salicylates (aspirin is acetylsalicylic acid) has been a folk remedy that works as an analgesic and antipyretic for thousands of years. Now we know that the primary action of aspirin is probably the irreversible acetylation (and consequent inactivation) of cyclooxygenase (prostaglandin synthetic enzymes) during the inflammatory cascade. But it was not necessary to know the mechanism to know that the drug works.

        Tu Youyou won the Nobel Prize in Physiology or Medicine in 2015 for her 1972 discovery of the standard anti-malarial artimisinin. That scientific tour de force was based on her reading of 2000-year-old Chinese medical literature that prescribed Artemisia annua (sweet wormwood) tea for the treatment of malaria. The exact mechanism(s) by which artimisinin has anti-malarial activity are still not completely understood. Nevertheless, WHO recommends artimisinin or a derivative as standard therapy, usually in concert with another anti-malarial, for treatment of malaria. Incidentally, the other half of that 2015 Nobel Prize was awarded to two scientists (one from Merck) for the discovery of ivermectin, which is not “horse paste” but is on the WHO List of Essential Medicines for treatment of parasitic infections. As for the potential anti-viral activity of ivermectin, a number of legitimate studies have shown that ivermectin has anti-viral activity in cultured mammalian cells, perhaps because it interferes with viral RNA synthesis. PubMed is ready when you are. Are these studies dispositive? Of course not. But they are suggestive.

        One could go on for a few thousand more words, but:
        (1) The lack of a molecular mechanism for the activity of a drug is not evidence that the drug does not work. This seems to be a consequence of something called “evidence-based medicine,” which basically means that only those interventions that are supported by large-scale trials are legitimate. This would, of course, mean that mRNA vaccines for coronaviruses are not legitimate.

        (2) Drugs are often found to have off-label uses, with thalidomide being one notable example. A drug used in Europe in the late 1950s as a tranquilizer and treatment for morning sickness had horrific consequences. One Frances Oldham Kelsey largely prevented this catastrophe in the United States, back before the FDA had been captured by the interests the FDA is supposed to regulate. Now? Thalidomide is used for the treatment of multiple myeloma, leprosy, and graft-versus-host disease (undoubtedly with a black box warning).

        (3) Contrary to what the “authorities” say, ivermectin is well-tolerated at high doses in humans, has potential anti-viral activity in vivo, and is cheap. Merck let the patent go a long time ago, probably because they realized there is no real money to be made on a drug that treats parasitic diseases in the Global South. But Merck has molnupiravir in the works as an antiviral that has billions in potential. Their results sound a lot like those reported regarding ivermectin by actual physicians on the frontlines of the pandemic.

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