“The Case for Being a Medical Conservative”

In previous essays, I discussed so-called medical “conservatives”, and alluded to why their unrelenting efforts to ensure unvaccinated, young people were repeatedly were exposed to SARS-CoV-2 were actually quite radical. Let’s review the philosophy behind medical conservatism and explore why several of its champions rejected their own teachings during the pandemic.

In 2019, Drs. John Mandrola, Adam Cifu, Vinay Prasad, and Andrew Foy wrote an article titled The Case for Being a Medical Conservative. They wrote that the “choice of the term ‘medical conservative’ does not imply a political philosophy.”  Instead, they recognized “that many developments promoted as medical advances offer, at best, marginal benefits”.  The crux of their article was that:

The medical conservative adopts new therapies when the benefit is clear and the evidence strong and unbiased.

Though reasonable people can have different ideas about what constitutes “strong and unbiased” evidence, broadly speaking, this strikes me as a reasonable philosophy. Medicine is full of tests and treatments that were widely adopted because they “made sense”, only to be abandoned when rigorous studies showed their risk exceeded their benefit. Many of these treatments were overly-hyped by “key opinion leaders” with ties to industry, and medical “conservatives” were right to warn us about such conflicts of interest. “Motivating biases need not be considered nefarious, only considered”, they wrote.

Of course, medical “conservatives” don’t have a monopoly on discussing overhyped tests and treatments. Such failures all been discussed here at SBM for years, and I discussed many examples in my non-bestselling book on cognitive bias in medicine. When COVID arrived, I took a medically conservative approach the virus. In my first ever article on COVID I wrote about my experience during New York’s 2020 COVID bomb and said:

I also made sure that no patient on my team received any experimental treatments (such as hydroxychloroquine). Doing “nothing” is often very difficult for doctors, but is preferable to giving out unproven treatments unless patients are clearly dying or in a clinical trial.

Medical “conservatives” weren’t the only doctors who wanted solid, unbiased evidence before unleashing a new treatment on large numbers of people. However, time is not an unlimited luxury in the middle of a raging pandemic, and different threats call for different approaches. The standards of evidence used to judge the value of a new knee procedure should not be applied to measures used to combat a rapidly-spreading, rapidly-mutating virus that would kill millions if left unchecked. Waiting for perfect evidence before acting may satisfying a doctor’s psychological need to feel blameless if harms result.  However, doing “nothing” as a virus rips through the population is doing something. As hospitals full of sick children showed, the consequences of excess “caution” can be severe.

Additionally, medical “conservatives” are not the only doctors who recognize the value of randomized-controlled trials (RCTs). I previously wrote “they are the gold-standard for their ability to randomize patients and minimize bias.” I showed my dedication to this belief not by writing essays demanding that other doctors do more RCTs, but rather by participating in a vaccine-RCT myself, bypassing my chance to get mRNA vaccines in December 2020.

Drs. Mandrola, Cifu, Prasad, Andrew Foy ended their article thusly:

The wisest of conservative physicians understand and embrace how little effect the clinician has on outcomes. While many may call this frame of reference nihilistic, the conservative clinician sees it as protective against our greatest foe—hubris.

Given this admonition against hubris, it is striking that with regards to SARS-CoV-2, many medical “conservatives” abandoned their caution, arrogantly treating a brand new virus as if it were a exaggerated, predictable entity.  Their haughty approach led them to repeatedly declare the worst of the pandemic over, to relentlessly mock those who tried to avoid the virus, and to minimize COVID’s worst harms, including dead children and young adults.

The Case for Being a Medical Conservative, Except For a Brand New Virus:

Part 1: “It’s May not March.“

As early as March 5, 2020, Dr. Mandrola praised the “strikingly calm words on #COVID19″ of a politician who warned “Fear can do more harm than the virus itself.”  Hundreds of thousands of Americans who chose not to “live in fear” are no longer here to expound on the wisdom of their decision. Even after the virus devastated New York City and multiple other cities here and abroad, Dr. Mandrola remained extremely confident that the rest of the country would be spared our sad fate. Though the virus had existed for just a few months, he was certain he could accurately predict its behavior. He said that those who disagreed with him, even before anyone had been vaccinated, were “fear-mongering” to “gain followers” on Twitter. Like other medical “conservatives,” he shamed and scolded anyone who actually took a conservative approach to the virus. Here are some of his preposterous predictions, with COVID’s cumulative death toll on that date.

• May 1, 2020 – 68,515 deaths: I recoil against the idea that moderation of distancing measures in places in the US and Sweden is akin to human sacrifice. That sort of hyperbole and fear-mongering in medicine always leads to bad decisions. Also, no US hospital is now unprepared. It’s May, not March 9.
• May 4, 2020 – 72,831 deaths: 1) US Hospitals not close to being over-run. It’s the opposite in most places 2) Everyplace I know of is opening up for more regular healthcare. Good. 3) We have learned how to limit nosocomial spread. It’s May not March.
• May 5, 2020 – 75,010 deaths: US hospitals are now prepared and in little danger of being over-whelmed. In fact, many hospitals are so dormant they are nearing financial ruin.
• May 7, 2020 – 79,237 deaths: May is different from March. People are not stupid. Public health surveillance is better. Hospitals are ready. NYC-like situations are unlikely now in the US.

November 1, 2020 – 231,003 deaths

• December 15, 2020 – 307,343 deaths: Barring something (very) unforeseen the #covid19 pandemic is over soon. Such good news!

January 27, 2021 – 434,380 deaths

February 13, 2021 – 483,543 deaths

February 14, 2021 – 484,694 deaths

• March 10, 2021 – 527,345 deaths: The more that people ride bikes, the more hip fractures and cranial bleeds we will see. The pandemic is essentially done. Human life has to be more than avoiding one pathogen. With respect…sir, please, stop.
• March 10, 2021 – 527,345 deaths: Ky has vaccinated about 1 in 3 older people. CT has done even better. The vaccine squelches severe cases Millions have natural immunity. Young have almost no risk. The pandemic (of bad disease) is nearly over. And this is a really worthy cause of celebration!!!!!!
• March 11, 2021 – 528,887 deaths: I wish I had wrote “almost done here in the US.” Frustration with fear-mongering got the best of me.
• June 11, 2021 – 595,482 deaths: It appears to me that we have crushed COVID by simply vaccinating susceptible adults. Why not wait for more data before extending these novel therapies to young people?
• July 29, 2021 – 608,526 deaths: If you were vaccinated and had mild to moderate URI symptoms, why on earth would you get a COVID test? Have the vaccines not transformed SARSCOV2 into just another regular respiratory virus?

July 29, 2021 – 608,526 deaths

• July 27, 2022 – 1,029,290 deaths: We now have a diff disease: many if not most COVID+ pts we consult on have + test but an adm Dx (admitting diagnosis) for something else The pneumonias of 2020-2021 are thankfully rare.

Over a million Americans have died of COVID since Dr. Mandrola falsely reassured us that “US Hospitals not close to being over-run.” To his credit, he has acknowledged some of his poor prognostications. In an article from December 2020 he evaluated his earlier predictions and said:

Assertion 6: Non-pharmaceutical interventions, such as social distancing and masks, would not lower the infection fatality rate. Verdict: Wrong.

Early on I saw little advantage to delaying infection. I wrote: “the only way fewer people die from COVID19 over time is if the IFR declines.” I then went on to describe the slowness of medical progress.

There have been two major medical developments that (now) argue strongly for delaying infection–especially earlier this year.

First is that clinicians better understand how to care for patients with COVID19 pneumonia…Second is the huge surprise of vaccine development. I wrote that “COVID19 vaccine development is sobering.” That was dead wrong.

That’s not a trivial thing for a doctor with a large audience to have been “dead wrong” about, especially considering he both failed to learn from his mistake and he frequently bemoans the lack of trust in medicine. I’m glad I don’t have to wonder if my farcical forecasts led a vulnerable person to abandon COVID precautions only a few months before vaccines were available.

That last two sentences are true

The Case for Being a Medical Conservative, Except For a Brand New Virus:

Part 2: “I want to write a children’s book about a bear who didn’t want to leave home till it was perfectly safe.

In addition to mocking those who doubted the end of the pandemic two years ago, medical “conservatives: similarly belittled strangers who they felt tried too hard to avoid the virus. During the winter wave of 2021, at the literal peak of death for the entire pandemic, on a day when 3,523 Americans died, Dr. Prasad sarcastically tweeted:

I want to write a children’s book about a bear who didn’t want to leave home till it was perfectly safe. He never left and life passed him by. In the sequel, he stands at the window shouting at anyone outside that they are killing fellow bears and spreading disinformation.

Most Americans were unvaccinated at that time, and nearly 700,000 Americans have died since.

Dr. Prasad would later say that “Fear of long COVID is irrational. In so far as it exists, you have to accept it” and that:

It’s time for medical professionals to advise young, middle age, healthy people to throw away your n95, leave your C02 monitor at home and get back to life. These are not proportionate responses. You are not acting reasonably. Someone needs to tell you.

He expanded on this theme in an essay titled “When Scientists’ Anxiety Disorder Interferes With Other People’s Lives,” in which he said:

What word do we use to describe doctors, scientists and policy makers whose personal mental health issues affect their policy recommendations? The lives of others?..It is pathologic for anxiety to harm your own life, but I believe we enter the realm of catastrophe when personal mental health issues affect sweeping policy matters.

He went on to shame and pathologize “vocal policy analysts (doctors, scientists, professors) who’s comments might be concerning.”  As the pandemic progressed, Dr. Prasad continued to say that people who were trying too hard to avoid the virus were mentally unstable.  In November 2022 he wrote:

Some adults who have had multiple boosters wear masks to concerts. Why? You will get COVID anyway later. One in 4 won’t eat at a restaurant. I am deeply concerned these people need counseling.

He said such people were “demented” and “betray a deep ignorance about COVID19, and more generally show that they are incapable of judging risk.” Of course, masks are completely normal in countries like Japan and Singapore, which suffered a fraction of our COVID loss.

When RSV, flu, COVID overwhelmed pediatric hospitals, Dr. Prasad said parents who wanted to limit playdates were “cruel and stupid.” He implied that only people who were willing to repeatedly expose themselves to SARS-CoV-2 were properly living. He wrote:

Despite millions of news stories on COVID19, no one asked the obvious question. Respiratory viruses exist because human beings have to be close to each other. We are a social animal. We have to breathe each others air, and everything wonderful in life happens in proximity.

Medical “conservatives” urged strangers to expose themselves to SARS-CoV-2 and other viruses on a repeated basis and pathologized anyone who was unwilling to do so. Echoing pre-pandemic, anti-vaccine balderdash, Dr. Prasad even told parents it was “natural and healthy” for children to get sick with COVID and other vaccine-preventable viruses.

The Case for Being a Medical Conservative,  Except For a Brand New Virus:

Part 3: “No, Young Adults Should Not Live in Fear from Coronavirus.”

It’s likely that medical conservatives were so nonchalant about the virus because they felt death from COVID was overrated, including the deaths of thousands children and young adults. After 19 children died of COVID in April 2021, Dr. Prasad argued unvaccinated children should remain vulnerable to COVID, reminding us that there are 330 million Americans who didn’t die this way. Imagine a doctor saying this if measles killed 19 kids in a single month. In a pro-virus article titled Should We Let Children Catch Omicron?, Dr. Prasad wrote what may be the coldest sentence I’ve read from a doctor this pandemic. He wrote:

And while the death of any child is a tragedy, Covid-19 is less deadly to children than many other risks we accept as a matter of course, including drowning, vehicle accidents, and even cardiovascular disease.

Similarly, in December 2020, after thousands of young people had already died of COVID and with vaccines on the way, Drs. Mandrola and Foy wrote a piece titled No, Young Adults Should Not Live in Fear from Coronavirus which concluded:

The young have many reasons- ethical and moral–to adhere to social distancing during the pandemic. Fear of death is not one of them.

“An excess of 12,000 deaths sounds bad”, they wrote, but they felt it was just a “tiny absolute increase in risk”. Of course death is not the only bad outcome from COVID, a fact unacknowledged by Drs. Mandrola and Foy.

Dr. Mandrola also said at that time that other longstanding ills, which he reflexively attributed to measures to control the virus, would be worse than COVID’s death toll, writing:

The intense political divide, the growing intolerance of ideas, the racial unrest, all argue for a pessimistic case that the lives lost from the viral infection will NOT end up being the gravest harm from this contagion.

In reality, the lives lost were the gravest harm from this contagion. COVID is now the greatest mass death event in American history.

Medical “Conservatives” Are Medical Radicals

Let’s revisit the core philosophy of medical “conservatives”:

The medical conservative adopts new therapies when the benefit is clear and the evidence strong and unbiased…The wisest of conservative physicians understand and embrace how little effect the clinician has on outcomes. While many may call this frame of reference nihilistic, the conservative clinician sees it as protective against our greatest foe—hubris.

Fair enough. However, I’d also add the wisest of conservative physicians understood and embraced how little we knew about SARS-CoV-2 at the start of the pandemic. We still have a lot to learn about it, especially the consequences of repeat infections. We also don’t know what variants might be lurking on the horizon. As such, we should take a cautious, humble approach to SARS-CoV-2. We shouldn’t abandon important principles just because the virus is natural and the vaccine manmade. I believe we should repeatedly expose unvaccinated young people to the virus only “when the benefit is clear and the evidence strong and unbiased”. Currently, there is no evidence that multiple bouts of COVID are benign for developing children, especially unvaccinated ones.

Though medical “conservatives” openly trumpet their refusal to recognize unwanted realities, there is evidence COVID is really dangerous for some young people.Over 44,000 Americans ages 19-44 years have died of COVID, 6 times the number of soldiers who died fighting in wars since 9/11. Medical “conservatives” told them not to worry about this outcome. Additionally, COVID has killed around 2,000 children, and a medical “conservative” said we should accept more unvaccinated children dying “as a matter of course.”  Tens of thousands more children have been hospitalized with COVID, including many healthy children. Rarely, they have needed amputations or had strokes.  They survived, but their lives will never be the same. Medical “conservatives” ignored or minimized their suffering as well. Some children suffer from long-COVID, and we’ll be learning about its long-term sequelae for the rest of our lives. It wasn’t until 2019 that we learned measles suppresses the immune system.

A true medical conservative would be similarly humble about the potential for repeat COVID infections to have unseen consequences years from now.  It’s the height of arrogance to just assume everything will turn out fine and dandy. No matter how many times medical “conservatives” insist that the “young have almost no risk“, the virus has repeatedly shown it doesn’t read their Tweets or monetized Substack articles. “Motivating biases need not be considered nefarious, only considered”, they wrote.

From “How Anti-Vaxxers Monetize Misinformation” by Derek Beres

And thus it becomes clear:  there is nothing conservative about medical “conservatives”.

There’s nothing conservative about telling parents it’s “healthy and natural” for children to get sick with COVID. There’s nothing conversative about repeatedly declaring the pandemic over when the worst is yet to come. There’s nothing conservative about saying people are mentally ill if the want to avoid repeated exposures to SARS-CoV-2. There’s nothing conservative about mocking and shaming people who wanted a valuable booster just before a new variant rips through the population. There’s nothing conversative about repeatedly spreading fake statistics to minimize COVID’s impact on children or fear monger about the vaccine. There is nothing conservative about demanding other doctors conduct RCTs while refusing to any oneself. There is nothing conservative about rejecting real-world observational studies on vaccines, while authoring VAERS dumpster dives that purport they do more harm than good. There is nothing conversative about minimizing the deaths of young people from COVID. There is nothing conversative about treating a rare, “mild and self-limiting” vaccine side-effect as a fate worse than death.

Medical “conservatives” were right to call hubris our “greatest foe”. Their unbroken record of poor predictions and conceited COVID-minimization shows the wisdom of that statement. Any doctor who pushes for the repeated mass infection of unvaccinated babies and toddlers with a novel, mutating virus, when an effective vaccine is available, is a medical radical.