“Conflicts of interest are an ongoing threat to medical practice.”
In their must-read article, Subscription Science: How Crowdfunding Has Become a Conflict of Interest, Drs. Benjamin Mazer, Michael Rose wrote that “Conflicts of interest are an ongoing threat to medical practice.” They further noted that:
Digital platforms such as Patreon, Substack, YouTube, and Twitter allow fans to offer recurring payments to healthcare professionals who produce opinion articles, explanatory videos, and podcasts… Substack, an online newsletter platform, is increasingly used by physicians to write medical commentary, with some newsletters reaching 10s of thousands of subscribers. Substack estimates that 5-10% of readers will upgrade to a paid tier, and paid subscriptions on the service cost a minimum of $5 per month. Although $5 sounds negligible, consider a newsletter with 10,000 total subscribers, 1000 of whom pay a $5 monthly fee. After subtracting Substack’s 10% cut, a doctor could expect $54,000 in annual payments. If physicians accrue 5000 backers, they can expect $270,000 in revenue. This is greater than the $265,000 average salary of primary care physicians in the US.
“Is a ‘model’ more believable than a double blinded, randomized, placebo-controlled study, with an N of 80,000?“
With this in mind, let’s revisit an article titled Not the Way to Pull Vaccines Back from a “Dangerous Tipping Point by Dr. Adam Cifu, a “medical conservative” and founder of Sensible Medicine, a Substack with 75,000 subscribers and 3 payment models.
Becoming a “Founding Member” for $250 per year
To his credit, Dr. Cifu wrote, “I am convinced of the safety of the COVID vaccine and know that the initial series saved millions of lives.” Dr. Cifu linked to a modeling study that concluded:
From December 2020 through November 2022, we estimate that the COVID-19 vaccination program in the U.S. prevented more than 18.5 million additional hospitalizations and 3.2 million additional deaths. Without vaccination, there would have been nearly 120 million more COVID-19 infections. The vaccination program also saved the U.S. $1.15 trillion (Credible Interval: $1.10 trillion–$1.19 trillion) (data not shown) in medical costs that would otherwise have been incurred.
Of course, we’ll never know exactly how many lives the COVID vaccines saved. We don’t have an Earth 2.0 where we can rerun the pandemic without them, and thus we need modeling studies to estimate their benefit. This situation is obviously not unique to vaccines. Modeling studies are needed to estimate the benefits of seat belts, for example.
Unsurprisingly, Sensible Medicine readers were unimpressed with this modeling study. They have been taught to reject all studies unless they are randomized controlled trials (RCTs)- “observational data has been used to support vaccines, but is plagued by confounding” – or they show potential vaccine harms. Indeed, one of the most liked comments on Dr. Cifu’s article said:
“know that the initial series saved millions of lives”.
The study you linked to is a model that claims:
“U.S. has administered more than 655 million doses”, “U.S. prevented more than 18.5 million additional hospitalizations and 3.2 million additional deaths.”
Let’s do a back of the envelope calculation. 655,000,000/3,200,000 = 204.6. That’s one life saved for every 205 doses. 655,000,000/18,500,000 = 35. That’s one less hospitalization for every 35 doses.
Add the two clinical trials together (Moderna, Pfizer). ~80,000 doses. 80,000/205 = 390,
80,000/35 = 2285. This predicts that we should have seen about 390 more deaths and 2285 more hospitalizations in the placebo group of the combined studies– but we saw no statistically significant reduction of death or hospitalization in these studies.
What was significant in the Pfizer study: -29 severe Covid events, +112 severe vaccine events. Looks like a net loss to me.
Is a ‘model’ more believable than a double blinded, randomized, placebo-controlled study, with an N of 80,000?
“The numbers are already cooked,” added another typical Sensible Medicine commentator in agreement.
“The primary analysis will be performed when approximately 151 cases have been observed in the study”.
Is this commentator correct? No, he is not.
The Sensible Medicine commentator fundamentally misunderstood how the COVID vaccine RCTs were structured. Perhaps if this person had been reading Science Based Medicine instead, they’d already know the COVID vaccine RCTs were designed to end when a small number of people contracted COVID. According to the Moderna protocol, “The primary analysis will be performed when approximately 151 cases have been observed in the study”. The Pfizer protocol set “a target of 164 primary-endpoint cases of confirmed Covid-19”. The Sensible Medicine commentator would have been sensible had all 80,000 people in the RCTs contracted COVID, but by design the trials concluded before the virus was allowed to harm more than several hundred people, 347 as it turned out.
The results were pretty impressive.
- In the Pfizer RCT, 21,720 people received the vaccine and 21,728 received placebo. There were 162 COVID cases in the placebo group and 8 in the vaccine group. There were 10 cases of severe COVID-19, 9 of which were in the placebo group, 1 the vaccine group.
- In the Moderna RCT, there were 15,210 participants in the vaccine and placebo groups. Symptomatic COVID occurred in 185 participants in the placebo group and in 11 participants in the vaccine group. Severe COVID occurred in 30 participants, with one fatality, all in the placebo group.
Incredibly, according to this typical Sensible Medicine commentator, these results looked “like a net loss” for the vaccine.
“Motivating biases need not be considered nefarious, only considered.”
I am not responsible for the comments on my writing and neither is Dr. Cifu. However, the people who take the time to respond to us reflect on us in some way, and our response to them, or our decision not to respond, reflects on us entirely. Though it happens rarely and I don’t see everything, if I spotted a ridiculous comment like that on one of my articles, I’d damn well correct it, assuming one of our astute readers had not done so already. I don’t want my writing to be a vehicle for people to spread anti-vaccine nonsense about RCTs. Part of being pro-RCT is correcting misinformation about actual RCTs, especially in spaces where one has some control and authority.
In contrast, Sensible Medicine doctors said nothing. They’ve said “do an RCT” countless times, but can’t be bothered to educate their readers about the RCTs that have actually been done. Given their purported admiration for RCTs, don’t you think they have an obligation to teach their misinformed readers about the basics of how the actual COVID vaccine-RCTs were designed and how they should be interpreted?
It’s revealing they haven’t done so already. As Dr. David Gorksi and I have discussed many times (here, here, here, here) these doctors performatively fetishize RCTs not to advance actual RCTs or to educate their readers about RCTs, but rather to stoke anger and foster mistrust. The ignorance of their commentators shows the predictable result.
Beyond this, Sensible Medicine readers must pay a fee to comment. Not only does this business model foster an echo-chamber of groupthink, it also creates dualities of interest and and motivating biases for Sensible Medicine doctors. After all, correcting commentators risks offending paying customers, even those who spread blatant falsities about precious, glorious, hallowed RCTs.
It’s entirely possible this financial incentive plays no role in refusal of of Sensible Medicine doctors to call out nonsense from their commentators, especially considering their own copious misinformation. However, I’m perfectly willing to follow the wise instructions they provided in their foundational paper, The Case for Being a Medical Conservative:
Dualities of interest must be considered in determining the quality of evidence…The medical conservative, therefore, is pragmatic about human nature and the prevailing business model of medical science. To wit, content experts, professional societies, or journal editors who too harshly criticize an industry product jeopardize future funding. Motivating biases need not be considered nefarious, only considered.
If you think I’m wrong for considering these dualities of interest and motivating biases, let me know. Everyone is welcome to comment here, and it won’t cost you a penny.