Covid-19 Reveals More Problems in Evidence-Based Medicine than just a Pandemic It’s Past Time that Medicine puts Human Welfare Ahead of Profit
Courtesy of: https://www.thefutureofmedicinefoundation.org/
Richard Z. Cheng, M.D., Ph.D. is a US and China Board-Certified Physician Successfully Treating COVID-19 Patients in China. Founder/Advisor, The Future of Medicine Foundation. Dr. Cheng is a Fellow and board certified anti-aging physician by the American Academy of Anti-Aging Medicine (A4M) and also a Fellow and board certified, A4m Integrative Cancer Therapy.
Dr. Cheng served in the United States Army as a commissioned officer (Major) and an Army physician and completed his Army duty in Dec. 2006. While in the Army, Dr. Cheng served in various positions including Chief and Medical Director of Pathology and Laboratory Medicine, Member of Risk Management Committee, Credentialling Committee, and Staff Physician of Soldier Readiness Program, Consultant to the Shaw Air Force Base Laboratory, and College of American Pathologist Inspection Team Leader for the Greenville SC Hospital Lab Inspection.
With the outbreak of Covid-19 and huge losses in lives and economies affecting nearly everyone in every corner of the world, a distorted and incomplete view of disease by the medical establishment and the resultant mismanagement of Covid-19 should serve as a wake-up call to everyone. Many lives could have been saved and would be saved should the governments start incorporating anti-viral nutrients, including high-dose intravenous vitamin C, into the Covid-19 fight, as did Shanghai and Guangdong.
One hundred years ago, the Spanish Flu infected one-third of the world’s population and killed 50 million. With today’s advanced hygiene, economy and technology, most of us probably thought pandemics of that scale are long gone. What a shock, ten months later we’re still immersed in Covid-19 chaos, with over 1,200,000 people killed and tens of trillions of dollars lost.
The world has seen many more epidemics and pandemics since the Spanish flu, but none at the scale of Covid-19. One would expect that the leadership in our public health systems, the medical establishment and worldwide governments would put the public’s best interest first when dealing with such a public health hazard. Needless to say, we are all sadly disappointed.
Covid-19 is revealing more problems in our current medical system, “Evidence-Based Medicine” (EBM), than just a catastrophic pandemic! Major problems of EBM revealed in the management of Covid-19 include the increasing bias in what constitutes “evidence”. Another is the lack of “mechanistic” (logical) reasoning in EBM. The third problem is the dominance of “Nobel Prize Mentality” in today’s clinical medicine, i.e., using narrowly focused basic science research principles to address complex and holistic clinical problems.
The EBM movement has become the central dogma of today’s medical practice. This doesn’t mean that medicine practiced in the past thousands of years is not evidence-based. Even today, approximately 50% of what a clinician does is experience-based. The practice of medicine has always been evidence-based. The key question is what is considered “evidence”.
What is Evidence-Based Medicine (EBM)?
Evidence-based medicine is defined as the integration of best research evidence with clinical expertise and patient values1. It aims for the ideal that healthcare professionals should make conscientious, explicit, and judicious use of current best evidence in their everyday practice1.
There are generally 4 different levels of evidence, from randomized controlled clinical trials (RCTs) to case studies to clinical expert experience (or empirical)2. It is clear that, although RCTs have the highest weight in “evidence”, they are not the only evidence in EBM. Unfortunately, most medical scientists and doctors with whom I have communicated view RCT’s as the only evidence in EBM. Another major problem of EBM is the lack of clinical or mechanistic reasoning. RCT results and treatment guidelines still contain limitations and financial conflicts which may result in bias. We clinicians must still reason through the best choices for an individual patient even in the absence of full and secure knowledge3, as in this Covid-19 pandemic.
Disturbing trend in the “best evidence” of EBM:
Publicly funded RCTs have been declining, while industry-funded RCTs are on the rise. This trend has a biased influence on our healthcare policy with potentially grave consequences.
There is no doubt RCTs are important. RCT results are considered the strongest evidence in EBM. But RCTs are very costly. A 2015 Johns Hopkins University study found the number of clinical trials funded by for-profit industry increased 43% while those funded by the NIH decreased by 24%, between 2006 and 20147. While the goals of NIH-funded RCTs are not profit oriented, the for-profit industry funded RCTs clearly exist to generate profits.
Not surprisingly, the Johns Hopkins University's Comprehensive Cancer Center found conflicts of interest in more than one-third of 1,500 cancer studies published in prominent medical journals in 20066.
Lifestyle and nutrition play a fundamental role in disease prevention and treatment. However, lifestyle and nutrition research results are usually not patentable. The for-profit industry doesn't fund trials most important for public health due to lack of financial incentive8, leading to a bias towards low representation of lifestyle and nutrition medicine in the “evidence database” that EBM relies on.
With a growing dominance of for-profit industry sponsored RCTs making up the “best evidence” in EBM, no wonder medical practice today is biased and heavily influenced by “big pharma”, to the detriment humanity.
Today’s medicine has been dominated by the “Nobel-prize mentality”
The Nobel prize is a crown jewel that attracts top medical and biological scientists. Those who reach the top of various medical specialties have spent most of their careers in basic research. There is a dichotomy between those who lead and those who practice medicine. Those influential experts who write “disease management guidelines” and influence healthcare policies are attracted by the “Nobel-prize mentality”. The proportion of clinicians to win a Nobel prize in physiology and medicine has been declining over the past 100+ years, from 65%-90% ~100 years ago to merely ~20% in the 21st century.10 Only ~1% of highly promising basic research is translated into clinical medical practice.11
Diseases have root causes, which, via certain pathological processes, cause clinical symptoms. Research into disease root causes and management are usually not patentable, whereas drugs to manipulate pathological mechanisms and suppress symptoms are patentable. Natural products that actually outperform drugs are not. As a result, the medical literature is full of research papers studying biological processes which may lead to new drug discoveries and handsome financial rewards. But we know clearly, interfering only at the mechanism and symptom levels, not at the root cause level, won’t heal a patient. As a result, although the market is full of redundant drugs for common chronic diseases such as diabetes and hypertension, none of these chronic diseases are curable with these existing drugs. This simple logic, unfortunately, is forgotten in today’s medicine.
References:
1. Hines, K. Evidence-Based Medicine. https://www.hopkinsmedicine.org/gim/research/method/ebm.html.
2. Tenny, S. & Varacallo, M. Evidence Based Medicine (EBM). in StatPearls (StatPearls Publishing, 2020).
3. Sniderman, A. D., LaChapelle, K. J., Rachon, N. A. & Furberg, C. D. The necessity for clinical reasoning in the era of evidence-based medicine. Mayo Clin. Proc. 88, 1108–1114 (2013).
4. Richard Z. Cheng. Protected Population Immunity, Not A Vaccine, Is The Way To Stop Covid-19 Pandemic. J Clin Immunol Immunother 6, 1–4 (2020).
5. Cheng, R., Kogan, M. & Devra, D. Ascorbate as Prophylaxis and Therapy for COVID-19—Update From Shanghai and U.S. Medical Institutions - Richard Z Cheng, Mikhail Kogan, Devra Davis, 2020. https://journals.sagepub.com/doi/full/10.1177/2164956120934768.
6. Cheng, Richard Z. Can early and high intravenous dose of vitamin C prevent and treat coronavirus disease 2019 (COVID-19)? Medicine in Drug Discovery 5, 100028 (2020).
7. Ehrhardt, S., Appel, L. J. & Meinert, C. L. Trends in National Institutes of Health Funding for Clinical Trials Registered in ClinicalTrials.gov. JAMA 314, 2566–2567 (2015).
8. Cohn, M. Industry funds six times more clinical trials than feds, research shows - Baltimore Sun. https://www.baltimoresun.com/health/bs-hs-trial-funding-20151214-story.html (2015).
9. Boston, 677 Huntington Avenue & Ma 02115 +1495‑1000. Remove the For-Profit Variable from Clinical Drug Trials. Health and Human Rights Journal https://www.hhrjournal.org/2017/05/remove-the-for-profit-variable-from-clinical-drug-trials/ (2017).
10. Ashrafian, H., Patel, V. M., Skapinakis, P. & Athanasiou, T. Nobel Prizes in medicine: are clinicians out of fashion? J R Soc Med 104, 387–389 (2011).
11. Contopoulos-Ioannidis, D. G., Ntzani, E. & Ioannidis, J. P. A. Translation of highly promising basic science research into clinical applications. Am. J. Med. 114, 477–484 (2003).
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