Saturday, July 24 is World Ivermectin Day, as "people of the world will come together to celebrate ivermectin for a day focused on unity, love, and gratitude for this precious gift from Mother Earth."

I will be with them.  Being of venerable age, I am at risk for COVID, so I follow the debates over the vaccines and treatments, such as ivermectin and hydroxychloroquine, with intense interest.

My conclusion, on which I am willing to bet my life, is that taking ivermectin is a superior alternative to vaccination, both for prevention and, should it come to it, treatment.  I am convinced by the careful scientific work of the FLCCC, the BIRD group, and independent researcher Andrew Hill and reinforced by the refusal of the government health agencies to respond in any coherent fashion.

A priori, one would not expect issues of drug safety and efficacy to be a political hot potato, but one would be wrong.  The Progressive wokesters, and especially their Deep State and Big Tech minions, are all in on the propositions that the vaccines are wonder drugs and ivermectin is worthless.  These positions are maintained by a refusal on the part of the health agencies to examine the evidence and by intense censorship by Big Tech.

The latest stroke in this conflict came from the lefty Guardian, which reported "Huge study supporting Ivermectin as Covid treatment withdrawn over ethical concerns."  The article identified a number of data problems with a particular study from Egypt, which, if true, would be serious, and the pre-print service that had published the paper withdrew it.  The author protested that he had been blindsided without a chance to defend his work, and the matter is now being explored.

Many media outlets echoed the Guardian, characterizing the problems of the Egyptian study as eliminating the most important randomized control trial (RCT) and thus knocking out a crucial pillar of support for ivermectin.  No other kind of evidence is regarded as relevant.

Supporters of ivermectin downplay the concerns because re-running the crucial meta-analyses (linked above) supporting ivermectin without the Egyptian data does not change the favorable result.  Multiple RCTs remain, along with significant observational and epidemiological studies, so the loss of the Egyptian data (even if the criticisms ultimately stand) means little.

Behind this specific dispute is a larger, important, and subtle conflict over the nature of evidence in medical research.

Everyone agrees that RCTs represent a high standard.  In an RCT, patients are divided into two groups.  One gets the drug under investigation; the other gets a placebo.  The study is double-blind in that neither patient nor doctor knows who is getting which, so expectations cannot influence the outcome.  If the results for the groups are significantly different, one can be confident that the drug is beneficial.  And if side-effects in the treated group are rare, one can also be confident of safety.

But total reliance on RCTs runs into immediate problems.  They are expensive, so their number is inherently limited.  In particular, no private company will fund one for any off-patent drug, which is why Big Pharma is opposed to research on ivermectin.  No one owns it.  Performing research on off-patent drugs should be a major task of government health agencies, but these appear to be under the thumb of Big Pharma and not interested. 

Recruiting for an RCT can be a big problem.  Identifying relevant population sub-groups is difficult, and the more possible sub-groups that exist, the more expensive the trial and the more difficult its design and interpretation.  Dosages must be determined, as must timing and possible interaction with other drugs. That RCTs adequately identify side-effects, especially for sensitive groups such as the elderly, is disputed.

An RCT that shows no benefit under one set of circumstances may be wildly wrong about the overall situation.  To show this, in 2018, a group of doctors once published a learned article showing that the parachute showed no benefit for people jumping out of planes.  The fine print noted that further research would be advisable because their experiment was conducted at zero altitude and zero speed.

In this tradition, if a researcher wants to show that a drug has no benefit, he can give it to patients already at death's door.

In the real world, RCTs are one component of a complex system for collecting knowledge.  A lot of preliminary works is necessary before one gets to the point of doing an RCT, and that work in itself produces evidence of varying strength.

Lab workers have looked at mechanisms of action and formulated and tested various hypotheses. As clinical research and experience accumulate, lab and clinical work cross-fertilize.

Clinicians have also observed diseases, formed ideas about what might work, consulted colleagues, and tried things out.  To a high degree, medical progress depends on crowd-sourcing by doctors. Once the FDA approves a drug for any purpose (which provides good information about safety), any M.D. can prescribe it for any other purpose.  Then they go to medical meetings, play golf, and compare notes.  Repeated clinical experience, especially from multiple doctors, and subjected to devil's advocate review, can be as good as an RCT.

A patient also serves as his own control group.  If a doctor gives a drug to a patient who has a longstanding condition and it immediately clears up, the doctor thinks, "Hmm."  This is an anecdote.  If it happens with a second patient, the doctor thinks, "Wow."  A third time and we are getting into the realm of "studies."

Yet another source of knowledge is epidemiology.  If a disease is prevalent in a population, a drug is distributed, and the disease recedes, this is evidence, especially if the disease remains in comparable populations that did not receive it.  Some of the best evidence of the efficacy of ivermectin comes from India and Mexico, which pass it out freely.

To reduce this complex system of producing knowledge down to a reliance on "nothing but RCTs" is not just stupid; it can be fatal. Anthony Fauci is a leading advocate of this view.  His position unnecessarily killed thousands during the 1980s AIDs crisis.

The major mystery remains: why would the health authorities take such a position?  And why does Big Tech, and so much of the media, support it as well?  Anyone who deals with facts in the real world — doctor, lawyer, scientist, engineer, spy — is familiar with the reality of different kinds of evidence and the subtleties of assessing them.  None of the ideas set forth here are novel.

So why are the health authorities and the media embracing a stance of deliberate stupidification?  One keeps trying to think of non-malevolent reasons, but the task keeps getting more difficult.

James V DeLong lives in the Shenandoah Valley.

Image: Ben Harvey via Flickr, CC BY 2.0.

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