An open letter to my Colleagues whose job is to care for people, not numbers!

By Prof.. Dr. Martin ZIZI, MD-PhD, Biophysicist. Former Scientific Medical Director at the Belgian Defense, Former Director of the Epidemiology and Biostatistics Division, Former Chairman of the Ethics Committee BE Def.

Twice already, hospitals and intensive care units have been overwhelmed and the first line of medical care has been almost completely shut down. Does it all make sense?

Many people with symptoms such as cough, fever, stomach problems or joint pain are without a family doctor. At best, they are offered to take a test and stay at home… The direct consequence of this is that most of these people who are isolated for 7 to 8 days, without any care, deteriorate and infect their relatives.

The first doctor to examine them and listen to their lungs is often in the emergency department or intensive care unit. Is this medicine? The answer is no. It is important to note that the first line of health defense is the non-hospital health workforce. Are we going to run the risk of waiting for a third or even a fourth alert and all the human, social, economic, but especially sanitary destruction that ensues to act? We are talking about « sanitary destruction », because people are treated too late…

How did we get here? The answer to this question contains part of the solutions needed to get out of this crisis in a logical and above all effective way, by breaking the cycle of induced and destructive fears to finally enter into crisis management.

As with the problem of PCR tests that were of no use on people without symptoms — the best being often the enemy of the good — shutting down general medicine is the cause of hospital overcrowding and many deaths. A few weeks ago, faced with a major inconsistency around PCR tests, I challenged any scientist in Europe to prove that what I wrote was wrong. I had talked about the total uselessness of PCR testing if people had no symptoms, and I had explained that the true measure of life-threatening risk for SARS‑2 was not the number of positive or negative tests, but the overall mortality rate measured in a population (IFR or infection fatality rate). This critical value for making informed and appropriate decisions has now been calculated more than 60 times around the world — each time published in leading medical journals — and gives us a value around 0.2% or 0.5%. This number is solid because it remains almost the same regardless of location or methods used. In short, we are at the level or even lower than some flu… and this statement is verifiable⁽¹⁾ by everyone. This is the strict medical reality and not reassurance or denial.

On the other hand, this famous IFR that would allow us to manage this crisis on much more objective and reliable bases than the cycle of alarmist information is still pending. And this has grave consequences, because the more this debate is denied, the more some of our fellow citizens will suffer, and risk their lives unnecessarily, or even die. This will have to be explained to the public at some point, but that is not the point of my presentation.

Why do we have to mention this famous IFR to relieve the hospitals? Because it is extremely low — and these low values are very reliable, because they were calculated by different scientists, at different places and times, with different samples. This RFI is a powerful signal to all health care workers — they know what it means and can finally say, « Let’s stop being afraid and start caring for people.

Primum non nocere

In this second open letter, I would like to address all the health care personnel in our country, whether they are my fellow doctors, nurses, nurses’ aides, students, trainees, physiotherapists, psychologists… in short, all those who, from near or far, have made it their profession to help others when they are weak, ill or in danger.

We have all taken an oath: to do no harm («  Primum non nocere  »). This Hippocratic oath is not a piece of paper. It represents the covenant by which we care for patients, whoever they may be, good or bad citizens, rich or poor, young or old, whether we share their views and opinions or not, beyond issues of gender or identity. Medicine is not an easy profession, but it brings us a unique privilege: that of being able to meet people as they are in a relationship of total trust — that famous medical secrecy, which is not a secret, but a way of keeping our patients’ private lives absolutely private. This privilege is given to us in exchange for our compassion, talent and availability and — all of us — have a huge responsibility to our patients. For the moment, hospitalists bear these responsibilities alone, which is a pity.

This public health crisis has hit us hard. First of all — because we are all human beings — fear and lack of understanding have paralyzed the entire health care system, especially front-line activities. Then came various directives from the Ministry of Public Health that imposed fictional « costumes », masks, and defined what was and was not allowed. We all remember white cards in the press from some generalist and specialist colleagues who sounded the alarm that we could not deny necessary care — think of non-covid patients undergoing chemotherapy, heart failure waiting for an organ, not to mention life-saving or neurological emergencies. In response to these concerns, some have used the word « triage » — that is, choices will have to be made between Mommy and Daddy — and others have pointed the finger at the public, with unfair words such as « it’s your fault, we don’t have a choice anymore. The non-assistance to a person in danger set up as a system… one believes to dream!

This is the past, I do not wish to comment on these facts. Today, with this letter, I would like to address all health professionals directly in order to include them in the solution and to propose a future that makes sense and that takes us out of this crisis from the top.

Are front-line medical staff really at risk if they see patients?

Dear colleagues, what is going on? Most people involved in health care take risks to care for patients with more seriously contagious diseases including meningitis or Ebola. SARS (1, 2 or MERS) is not Ebola… why then stop front-line medical practices? Because of the numbers of fear?

These numbers are not the right measure of danger. We know, for example, that it takes a transfer of 10,000 particles of the HIV virus to have a chance of being infected. For hepatitis 10 particles are sufficient. This is why mosquitoes can transmit hepatitis B and not Ebola, because the volume of their proboscis cannot contain more than 10–20 viruses! For SARS, this number of particles (calculated on cell cultures) is between 10,000 and 100,000, which is why measuring the presence of the virus is not the true measure of risk. Only viruses that enter our bodies in sufficient concentration put us at risk. Having a hundred viral particles in our bronchi will not make us sick. Then SARS ping-pongs between us and almost all mammals⁽²⁾. Does it make sense to all of you biologists, physicians and others to try to narrow the problem by isolating people from each other when the transmissions are broader? Denmark has started to kill tens of millions of mink — because they have « rediscovered » this already known ping-pong phenomenon⁽³⁾. Knowing that SARS can infect cattle — remember that many slaughterhouses had to be closed — do you think that butchers in all countries have a genetic propensity that makes them susceptible to the virus? Of course not, the virus is present in the carcasses of the cattle that they simply have to cut up. The virus is present in cats and dogs⁽⁴⁾ this is known since 2003. So are we going to continue in this way and kill all the livestock, cats, dogs…? Let’s come back to earth a little.

How to find the way back to serenity and good medical practices? Patients should be cared for within the first 48 to 72 hours of their first symptoms. My colleagues, you have the culture, the knowledge, the practice and the time — get informed. In the scientific literature of the past preferably, we know these viruses for almost 20 years, time stabilizes the science and our knowledge, and recent publications in the media emergency are often uninformative. You will quickly understand that the mortality rate of this virus is in fact extremely low. However, people are dying, this virus is extremely dangerous. To deny this is shameful. Not only for those at risk, but also for each of us.

How to find the way back to serenity and good medical practices? Patients should be cared for within the first 48 to 72 hours of their first symptoms

Why do we die then? The greatest life-threatening danger comes not from the virus itself, but from the course of the disease (COVID). Why? This virus, like all viruses, brings bacteria to us, and unlike other viruses of this family of cold viruses, with SARS‑2 everything goes very fast. Between the first serious symptoms and blocked bronchial tubes or bacterial superinfections, it can take as little as 48 hours! So, staying confined while waiting for a test, or isolating yourself for 7 days (a purely random number), is playing Russian roulette. This is a perfect description of the situation of the Prime Minister and it has led her straight to the intensive care unit. We give the advantage to a virus that creates severe complications faster than any of its congeners. Testimonies — all of them concordant — exist in great number. Some of our colleagues have reported this to me, some independent minds — after talking to me — have checked the situation in Brussels, Wallonia and Flanders, and they all confirmed to me that most patients are not seen in consultation and are brought for testing. You all know this better than I do, and you have your own stories to add to this list. And this is not even mentioning the non-void patients who also risk their lives due to lack of care or essential diagnoses.

We all took an oath — of course this article is not asking you for a collective suicide pact, but if after checking for yourselves the solid data that is not making headlines for inexplicable reasons, you understand that the risk is that of complications, please — I beg you — return to Primary Care.

Of course you will have to be careful, of course you will have to overcome this fear that has no reason to be. By reopening your practices, you will help our hospital colleagues and avoid these disaster scenarios and all these really eugenic and absurd notions of ‘triage’ — having to choose between two patients when you are a medical staff is heresy, especially in a rich country with a solid infrastructure. Once again, COVID is not Ebola!

What to do practically? Personal protection — See patients in person — Use what we all already know: Amantadine — Antibiotics, and everything else. A virus — as you know — attacks us in several stages. First of all, it enters our bronchial tubes via our nostrils and/or our mouth. Then it attaches to our cells in our bronchial tubes. Then he goes back into these cells. At this point it does 2 things: it creates clogs in our bronchial tubes by destroying our cells and reproduces. This invites bacteria that take advantage of the virus to infect us in turn. Then the virus creates an immune response. Finally, it goes deeper and deeper, reaches the alveoli and then passes into the bloodstream. At this point, we have viral and often bacterial sepsis and need heavy medical assistance and intensive care. At each of these stages, however, we are far from helpless.

Personal protection, as recommended, masks and visors, gloves and all the aseptic measures that we have always taken to heart in our practice and that our expertise considers necessary. Of course. But remember, the RFI is on par with the flu — whatever the press has been peddling. So our knowledge is sufficient and there is no need to dress up as a cosmonaut. It is crucial to put stethoscopes back on people’s chests, which is impossible to do by zooming. I’ve heard some awful stories of doctors refusing to even help old people who have had domestic accidents in their homes. Our priority should not be to establish a fee for teleconsultation, but to help health care staff take care of people and do real consultations again.

If we or our patients have bronchitis, we have medications that are proven to be effective — depending on whether people have a cough with mucus or not. The old among us remember amantadine, the molecule used against the flu during the 70s and 90s. It acts by preventing the formation of bronchial plugs as you know. The influenza virus has become resistant to it, and nowadays it is used for livestock. But the good news is that this old molecule has been studied and tested against SARS‑2, and the results are excellent. It binds to the correct SARS‑2 protein⁽⁵⁾, when prescribed up front, it reduces bronchial plugs in patients⁽⁶⁾, and demonstrates a survival rate of nearly 97% in users⁽⁷⁾.

In addition, in a high-quality study⁽⁸⁾, 100% survival was reported in 22 COVID patients who were elderly and had every reason to die given their co-morbidities. Why did they magically survive? Because they had Parkinson’s disease or other neurological disorders, and therefore were receiving amantadine permanently for that disease, and once infected with SARS‑2, they were protected right away! This — and not the latest PCR figures — should be headline news. This is a way out. No need for long clinical studies to confirm, this drug was a recognized antiviral, and was only withdrawn from certain markets because its patent had expired. But it’s still in production and seems to be reserved for livestock — which is the last straw! Putting amantadine back on the market is easy — one meeting and one ministerial order — and don’t let anyone argue the contrary — I was in the shoes of our experts between 1998 and 2005, so I speak with full knowledge of the facts. In the meantime, you can get it in France for example…

When a patient presents with sputum, we know that he is at risk of superinfection, so why not prescribe antibiotics right away? We all know that antibiotics are ineffective against viruses, so RIZIV and the health authorities have discouraged blind prescriptions. But in the event of a serious epidemic or pandemic, it is common practice to treat with antibiotics without even looking to see if bacteria are present. Dr. Fauci himself published a classic paper on this subject in 2008⁽⁹⁾, during the famous H1N1 flu pandemic, because mortality from respiratory viruses is mainly related to bacterial infections. Why should what was excellent in 2008 become taboo in 2020–2021? Trying to prove the presence of bacteria that occur in 80% of cases anyway is a waste of time and allows the virus to win the race against medicine. Furthermore, when 90–93% of the population will not have symptoms and only half of the remaining 10% will have serious complications, it is not creating a problem of antibiotic resistance to treat people.

Influenza killed a lot of people in 1918 because penicillin didn’t exist, and we developed vaccines to control it, but we never gave up on antibiotics, that I know of. How is SARS viewed differently? When in doubt, treat or at least prescribe antibiotics and give clear instructions to the patient — take the antibiotics if there is significant sputum, for example. I have had over 20 people contact me for prescriptions or help because their primary care physician refused to give them an antibiotic, and they were feeling worse and worse. These calls for help often happen on a Friday… and I can certify that none of these people have deteriorated or been hospitalized.

It is completely illogical and dangerous to base our response on « all vaccines ». We need to be faster than the virus. Of course, we will have to develop vaccines, but to remain closed in, to degrade, to destroy society, to put people on the edge, neglecting the elementary principles of good medical practice, is this what we want?

My dear colleagues, you have the power to defeat this virus, you alone — because you are the front line — can reduce mortality to negligible values and therefore not let this virus take our lungs by storm. But you have to be faster than him. Your Hippocratic oath is in you, no administration takes that oath. No institution has the empathy and personalized knowledge of your patients. Only you can tell if a patient is unwell or just scared. Only you can help them avoid depression, and domestic violence, heart attacks and suicides… only you have the power to prescribe antibiotics for your patients. Our hospital colleagues are doing a lot of work under difficult conditions, so let’s help them. I beg of you. The structures and the authorities do not treat: at best, they do logistics… The INAMI will never sue us for having saved lives, even outside the conditions of prescription.

This is again a challenge…I challenge all of us to practice the medicine we know, despite the noise of conflicting information, despite the rules that don’t help us. Let’s replace resignation and isolation with medicine and social connection. Primum Non Nocere !