Kimberly Milhoan, MD

Sam Quinones, in his 2015 book Dreamland, which chronicles America’s opiate epidemic, tells of a seemingly innocuous one-paragraph letter to the editor, written by then graduate student Jane Porter and Dr. Hershel Jick, published in the New England Journal of Medicine (NEJM) on January 10, 1980 which laid the foundation for the subsequent crisis. Dr. Jick had analyzed drug effects for almost twelve-thousand patients treated with opiates in Boston hospitals before 1979 and found only four had become addicted. The chilling effect of Dr. Jick’s observations in written form is a cautionary tale. I suspect another astute investigative journalist like Sam Quinones will one day be able to chronicle similarly seemingly innocuous foundations on which a tragic response to the COVID-19 crisis of 2020 were built.

The power of the letter that came to be known simply as “Porter and Jick” was that it had been published in the revered New England Journal of Medicine. Though it was a retrospective observation of hospitalized patients and not a peer-reviewed scientific study, it was first cited in a 1986 paper in the journal “Pain” and eventually summarized as a “landmark study” establishing the unqualified truth that opiate addiction was rare in patients treated with narcotic pain medicines. Before NEJM put its archives online in 2010, reading “Porter and Jick” meant finding the actual issue it had been published in. Its supposed conclusions were passed on as dogma affecting medical training and practice, as well as public health policy, when few, if any, had actually read it. The results were deadly.

Examination and critique of the medical literature is foundational to medical education and training. We are taught to not simply accept claims of fact but actually review the evidence underlying those claims, thus the propagation of misinformation from “Porter and Jick” is particularly damning. Prior to the dogma of “Porter and Jick,” physicians were actually concerned about creating opiate addiction by their prescription of painkillers to their patients. As a physician anesthesiologist trained under the consequences of “Porter and Jick,” I can attest to a transformation of my practice since we as a medical community woke up to the error of our ways.

When the medical community first started hearing about COVID-19, we thought about it and prepared to deal with it like every other respiratory virus we’ve ever encountered. Then, in March 2020, the World Health Organization (WHO) estimated a case fatality rate as high as 3.4% and the Imperial College of London projected devastating consequences for the world. As the medical community began advocating either for or against extreme public health policy measures in response, debate arose as to what information was worthy of consideration. The perception was there had been insufficient time to develop the library of hallowed peer-reviewed medical literature on which to base decisions. Any voices for a moderated response were countered with the now foundational dogma of COVID-19 that it is “novel,” so “nobody knows” anything about it. On this foundation, we’ve built worldwide devastatingly costly public policy that continues to be reliant on the “precautionary principle,” defined as “a strategy for approaching issues of potential harm when extensive scientific knowledge on the matter is lacking.”

The internet and social media have transformed medical practice just as they have transformed so many other dimensions of our lives. Medical data and literature are broadly available, expanding the pool of individuals capable of weighing in with analysis and opinion. While debate was raging in March, two different data analysts, Aaron Ginn and Tony Pueyo, published articles on, Ginn advocating for a measured response and Pueyo for the more drastic response that most of the world has chosen. Ginn’s article was not criticized on its analytical or scientific merits but for its author’s politics, profession, and lack of adherence to the precautionary principle. It was deemed dangerous and, after gathering widespread attention and circulation, taken down within hours. Dr. John Ioannidis, a well-respected and well-published Stanford physician and epidemiologist, was making similar arguments for moderation based on established medical knowledge regarding respiratory viruses in general and his review of data on COVID-19 from the Diamond Princess cruise ship in particular. Since he could not be criticized for politics or profession, his analysis was discounted because it was not yet peer-reviewed and it also failed to adhere to the precautionary principle for this novel virus.

Having been burned in my local medical community for sharing Ginn’s article, and realizing Ioannidis’ viewpoint would not be accepted as a counterargument, I have since attempted to play by the rules of examination of only published medical literature. Canceled medical missionary travel had me not in the hospital for the first four weeks that coincided with Hawaii’s stay-at-home and travel quarantine orders so I purposefully avoided reading much on the virus, allowing time for data and analysis to accumulate. As I prepared to go back to work, I did a medical literature search on April 17 that countered the argument “nobody knows.” At that time, there were hundreds of articles on COVID-19, from respected countries in respected publications, from which I wrote a summary for friends, family, and members of our church. A medical literature search today reveals over 38,000 articles. It is well past time to dispense with claims of “nobody knows.”

I have attempted to examine the evidence behind every “truth” that has been claimed about this virus: it is easily spread and highly lethal, there is no herd immunity, the asymptomatic spread it, its transmission is airborne, masks and quarantines reduce its spread, people should stay six feet away from one another, there is no treatment, hydroxychloroquine either doesn’t work or is dangerous, antibodies are either ineffective or don’t last, children are at risk and transmit it to others. The best medical advice I’ve believed you could give someone was to ask your physician what they would do for themselves and their family members. Leaving aside guidelines I adhere to in the hospital setting, from the beginning of this virus, for those in the community, I’ve advocated and practiced handwashing, covering coughs and sneezes, and staying home if ill. Staying home if you even think you are ill is a change in my thinking because COVID-19 viral load and infectivity is higher earlier in its course than other respiratory viruses.

Based on all my examination of the evidence, I still think these are the most important principles. I transgress the 6-feet rule, I hug people, I go to church, I sing in church, I didn’t wear a mask until I had to and wouldn’t wear one if I didn’t have to. I would return to our previous way of life, allowing businesses and churches to be open, eating in restaurants, traveling on airplanes and cruise ships, having funerals and weddings, visiting loved ones in hospitals and nursing homes, and sending our kids to school. Those who are over 65 and those with co-morbid conditions such as obesity, diabetes, and heart disease have to be more careful. My 80-year-old mother has been on the receiving end of many lectures on when and how to wash her hands. If I were ever suspicious she had contracted COVID-19, I’d test her early and treat her with hydroxychloroquine, zinc, and azithromycin. If she were hospitalized, I’d make sure she was treated with corticosteroids.

As you pick your jaw off the ground and try to analyze what is wrong with me, let me disabuse you the notion that I believe COVID-19 is a hoax. It is a serious disease from which many have and continue to suffer and die. My physician and pastor husband and I have risked our reputations and the health of our church community, as well as our 80-year-old mothers, on our belief in the evidence. We were among the last to cease worship services on our island and among the first to resume them. In the meantime, we staffed a seven-day a week food pantry with well over 50 volunteers and several thousand clients. We have a record of safety of few positive tests, no hospitalizations, and no deaths. We actually did an antibody study of over 100 of our church members. Seven of us, including me but not including my husband and two others in my household, have antibodies. I think I contracted COVID-19 while traveling in March 2020. I was with my mother and her friend, neither of whom ever got sick nor do they have antibodies. In hindsight, maybe I felt a little “off” after that trip, but never considered myself “sick.” I was maniacal about handwashing at that time because I was trying to protect my patients, family members, and church members.

If you follow what I used to believe was my best medical advice, asking physicians what they would do for themselves and their families, I’m suspicious the majority of physicians would disagree with my opinions. Now, before you ask a physician what they would do for themselves and their family members, you have to have a sense of their risk tolerance. As a Christian, I have faith in my eternal security, but that does not make me cavalier with my or anyone else’s life. As an anesthesiologist, I have a front-row seat in observing the inherent riskiness to life. You can do everything “right” and still get COVID, or cancer, or any other number of diseases, or die getting in a car or on a plane. The risk of death from COVID is probably about the risk of regularly getting in a car. The great majority of people, at every age, who contract COVID survive it. Most people have overestimated their personal risk from this disease. Given, however, that the risk is not zero and it cannot be entirely eliminated, each person is left to determine what kind of life they want to live and to what lengths they want to go to protect themselves. In order to protect others, we should all wash our hands, cover our coughs and sneezes, and stay home if we even think we are ill.

If there is enough evidence out there to counter the prevailing “truths” regarding COVID-19, why do they persist? We’re back to “Porter and Jick.” Its supposed truth was passed on as dogma without critical examination of the evidence. Then, it was difficult to find the source of evidence. Now, we have an overabundance of evidence. Who can read over 38,000 articles? We need someone to curate that information for us. I get several e-mails a day from different societies and services that provide summaries and links to articles on COVID-19. Some of those articles are in medical journals, but some are in mainstream press publications. The role of the internet and social media have become increasingly important in our access to and interpretation of information. The battle lines in this crisis were drawn early. I had never before heard the criticism of medical data analysis based on the politics of the analyst, nor seen it disappear because it was “dangerous.” Early decisions were based on the precautionary principle because the virus was “novel” and “nobody knows.” Any new evidence can easily be dismissed by this dogma, so later decisions are still based on it. Those who desire to present opinions or evidence in dissent have been relegated to alternative forms of media that invite suspicion simply because they are not part of the august tradition of the peer-reviewed medical journal. There is enough evidence there, or will be there, to one day help us realize that for a lot of our decisions in yet another American crisis, we were again living in Dreamland. I believe waking up from this nightmare is going to break our hearts.