Image of a statue of Hippocrates (460 BC – 377 BC), considered the “father” of Western medicine.
Source: Pixabay, no coyrights
Introduction
In this text, I address processes in which science is being claimed, shaken, disputed, and unpredictably rearticulated in Brazil’s medical field. Specifically, I consider denialist practices and movements during the Covid-19 pandemic. Based on an ethnographic approach to a variety of actions by medical groups and institutions that are critical of vaccination against Covid-19 and instead defend the use of drugs (considered ineffective by others) for the “early treatment” of the disease, I seek to highlight how their practices rearticulate, transform, and dispute new meanings, values, and practices of science, rather than simply reject it. Although they are publicly named by the media and scientists as denialists, their practices and discourses, as well as the repercussions of their actions, do not seem to be well explained by mere vulnerability to misinformation, lack of understanding of the technical aspects of the disease, or even the supposedly self-explanatory diagnosis of a frankly anti-science position. On the contrary, as I demonstrate in this essay, these groups resort to different constructions of science to produce their arguments and defend themselves against criticism. They do this by repositioning the content and legitimacy of the evidence on different axes than those of Evidence-Based Medicine (EBM), while at the same time, claiming EBM’s authority. In this sense, the following question animates this text: since the practices of these doctors can be recognized as denialist, how can this concept refer to something beyond a simple and direct refusal of everything that is usually called “science”?
According to the Cambridge Dictionary, denialism means “the claim or belief that something did not happen or is not true when it is generally accepted that it did happen or is true.” In other directions, contributions from the Science, Technology, and Society (STS) field have thickened more restrictive perspectives of the concept of denialism, signaling dimensions and active practices common to different social actors involved in this type of social action. Different studies have dissected characteristics of the central actions of groups and institutions involved in articulations related to climate, historical, pandemic, and other denialisms in specific contexts, tackling their diverse lines of mobilization, argumentation, and updating. Examples range from the production and dissemination of dissent and doubts regarding evidence considered consensually consistent in the scientific community (Oreskes and Conway 2010; Latour 2014); to the activation of scientific credentials associated with the production of “pseudo-facts” (Raj et al. 2022); and to the practices of digital influencers, which lend credibility to conspiracy theories and contribute to the formation of collectivities of “believers” (Baker, McLaughlin, and Rojek 2023).
During the most intense years of the Covid-19 pandemic, the concept of denialism, widely studied in the field of STS, became a nationally known word in Brazil. Whether as a noun or inflected as an adjective, this word has been circulating in the Brazilian press in reference to the disqualification, neglect, or even confrontation of scientific statements made by former far-right President Jair Bolsonaro and his ministers, allies, supporters, and voters. On the other hand, the same term has been used to describe a broader set of practices that are not limited to the withdrawal or active refusal of information arising from evidence or scientific consensus. For example, on May 3, 2023, an article published in one of the largest newspapers in the country stated: “As president, he [Bolsonaro] propagated denialist speeches and used the words hysteria and fantasy to classify the reaction of the population and the press to the pandemic. Bolsonaro also distributed ineffective medicines for the disease, encouraged crowds, acted against the purchase of vaccines [by the Ministry of Health], spread false information about Covid-19, and carried out campaigns of disobedience to protective measures, such as the use of masks” (Folha of S. Paulo 2023). Referring to issues related to the speeches, movements, and decisions of the former president, the news highlights a wide range of actions and practices that constituted the denialist policies of Bolsonaro’s government during the pandemic.
Faced with the traction that denialist practices gained in the pandemic, Amit Prasad (2023:9) argues that “overarching categories such as science/anti-science far from making us better understand what is going on trap us into dualistic divides within which techno-social and historical specificity of the context in which misinformation spreads is lost.” In this sense, the author proposes that we deepen our reflections on “the deployment of ahistorical categories of science/anti-science” (Prasad 2023: 9) in contexts of disinformation, as part of a strategy to better understand and act in relation to these practices. This proposition is particularly pertinent when we ethnographically approach the phenomenon of the formation of groups of Brazilian doctors who defended – and still defend – the use of drugs for the treatment of Covid-19 whose efficacy and safety were consistently discredited by international scientific and public health communities (Singh et al. 2021; WHO 2023).
Inspired by this concern about the specific and contextual dynamics of denialist groups, in this essay I describe how Brazilian denialist medical groups and institutions simultaneously criticize and appropriate EBM, characterizing it as a field corrupted by “collectivist” interests and “Big Pharma.” On the other hand, I highlight how they claim EBM to support their own medical practices. In doing so, however, they translate EBM into something different, less related to the socio-technical practices of randomized clinical trials (RCT) and closer to what they call “Hippocratic medicine,” i.e., medicine based on the doctor-patient relationship and on knowledge arising from the doctor’s individual experience. In this context, I argue that experiment and experience are tensioned and constitute a fundamental element in the dispute for medical authority through the resource and transformation of EBM contents and practices – and not necessarily in spite of it. Identifying the terms of this dispute is, therefore, a fundamental step towards critically understanding the values and practices that constitute the epistemic dimensions of denialism and mapping its deleterious effects on global and local health policies and institutions.
Medical autonomy, medical authority
“Can medicine be bureaucratized by evidence-based practice to the point of impeding physician autonomy?” This is how, on March 28, 2022, an anchor journalist began a live broadcast by the Associação Médicos Pela Vida [Doctors for Life]. Such live broadcasts are one of the main activities of the group.[1] The MPV is an association that has been operating since the beginning of the Covid-19 pandemic and, as stated on its website, aims to “treat people affected by covid-19 early, in order to prevent them from being hospitalized, intubated and at risk of death.”[2] During the pandemic, the positions defended by the MPV and other professionals in tune with its perspective were strongly criticized by scientists from renowned institutions, press vehicles, and civil society groups, given the denialist, conspiratorial, and anti-vaccine content of their speeches (Ferrari et al. 2022). Since then, the group has argued that its positions cannot be seen as opposition to science, but rather a defense of the fundamental freedoms of medical practice based on scientific evidence. In this sense, still in the introduction to the aforementioned live broadcast, the host read the following message from one of the MPV coordinators: “Doctors for Life is not against evidence-based medicine. It is against this attempt to make laboratories and media more important than the doctor. Hippocratic medicine establishes a relationship between the doctor and the patient that no one can interfere with. It is the doctor who defines [the treatment].”
The discussion proposed in the video connects to a broad set of MPV actions. Since 2020, the date of publication of its first manifesto, the group brings together thousands of doctors from different Brazilian states. On the internet, MPV organizes discussions, live broadcasts, online courses; and also publishes articles and opinion columns on Twitter and Gettr, in groups on Telegram, and on its website. In these digital spaces, the MPV disseminates its proposals and practices that are critical of vaccination and non-pharmacological measures to prevent Covid-19 and yet, at the same time, defend different pharmaceutical treatments for Covid-19, both for the early stages of the disease and for preventive use. For the group, Covid-19 has a simple and cheap cure: the “early treatment” with drugs such as chloroquine, hydroxychloroquine, ivermectin, nitazoxanide, zinc, vitamins, colchicine, androgen, and other compounds. In this scenario of strong sympathy for medicines, the exception is the vaccines against Covid-19, the use of which the group emphatically rejects. Characterized as dangerous “experimental” technologies, vaccines are recurrently described as products whose risks are underestimated and intentionally ignored by pharmaceutical companies, national and international health organizations, scientific associations, and political leaders.
These technologies are evaluated against a background that depicts sanitary measures to contain the pandemic as “a perverse global alignment prioritizing the control or suppression of individual freedoms” (Loureiro 2023). As described in one of the articles signed by one of the MPV’s coordinators, the Covid-19 pandemic corresponds to a “planned” and “premeditated” event, constituting the “greatest health fraud in the history of mankind” orchestrated by institutions such as “the WHO, health agencies, mainstream media, social media, large corporations, and governments with authoritarian tendencies, all lined up” (ibid.). According to the doctor who authored the article, the offering of a “magic solution” to the pandemic would be associated with the imposition of collective behaviors of adherence to immunization, driven by the greed for profits of “Big Pharma.” Thus, the use of this technology (vaccines) would be far from being based on science and closer to “faith” and corruption: “First, we need to know if we are talking about faith or science because science is done with the free debate of ideas, arguments, and scientific articles. And what we are seeing is the curtailment of the debate, and, as the final word, [there are] the speeches of the CEOs of the pharmaceutical giants” (ibid.).
Members of the MPV view the questioning by scientific organizations about “early treatment” drugs and the defense of vaccination with similar suspicion. In that same article, the coordinator of the MPV argues that the scientific legitimacy of vaccines was only made possible through the discrediting of treatments for Covid-19 – and, therefore, the “truth” about the efficiency of “early treatment” was masked: “But the approval of these experimental products by the agencies, erroneously called vaccines, depended on the total lack of drug options. What is the result? A fight against truth never before seen in humanity, perhaps worse only in the Middle Ages, where scientists were burned at the bonfire of the Inquisition” (Loureiro 2023).
In that direction, a gynecologist and obstetrician present at the MPV livestream mentioned above asked during her presentation: “Why can you only vaccinate and can’t provide treatment, right? That’s what we’ve been asking ourselves all this time.” In her answer to this question, the doctor returned not only to the elements of the so-called “sanitary fraud,” but linked them to the field of EBM: “And then we began to see the second fact, evidence, evidence, scientific evidence that there is a huge conflict of interest between the manufacturers and the journals that publish this evidence. Who is funding this? So, who is behind all this?” In this framework, the production of evidence and its evaluation and publication in scientific journals is described as part of a suspicious articulation of national and international actors that threaten diverse nations with authoritarian measures – such as vaccination and the development of protocols for medical practice.
Therefore, in different activities organized by the MPV, doctors and guests advocate for medicine based on the observations and experiences of the doctors themselves, in the interaction with their patients. As explained by the surgeon member of the MPV association at the end of his participation in the aforementioned March 2022 broadcast: “From now on, medicine will be different. Medicine will be practiced by doctors and not by protocols based on evidence of stock profits from [those] who manufacture these drugs […] We need a Brazilian Society of Infectology, and others like it, committed to patients, committed to the dignified, ethical use of medicine, based on our clinical observations, not based on protocols issued as if they were releases by the pharmaceutical industries.” This medicine, according to advocates of “early treatment” would simultaneously rescue the fundamentals of scientific practice and the values of Hippocrates, both assumed as pillars for the medical practice and healthcare.
In this equation of EBM with corruption, combined with the presentation of practices based on the individual experience of doctors as a rescue of medicine, scientific evidence does not have its place in medical practice completely discarded. On the contrary, “early treatment” defenders evoke a particular synthesis of clinical practice and evidence production to corroborate the systematization of individual medical care and the exchange of information between professionals as a legitimate and privileged space for knowledge-making. In the first months of 2020, the Federal Council of Medicine (Conselho Federal de Medicina – CFM), the highest regulatory body responsible for supervising medical practice in the country, issued a document that authorized Brazilian doctors to prescribe chloroquine and hydroxychloroquine for cases of Covid-19 in all the stages of the disease (CFM 2020). Recognizing the lack of scientific evidence to associate the use of these drugs with the treatment of the disease, the CFM’s position to “release” the “early treatment” was based on “medical autonomy” to prescribe and define treatment, and exempted its prescribers from any possibility of punishment (Castro 2021). In 2021, during an interview with Estadão, one of the biggest newspapers in the country, the president of the CFM at the time, Mauro Ribeiro, explained the content of the document like this: “We do not support any type of treatment, nor do we condemn it. We do defend the autonomy of the doctor, a Hippocratic principle, and we will always defend it. The treatment of diseases is being criminalized in Brazil. Journalists give definitive opinions, politicians give definitive opinions. The only one who is not being heard is the Brazilian doctor” (Jansen 2021).
During the interview, Ribeiro also evaluated scientific evidence and how it should be used in the context of clinical practice. When asked about the different clinical studies and positions taken by institutions such as the WHO concerning chloroquine and hydroxychloroquine, he contrasted the evidence produced in controlled studies with that arising from clinical practice – the first, manufactured “in air conditioning, without stress” and the second, the physician’s “observational experience,” produced within the scope of experience, “with an insecure patient crying in front of us, afraid of the disease, with their family stressed.” In this sense, the doctor explained that, given the context of the pandemic, it would be necessary “to take into account the doctor at the end; not the one who stays in the office reading studies and has never met a patient in his life. The practice of medicine is a different thing. And we have to take all that into account. We cannot take scientific studies and make a decision based only on these factors. They are important, but not the only ones” (Jansen, 2021).
Under this framework deployed by the former CFM’s president, EBM is not described as a broad field of suspected corruption. Instead, it is a set of practices that do not automatically exclude evidence from clinical trials, but articulate and subordinate them to the physicians’ “observational experience” accumulated throughout their clinical practice. Thus, in line with Cesarino (2022: 249), doctors operate an “inversion of the pyramid of evidence,” in which “what was at the base went to the top, what was marginal went to the center, and what was orthodoxy and the gold standard, has not been overlooked, but has been pushed into the background.”
On the other hand, the reorganization of the pyramid of evidence-based medicine on the affirmation of medical autonomy and the primacy of individual judgment establishes medical experience as an encompassing axis of experimentality, re-articulating it as a privileged field of production of evidence for medical practice. In this sense, some events like the CFM’s document that authorized the off-label use of some drugs to treat Covid-19 can be cited as examples of this re-articulation. Likewise, there are the ways different professionals involved in the MPV’s actions developed their hypotheses, observations, and specific medical procedures for patients with Covid-19, triggering different drug combinations according to their own clinical evaluations. With their specificities, both perspectives on EBM outlined in this essay converge towards a defense of the autonomy of practice and the authority of medical experiences, synthesized in the notion of “Hippocratic medicine.” As highlighted in the figure below, one of the posts of the campaign launched by the CFM on its social network accounts in 2021, the organization understands that medical autonomy to prescribe drugs for Covid-19 also implies the recognition of its maximum epistemic and professional authority in the definition of health treatments.
Post from CFM’s institutional Twitter account, 2021. It translates to “Only the physician knows what’s best for their patient.” and over the image “CFM emphasizes, the Brazilian physician is competent: respect their autonomy.” Accessed on March 30, 2021
In this context, the activation of the “Hippocratic” tradition resumes an old conflict present within the field of medicine, corresponding to different tensions, combinations, and disputes between artistic and scientific approaches to medicine. In the words of Steven Epstein (2007: 138), the dispute can be summarized as follows: “On one hand, modern scientific medicine is associated with universal, homogeneous and standardized approaches to patient care – often preached under the rubric of a movement called evidence-based medicine, which prescribes treatment protocols that are well supported by research. On the other hand, when treating individual patients, physicians frequently reject these standardized formulas (which they sometimes dismiss as “cookbook medicine”) in favor of more particularistic approaches that depend less on data than on experience and seasoned judgment – the ‘art’, as opposed to the ‘science’ of medicine.” In the case discussed here, however, there are different ways of equating “artistic” and “scientific” elements of EBM. While some physicians conspiratorially characterize EBM and advocate the need to purge its protocols, considered suspicious and spurious, others bet on an encompassing combination of individual medical practice with scientific studies, subordinating the evidence produced in experimental contexts to “observational experience.”
Against protocols, towards a (more) neoliberal medicine
There is no doubt that what is called, constructed, disseminated, and disputed as a science in the field of Brazilian medicine is now seated on murky grounds. However, what is at stake is not just a stricto sensu anti-science position but a disqualification of EBM as part of a broader set of criticisms of measures to regulate social practices (including medical ones), especially the ones in which there is a certain collectivity as a target audience or subject of care. In general, MPV and other defenders of “early treatment” for Covid consider actions by the state and by national and international public health organizations as threats to individual freedom and national sovereignty – in line with movements by other groups that disseminate neoliberal conspiracy theories in the context of the pandemic in Brazil (Cesarino 2020). Regarding this aspect, a journalist invited to a live broadcast by MPV on March 14, 2023, entitled “The future of medicine and doctors in Brazil”,[3] stated that the filing of protocols in the field of medicine is part of a broader global movement. In his words: “This health issue is a fundamental vector in the current dispute between a unipolar world and a multipolar world. A world where in unipolarity it was desired that countries would lose their sovereignty in their policies, including health policy, losing that sovereignty that would be placed at the level of international organizations such as the WHO.”
In this context, if tensions between EBM and artistic medicine did not straightforwardly emerge with the pandemic, the pandemic nonetheless denoted a different, particular unfolding of this conflict, marked by the strengthening of strategies for articulating the classical medical tradition with contemporary forms of economic, political, and epistemic neoliberal organization. Despite systematic discourses of “return” or the conservation of values and practices of classical medicine, the defense of Hippocratic values heralds efforts that go beyond claiming the place of medicine in previous centuries. The recent movements of the MPV group and the CFM point to the configuration of sociabilities and practices in which the evocation of Hippocrates rejects protocols in different plans of action and moves towards the expansion of the sphere of individual freedoms to the professional field of medicine. In this sense, the “protection of the personal ‘protected sphere’, so expanded, is the means by which tradition and liberty repel their enemies – the political and the social, the rational and the planned, the egalitarian and the statist” (Brown 2019:105). Therefore, criticisms of EBM’s standardized and protocol-based conduct (including state policies based on scientific evidence) are associated with the defense of the use of “early treatment” drugs, anti-vaccine positions, the questioning of institutions and scientific consensus, and even the support for extreme right-wing leaders. Furthermore, they dangerously converge to a broad rejection of measures with collective basis and to a strong defense of neoliberal forms of practicing medicine. Within these groups, evidence-making and medicine-practicing are considered legitimate as they reject institutional and regulatory mediations and health actions aimed at collectivity in favor of individual instances of knowledge-making and healthcare.
Notes
[1] Video available at: https://medicospelavidacovid19.com.br/videos/a-medicina-alem-das-evidencias-comunica-mpv-xxiii/. Accessed on May 10, 2023.
[2] https://medicospelavidacovid19.com.br/quem-somos/. Accessed on June 21, 2023.
[3] https://medicospelavidacovid19.com.br/videos/69a-comunica-mpv-o-futuro-da-medicina-e-do-medico-no-brasil/. Accessed on June 26, 2023.
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