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Peace be upon you, dear audience,
We live in an era of an information revolution and are lost amidst a huge pile of news about the effectiveness of this or that drug in treating a certain disease, such as the disease caused by the new coronavirus. We receive dozens of messages on WhatsApp, Facebook, YouTube, and others every day.
In this talk, I would like to explain to you the methodology of dealing with this news and information, so that you pay attention to some of it, and on the other hand, do not bother to open or look at the rest, thus saving your time and reaching the useful and documented information. This methodology is beneficial to us in life in general.
In observational science, there is what is known as the "hierarchy of evidence" (Pyramid of Evidence). Today, I am forced to mention English terms because their Arabic translations do not convey the information. May Allah restore our nation to the forefront of leadership in all sciences.
Now, this hierarchy of evidence is very useful. The evidence at the bottom of the hierarchy is the least important, and that at the top is the strongest. Let us start from the bottom to the top in the form of a story about a drug to treat corona, and let's call this drug X.
There is what is called "expert opinion" (Expert Opinion) in the field. For example, a doctor specializing in medical chemistry might say: "I studied the enzyme of the new coronavirus and found it similar to the SARS enzyme. This enzyme is essential for the virus's ability to reproduce and kill, and the enzyme of the old SARS virus was inhibited by drug X, so I believe that drug X will also inhibit the coronavirus enzyme and prevent the virus from reproducing."
He says this without conducting an experiment on the new coronavirus; he has not yet conducted an experiment. Can his prediction and opinion be correct? Yes, it is possible, and relying on it is better than relying on nothing, but it remains weak evidence unless supported by experimental evidence.
Alright, let's assume that this doctor or someone else took another step and tested the drug on cells that were experimentally infected with the virus. This is called an "In Vitro" study, meaning outside living bodies. The researcher found that the drug is effective in preventing the virus from reproducing.
Is this study significant? Yes, but does what happens in the cells in the lab necessarily happen in an infected human? No, and the drug X may be effective in eliminating a virus, but it is toxic if given to a human. These studies are at the lowest ranks of evidence, and yet sometimes the media picks them up with exaggerated headlines: "Drug X is effective in eliminating the disease." If you read the details that the drug was tested on cells, know that it is the lowest rank of evidence.
The researcher may take another step and test the drug on laboratory animals that have been injected with the virus, finding that the drug is effective in this case.
There is what is called a "Case Report," for example: the primary use of this drug was to treat diabetes, and we did not know that it had any effect on corona, but the doctor noticed that this patient who used drug X recovered from the virus faster than usual for someone of his age and condition. So, he published the details of this case.
Many people circulate stories similar to this case report, that so-and-so used such-and-such drug and recovered from the disease. These individual stories, even if proven, are still at a low rank of evidence, as other factors may have affected and contributed to the recovery, not what we believe to be the cause.
Another, third, and fourth report may come with the same result, that patients who take drug X recover from corona faster or are not affected by the disease at all. Thus, we have a "Case Series," a series of cases pointing to the same result, strengthening it.
We will skip the "Cross-sectional studies" and "Case control" due to time constraints and refer to them in the comments, God willing.
A higher rank of studies is what is called a "Cohort Study" or study of groups. For example, a researcher notices from previous studies a relationship between the drug and recovery from the coronavirus, so this researcher follows two large groups of people to be more certain of this relationship: a group that takes the drug naturally to treat another disease, and a group that does not take it. The researcher observes what will happen to them, then after months sees which of the two groups is more infected with the virus to conclude whether this drug actually reduces infection with the virus or not.
This study is not at the highest ranks, as there may be other factors such as dietary, medicinal, and environmental factors that affected the result. Those who take the drug may be more concerned about their health and follow other factors that reduced the incidence of the disease.
The best type of studies is what is called "Randomized Controlled Trials" or "RCTs." In the previous types of studies, we observed what happened to the people we studied without fully controlling the other factors that could affect the result. In this type, there is a "Control," there is control.
We come with a number of patients and distribute them into two similar groups in terms of the severity of symptoms, the ratio of males to females, and others, and we control the nature of food and influencing factors. We give the first group drug X, and the second group the "Control," we give them placebo pills that resemble the drug pills, but they do not contain the active ingredient, and they agree to that. Then we follow the patients, and we monitor the recovery rate in each of the two groups, and we see if the recovery is higher in the group that took the drug or not.
If you receive news containing this type of study, it is undoubtedly higher and more important than studies on cells or animals or individual reports. This is on the condition that the "RCT" study was conducted correctly and its results were published honestly.
Different groups of researchers in different countries may conduct this type of research on the effect of drug X on "COVID-19" caused by corona. The groups may come out with different results. Some say that those who take drug X recover at a high rate, another study says that the recovery rate is low, and another study says that there is no benefit to the drug at all.
Here comes the role of an analysis called "Meta-Analysis," where studies with problems in their design are excluded, and the good studies are analyzed statistically, resulting in a unified result that drug X is effective, for example, in treating corona.
This is not the end of the road. Instead, experts gather to study these results and the results of studies on other drugs that have proven effective in treating the disease to varying degrees. Then, these experts compare these drugs based on their effectiveness, side effects, cost, and impact on other diseases that the patient may have, such as kidney failure, asthma, or cardiac muscle failure, among others.
These experts then produce what is known as Clinical Practice Guidelines, meaning guidelines for clinical practice, for healthcare providers to refer to, in order to give the appropriate drug to the appropriate patient at the appropriate dose, taking into account any other diseases the patient may have, such as kidney failure or high blood pressure, among others. They also provide recommendations on what to do if there is something preventing the use of this drug or if it is not successful in treatment, and what alternatives to use in this case, among other details.
For the general public who are not experts in the medical field, the first and most important thing for them is to consult a skilled doctor who is aware of these guidelines first and foremost.
For those who want to educate themselves out of scientific curiosity, they should focus on these clinical practice guidelines that we have mentioned, and not pay attention to the previous types of studies. Even with this, they should not treat themselves even if they have read the guidelines themselves, but should refer to the experts.
In fact, often, there are just predictions and claims that have no scientific basis at all. Amidst this huge pile, the useful information is lost. I personally receive constant questions from here and there about pharmaceutical, herbal, and dietary options. Someone watches a video or reads a news item and then sends me a message asking, "What do you think about this?" I wanted to provide a general methodological framework.
Now, dear audience, clinical practice guidelines are available for diseases like corona, for example, and they are based on evidence. There is no point in wasting your time with the huge amount of claims and low-level studies.
Relying on evidence is something our religion has taught us: "Say, 'Bring your proof, if you should be truthful.'" [Al-Baqarah 2:111]. We do not accept anything without proof. "Say, 'Do you have knowledge, so you will produce it for us?'" [Al-An'am 6:148]. Give us something scientific.
Balancing the levels of therapeutic evidence is like the principles of jurisprudence in balancing the levels of legal evidence. As my friend, who took a course in this science from the University of Cambridge, used to tell me, "I read about evidence-based treatment as if I were reading about the principles of jurisprudence."
Of course, is everything published as scientific research necessarily correct and free from fabrication? Are the experts who formulate clinical practice guidelines necessarily honest and will always choose the patients' interests without being influenced by the financial incentives of pharmaceutical companies? The answer to both questions is "no," unfortunately.
Recently, scientific papers are published under the title "Evidence-Based Medicine Has Been Hijacked," and these studies provide evidence that many experts put their financial interests above the patients' interests and the public interest. You can read a useful and enjoyable book titled "Saving Normal," which is a translation of a book by Allen Frances, which sheds light on some of this misuse.
This is an incentive for us Muslims to strive in these sciences so that we can be confident in them and benefit people with them.
Imam Al-Dhahabi narrated in the tenth part of "Siyar A'lam Al-Nubala'" that Imam Al-Shafi'i, may God have mercy on them both, said: "I do not know of any science nobler than that of the halal and haram, except that the people of the book have surpassed us in medicine." I do not know of any science nobler than that of the halal and haram, except that the people of the book have surpassed us in medicine.
Muslims excelled in medicine and in general sciences after the time of Al-Shafi'i, then the decline that we witness occurred. May God teach us what benefits us and benefit us and others with what we learn.
Peace be upon you and God's mercy.