Elon Musk’s claim that ventilators killed COVID-19 patients confuses correlation with causation

In early November 2023, a reader reached out to Health Feedback, asking us to review the credibility of a claim made by Elon Musk, the owner of the social media platform X (formerly Twitter), on the podcast The Joe Rogan Experience. Musk’s claim also received coverage from The Epoch Times and ZeroHedge, both recognized as sources of misinformation.

On the podcast, Rogan stated “80% of people they put on ventilators died”. Musk, who has no training in medicine, then followed up by claiming that putting people on ventilators is “what is damaging the lungs, not Covid. It’s the treatment, the cure is worse than the disease”.He alleged that he received this information from doctors in Wuhan that he called. Taken as a response to Rogan’s statement, Musk’s remarks can be interpreted to mean that it was ventilators that had killed COVID-19 patients, rather than COVID-19.

His reply to a user on X/Twitter who shared a clip of the podcast containing Musk’s claim  (“For many it was a death sentence”), further reinforced this meaning.

The podcast has platformed several notable figures that spread COVID-19 and vaccine misinformation, such as scientist Robert Malone and cardiologists Peter McCullough and Aseem Malhotra.

Its host, commentator for the Ultimate Fighting Championship and actor Joe Rogan, has inaccurately claimed that ivermectin is an effective cure for COVID-19 and that the COVID-19 vaccine is gene therapy.

As another public figure who has propagated health misinformation, Musk is in good company. In a tweet from November 2020, he implied that spikes in COVID-19 cases were due to “Something extremely bogus” going on with COVID-19 tests. He also predicted (wrongly) that there would be “close to zero” new COVID-19 cases by the end of April 2020. As it turned out, more than 23,000 new cases were reported in the U.S. at the end of April 2020.

This is also not the first time that Musk publicly made remarks about the use of ventilators in COVID-19 patients that show a lack of understanding of clinical decision-making and the physiology of breathing. We explain below.

The claim confuses correlation with causation

His claim about ventilators being the true cause of deaths in COVID-19 patients isn’t original—it has circulated since at least May 2020, as Health Feedback documented in a review at that time.

It is also false. Coupled with Rogan’s statement that “80% of people they put on ventilators died”, Musk’s claim demonstrates a confusion of correlation with causality. The simple fact is that patients who are put on ventilators are the ones who are most ill, and those who are the most ill tend to be at a greater risk of dying than people who aren’t.

In other words: people put on ventilators are more likely to die than those who aren’t on ventilators because of their poorer health, not because ventilators increase the risk of death.

The implication that there would have been fewer COVID-19 deaths if ventilators weren’t used has been panned by experts.

Alison Pittard, an intensivist (a doctor who specializes in caring for critically ill patients), told The Guardian that “if you are faced with a patient who needs to go on a ventilator … if they don’t go on a ventilator then the chances are that they will die. So, that is almost saying there is a 100% chance of dying. Whereas if they go on a ventilator then they will have a 40% chance of dying”.

Pepe Alcami, a virologist and immunologist at the Carlos III Health Institute, spoke to Spanish fact-checking organization Maldita on the subject of ventilator use in COVID-19 patients. He stressed that ventilators save lives, and many patients who would otherwise have died survived because of ventilators.

“To say that mechanical ventilation is harmful because patients on assisted ventilation sometimes die is like saying that a hospital is as dangerous as a criminal neighborhood because more people die in it as compared to elsewhere,” he said.

In an article for MedPage Today, Rohin Francis, a cardiologist and science communicator, also refuted the claim that ventilators were what killed COVID-19 patients, citing “breathless articles in the news stating that 80% of patients placed on ventilators die”:

“Now, one interpretation is that ventilators are killing people. Another, more logical, interpretation is that the people being placed on ventilators are so sick that even a ventilator cannot save them. What if I told you that 80% of people who die in motorway crashes were wearing seat belts? Would you conclude that seat belts are killing them or were they just traveling so fast that even the seat belt didn’t save them?”

On the flip side:

“Another statistic that’s important to know here is how many people not wearing seat belts — i.e., people who weren’t intubated at the same disease severity — go on to die. If 100% of them die, then your intervention has actually saved 20%, which is still very unsatisfactory, but it’s a long way from saying ventilators are killing patients.”

In his article, Francis also dissected claims by public figures that ventilators weren’t used properly for COVID-19 patients, one of whom was Musk. He commended Musk for getting CPAP machines (a form of non-invasive breathing aid, unlike ventilators) to hospitals during the pandemic, but found Musk’s opinions about mechanical ventilation showed a “complete lack of understanding about what doctors actually do”.

In response to Musk’s belief that “ICUs are jumping the gun and setting [positive end expiratory pressure] and O2 too high”, Francis stressed that “The very core principle of ventilating a patient is to reduce oxygen and pressure being delivered as much as possible. ITU nurses are experts at doing exactly this and it’s been an absolute fundamental of management for decades”.

Musk also opined that ventilators shouldn’t “go much above the patient’s natural lung pressure”. The problem with this is that the mechanics of breathing rely precisely on the existence of a pressure difference: air is drawn into the lungs because the pressure in the lungs is negative.

Cardiologist James Dundas responded to Musk’s tweet: “It doesn’t make any sense […] in health, normal thoracic pressures are NEGATIVE (you increase your chest volume to suck air in). All modern ventilation is positive pressure and so way ‘above normal’.”

Francis also came to the same conclusion, stating “it’s literally impossible to ventilate anyone without going above their intrinsic lung pressure”. That particular tweet by Musk was later deleted.

The video below by BMJ explains the mechanics of breathing and how mechanical ventilation works.

Francis concluded his evaluation of Musk’s claims about ventilators being aggressively misused on COVID-19 patients thus:

“Elon Musk might think that ITUs are blindly setting everybody to high pressures and oxygen settings, but being a #zentensivist is about making tiny adjustments, watching, waiting, adjusting again, being aggressive in your conservatism, and doing your utmost to do as little as you can to the patient. The idea that Elon has of doctors turning the ventilator up to 11 and just walking off is nonsense.”

Initial uncertainty around the care of critically ill COVID-19 patients

Gideon Meyerowitz-Katz, an epidemiologist at the University of Wollongong, penned a Medium article in May 2023, pointing to the lack of evidence supporting the claim that ventilators were the true cause of death in COVID-19 patients rather than COVID-19. In his article, he highlighted the fact that there was a great deal of uncertainty as to whether putting seriously ill COVID-19 patients on ventilators early or late would make a difference to these patients’ likelihood of survival.

A synopsis of clinical guidelines published in the journal JAMA in March 2020 recommended that doctors put critically ill patients with worsening respiratory failure on ventilators early^[1]. Respiratory failure can occur as a result of acute respiratory distress syndrome (ARDS), a complication associated with COVID-19.

Meyerowitz-Katz wrote that such a life-threatening complication compels doctors to intervene instead of doing nothing, as doing nothing for people who have difficulty breathing can lead to their death. There exists a range of interventions for respiratory distress, and doctors typically begin with the least invasive option and work their way up only if less invasive options don’t work.

But some specialists initially thought early intubation would be more effective for managing severe COVID-19. Some U.S. hospitals did recommend early intubation among other measures for managing severe COVID-19, Meyerowitz-Katz wrote.

Francis explained that doctors initially believed COVID-19 would behave like other pneumonias that also cause ARDS, which is why the initial approach of intubating early was used. “These patients have stiff lungs and require high pressures, and we were told to intubate early,” he wrote. However, over time, doctors discovered that while many patients did behave like this, many others didn’t.

Meyerowitz-Katz noted that the practice of putting patients on ventilators early stuck around for only a brief period of time, about two to three months, before being abandoned. As this period of time was short, not a lot of data could be collected, which hindered researchers’ ability to determine if early intubation did make a difference to patient survival. A systematic review of studies didn’t find any difference in patients’ likelihood of survival between early and late intubation^[2].

But this debate over when and how to use ventilators became twisted into the claim that getting ventilated was what caused hospitalized COVID-19 patients to die. The claim gained prominence particularly after a YouTube video was posted by emergency physician Cameron Kyle-Sidell in March 2020.

In the video, Kyle-Sidell stated that he observed how some COVID-19 patients didn’t exhibit typical ARDS, and that he believed the way ventilators were being used at that time was doing more harm than good to COVID-19 patients.

Kyle-Sidell’s video created much controversy, which was covered in Time Magazine and STAT News. However, he didn’t say that ventilators were unnecessary or that doctors should stop using them for COVID-19 patients. In fact, he stated that “we need a great many number of ventilators”. What he did suggest was that ventilators should be reprogrammed so that they were used “in a safer way”.

Francis considered Kyle-Sidell’s remarks as “part of a healthy, normal discussion about the changing understanding of a new disease”, but became distorted by conspiracy theorists who used his statements as evidence that “doctors don’t know what they’re doing and that no COVID patient should be intubated”.

In fact, what happened was that doctors around the world shared their experiences with each other, which gradually led them to rethink their approach. “In ITUs [intensive treatment units] all over the world, people had already realized that some patients don’t need those high pressures and were changing their guidelines,” Francis wrote.

Misinterpreted study on ventilator-associated pneumonia leads to resurgence of the claim

The claim later saw a revival in May 2023, when an article by known disinformation outlet The People’s Voice/Newspunch seized on a study published in the Journal of Clinical Investigation to proclaim in its headline “Ventilators Killed Nearly ALL COVID Patients”^[3].

The study examined the outcomes of patients who developed pneumonia while on ventilators. This group of patients included those with severe COVID-19, but also those with unrelated conditions. The researchers found that if a patient developed pneumonia while on a ventilator, and the pneumonia couldn’t be treated with antibiotics, the patient was at a greater risk of dying.

Benjamin Singer, the study’s lead author, told Associated Press that ventilator-associated pneumonia is “a known issue in the field” and isn’t unique to COVID-19. In such cases, when a patient’s lungs aren’t working properly, the tube from the ventilator in the windpipe provides bacteria an opportunity to enter and cause infection.

But saying the ventilators caused the deaths mischaracterizes the study. Singer explained that this is like “a patient in a severe car crash who dies despite surgery attempts; it’s the car crash that’s ultimately the cause of death”.

“These are all patients who would have died if they had not been put up on a mechanical ventilator,” he said. “You can’t be at risk for a ventilator secondary pneumonia if you’re dead”.

Conclusion

Meyerowitz-Katz writes that “The precise impact of early pandemic policies is, to this day, very uncertain. It’s not impossible that early ventilation recommendations caused deaths, and also not impossible they saved lives”. However, “the idea that huge swathes of people with COVID-19 were killed because of ventilators is a complete myth”.

The claim that ventilators were responsible for most COVID-19 deaths, and not COVID-19, began in the midst of early debates over when and how to use ventilators for COVID-19 patients who developed trouble breathing. Because COVID-19 was a new disease at that time, physicians had to fall back on existing knowledge of other types of pneumonias when treating severe COVID-19. Over time, as they gained a better understanding of COVID-19, their approach to ventilator use evolved to adapt to COVID-19.

Still, this false claim persists, folded as it is into various conspiracy theories about the pandemic, which accuse healthcare workers of placing people on ventilators to line their own pockets and inflate COVID-19 deaths to convince people COVID-19 posed a public health threat. Such misinformation isn’t harmless. Indeed, physicians have seen patients refusing to go on a ventilator, despite the fact that this may be the only chance of survival for these patients.

It is important to understand that only the most seriously ill patients are placed on ventilators, and this group’s risk of dying is greater than those with less severe disease who aren’t on ventilators. While many COVID-19 patients who were put on ventilators died, this doesn’t mean that ventilators caused those deaths. Experts have pointed out that ventilators saved the lives of many of such patients who would otherwise have died.

REFERENCES

• 1 – Poston et al. (2020) Management of Critically Ill Adults With COVID-19. JAMA.
• 2 – Papoutsi et al. (2021) Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: a systematic review and meta-analysis of non-randomized cohort studies. Critical Care.
• 3 – Gao et al. (2023) Machine learning links unresolving secondary pneumonia to mortality in patients with severe pneumonia, including COVID-19. Journal of Clinical Investigation.