| Mr. Trump has promoted hydroxychloroquine as a game-changing drug in the treatment of Covid-19 ever since mid-March when he first acknowledged the threat of the disease. Detractors of Mr. Trump looked for a personal financial interest in Plaquenil, the brand name version of the drug, but he holds only a minor interest (around $1500 of Sanofi stock held by a mutual fund). The truth, as I see it, is more worrisome. The president and many of his followers, some of them otherwise well-educated, simply fail to understand the nature of scientific inquiry. Mr. Trump has faith in what he “hears from a lot of people,” people he trusts. At the same time he is deeply distrustful of the motives of “experts,” defined as all those who question the truth of the statements he makes. Hydroxychloroquine was approved for medical use in 1955. Its multiple side-effects are known, manageable, and less serious than the conditions it treats, primarily rheumatoid arthritis, systemic lupus, and malaria. Previously approved and relatively safe drugs are often considered for treatment of emerging diseases. So it was with chloroquine (the parent drug of hydroxychloroquine) during the original SARS epidemic (2002-2004). A group of scientists (mainly at the CDC) tested chloroquine in a culture of monkey kidney cells (what we think of as “in a test tube” or “in the laboratory”). They found that chloroquine inhibited the spread of the original SARS virus from cell to cell. Their findings were published in 2005, a year and a half after the last cases of the original SARS were reported (in January 2004) by the World Health Organization. On account of the timing, chloroquine and hydroxychloroquine for treatment of the SARS-1 understandably gained little attention. Fourteen years later Covid-19 appeared. Prof. Didier Raoult, a flamboyant, outspoken, iconoclastic French researcher in Marseilles was ready. In early March, Raoult and his institute tried hydroxychloroquine against Covid-19 in a tiny, open-label, non-randomized human trial (36 virus-positive patients divided into three groups), comparing viral shedding in treated versus untreated groups. On the basis of six-day results of this tiny trial, Raoult announced, “We know how to cure the disease.” Is this science or self-promotion? It is certainly not an adequate human trial to justify treating hundreds of thousands of patients. Raoult’s story was covered in a lengthy article in the May 12, New York Times Magazine, “He Was a Science Star. Then He Promoted a Questionable Cure for Covid-19.” A cure offered by a medical researcher? That’s headline material. “Lots of people” talking about it, especially reporters on Fox News? That’s proof enough for Mr. Trump, reason enough for his enthusiastic, headline-grabbing endorsement. But that’s not how actual scientific progress happens. (See P.S. below) Raoult’s study, with only thirty-six patients, raises far more questions than it answers. How does a reduction in viral shedding relate to the disease process? How old were these patients and in what state of health? Most importantly: were Raoult’s results any better than chance? In Fox News and Trump world, the world of science illiteracy, none of that mattered, nor has it much mattered that a number of much larger studies since Raoult’s have looked at chloroquine and hydroxychloroquine, and failed to demonstrate any benefit. More alarming, several studies suggested that more treated than untreated Covid-19 patients died–of cardiac complications known to associated with these drugs. In a sane world with a president whose background included more science than reality TV, hydroxychloroquine would have been mentioned as one treatment being tested, not as a wonder drug. If we don’t rid ourselves of this man in November along with many of the elected officials that prop him up, our country is doomed to slide back to a time when policy was determined not by progress of scientific understanding but by whatever bright and shiny idea is whispered in the king’s ear. Keep to the high ground, Jerry P.S. The general story of excitement over a new drug or the new use of an old drug is familiar to every physician and scientist. A physician tries a drug that is already on the market as treatment of a few patients with a different disease. (That’s ethical, as long as the drug has only well understood and manageable side effects.) The patients’ condition improves (See P.S. below). The news media, sensing an eye-catching story, hype the new “discovery.” Sober medical researchers then invest time and effort running blinded, placebo-controlled studies of the new use of the drug, testing it in much larger groups of patients. Often these studies prove the initial enthusiasm was overblown. Either the drug shows some benefit (often rather minor and statistical) and becomes an accepted treatment OR the large studies demonstrate the drug to be no more effective than a sugar pill OR, worse, the frequency of nasty side effects is greater than the marginal benefit. Finally, the news media barely cover the more sober assessment of the new use of the drug and the whole episode drains out of the public consciousness. P.P.S. Scientific illiteracy is distressingly common–and it is used by some for political advantage. One of the confirmatory voices Mr. Trump heard in support of his faith in hydroxychloroquine came from this April 7 article in the right-leaning New York Post: “Michigan Democratic lawmaker says hydroxychloroquine saved her life.” The article is an inspiring and sincere testimonial to humanity’s overwhelming desire to “connect the dots.” We naturally tend to credit the next thing that happens to the last thing we did, especially if the thing that happens is dramatic and apparently life-saving. No one will ever convince this Democratic legislator that her dramatic improvement after taking hydroxychloroquine might have been pure coincidence–or that proof of the cause and effect relationship she perceives depends on further study. (I am certain Mr. Trump referred to this legislator’s testimonial in one of his press conferences, but I cannot put my finger on the reference at this moment.) P.S.P.S. For those who enjoy podcasts, a May 13th Fresh Air on NPR, Doctor With Rare Disease Decides To Find His Own Cure, is not only a fascinating story about a rare disease, but a window into how real medical science is trying to test for drugs useful in the treatment of Covid-19. It stands in stark contrast with Trump’s headline grabbing. |