Deconstructing the News: Expert analysis on hydroxychloroquine you won't find on cable news
Part 2 of our coverage
Greetings,
As I suspected would be the case, my podcasted interview with antimalarial toxicity expert and Quinism Foundation executive director, Remington Nevin, MD, MPH, DrPH, about the use of hydroxychloroquine has become one of the most popular docu-mental podcasts to date. To me, this reflects the need for clear public health information about COVID-19, not the politically charged blah-blah the mass media is looping endlessly.
The transcript of this podcast is now fully edited, has been reviewed by Dr. Remington for any errors on my part, and so should be of reliable use to anyone who needs this information to make the most informed decisions about the use of hydroxychloroquine or any other drug in the quinoline class. I also highlighted sections of the transcript that I think will be of most interest to you if you are looking for the larger context of the use of this drug as a public health measure.
In part one of this special issue, I complained that the media covering the use of this drug class in the fight against COVID-19, particularly the cable news media, were not adequately presenting the full risk-benefit profile. Sadly, the pros and cons of this drug class are not being presented fully in one place in the media, whether that be conservative or liberal (“progressive”) media.
Since Wednesday, April, 14, 2020, when the podcast originally aired, not much has changed regarding the coverage, although that is primarily because then, the president went off on a tear, pummeling the World Health Organization and yanking US funding for it, sending the media scrum to tackle that news story, leaving nes about hydroxychloroquine et al to bleed on the field.
But use of these drugs continue, which means they remain important to consider in our current lock-down state.
To that end, in case you don’t want to listen to the entire podcast, but you do want the full story, here’s a recap.
First of all, in his capacity of executive director of the Quinism Foundation, Dr. Nevin is not only the world’s foremost authority on the toxicity of antimalarials, which are what hydroxychloroquine and chloroquine are, but he is also an epidemiologist and a physician, making him an expert in preventive medicine in the public health context. This enables him to authoritatively address not only the risk-benefit of the drugs, but also put their use in context with other public health measures we are currently employing to help save lives during this pandemic.
If you’re watching Fox News or the like, you are hearing a lot about how this is a drug that could save lives and potentially help get the economy back up and running. The support in favor of this perspective, as per Dr. Nevin, is that of all the potential drugs currently available to us for either prevention or treatment of COVID-19, hydroxychloroquine and to some extent, chloroquine, currently have the most science behind them. That is largely because there is precedent for their use in previous outbreaks of SARS viruses, including the novel coronavirus that causes COVID-19 is a type of SARS.
But what you are likely not hearing when you hear that argument on the Fox News Channel (just wait, I will beat up CNN and MSNBC in a sec) that this experimental drug should be used more frequently is that the entire class of drugs to which hydroxychloroquine belongs has long been associated in the medical literature with a range of downright scary neuropsychiatric symptoms. What’s more, if a person continues to experience these symptoms, there is a chance they will coalesce into a full-blown disease that currently has no cure, something Dr. Nevin and his colleagues have identified as “quinism”.
What is quinisim? Let’s start with ringing in the ears, auditory disturbances, dizziness, vertigo, disequilibrium and seizures, among others. Then, add the potential for insomnia, anxiety, depression, paranoia, panic, and even more serious psychiatric symptoms such as hallucinations, delusions, thoughts of suicide, and violence.
For the rest of your life.
That’s right – if you end up with these symptoms, and they persist, they will have likely changed your brain and brain stem enough to have become a permanent condition and at present, to repeat, there is no cure.
Dr. Nevin said between one and ten percent of those exposed to hydroxychloroquine will experience these side effects. That is not to say they will go on to have quinism – the odds of that are still being studied, however, by mid-May we should have enough data, both from formal clinical trials and from current in-hospital use, to have a clearer risk-benefit profile of hydroxychloroquine, according to Dr. Nevin.
So, when the president refers to use of these drugs and says, “What have you got to lose?” now you have a better idea of how to answer that question, rhetorical though it may be.
Meanwhile, for those of you glued to CNN or MSNBC, you might be hearing more about these neuropsychiatric side effects that might end up becoming potentially life-long. Maybe. I haven’t heard these reports about the neuropsychiatric effects on these networks as much as I have heard about the known cardiac and ocular risks that these drugs pose. In fact, a small Brazilian study of chloroquine in COVID was halted recently because some in the study who were given the drug at the higher dose died from cardiac complications. To quote Seinfeld, “That, I heard.”
Viewers of non-Fox networks and the like might also not be hearing that these drugs are actively being sought by many clinicians who do very much want to try these drugs. This is not because they are supporters of the administration, but because they are doctors whose number one job is to do whatever they can, without harm, to help save lives. This predisposes many of them to want to try using these drugs. Why they might not want to try the drugs is because of the risk-benefit profile still being unclear. It’s up to each physician’s clinical judgement, especially as there is currently no gold standard treatment for this virus.
It is largely for this reason that the administration asked the FDA to issue an emergency use authorization (EUA) of these drugs in certain settings such as hospitals in New York City and elsewhere. The EUA indemnifies clinicians, hospital administrators, and manufacturers of the drugs against any claims of harm should there be any. And, said Dr. Nevin, there will be many:
“I can reasonably predict a very large volume of lawsuits related to the off-label prescribing of these drugs, but by well-intentioned parties all around.”
Off-label, for those of you who are unfamiliar with that term, is the use of a drug by a clinician for a condition which it was not originally indicated by the FDA to treat.
To that end, Dr. Nevin said the Quinism Foundation is urging the administration to prepare for the wave of claims to come even after this pandemic has been resolved. There is already a mechanism in place for that, the Countermeasures Injury Compensation Program (CICP).
Also, what you’re probably not hearing on any of these networks is that if you or a loved one is treated with one of these drugs by anyone who is NOT participating in the program set up by the FDA under the emergency use provisions, then you and your loved ones will NOT be able to make any claims on the fund put aside in the CICP.
That is important because…there is a lot of crazy stuff on the internet, in case you weren’t aware.
For example — and you will most certainly not hear this important piece of information on Fox News, lest it disrupt any of its ambivalence on reporting Russian-backed shenanigans — there is a Russian-backed disinformation campaign currently underway in social media suggesting that if you need hydroxychloroquine or chloroquine but can’t get a hold of it, then don’t worry, Russian scientists have shown that mefloquine, another drug in this same class, will actually be even more effective.
This is patently false, and also highly dangerous: of all the quinolines, as Dr. Nevin outlines at the beginning of the podcast, mefloquine is established in the medical literature as among the most likely to leave you with neuropsychiatric damage, and not only that, is highly associated with psychotic rages, the kind that tend to fuel mass shootings with semi-automatic weapons.
So, if you or someone else decides to treat or prevent COVID with a substance not covered under the FDA program, you and that other party are on your own. No CICP claims for you.
It’s for this reason of indemnity and to protect citizens from potentially lethal disinformation that Dr. Nevin and his foundation are urging the administration to not just stop with the EUA, but to also use the Strategic National Stockpile to federally command and control the drugs. This would also ensure that no one health system or other entity exerts their influence to hoard or prioritize the drugs according to who can pay.
Meanwhile, if you’re in the camp that says “release the hounds” on this drug, here’s something else to consider: the president has not made its use mandatory.
Says Dr. Nevin: “If the president is such a rabid fan of this drug, as some of the media would have us believe, then why hasn't he taken the very simple step of directing that all members of the Teddy Roosevelt aircraft carrier be started on chloroquine? I think probably because he recognizes that the drug is not as safe as some might believe, and that the risk benefit profile for prophylaxis might not be advantageous.”
This argument presupposes that if the president touting these drugs really was all about getting the economy up and moving, as some have claimed, the administration does have the authority to send every household in the US a packet of these pills and, if not make it mandatory we take them, then at least give us the option. That way if we don’t use the drug, and also don’t use our masks or gloves, and we get sick, that’s on us not the president, and the economy could open right back up.
Again, Dr. Nevin: “The president has the authority to do this and he hasn't, and there's a reason for this: probably because he recognizes, and his administration recognizes, that the drug simply hasn't been proven effective for that indication and the risks are simply not worth it. But, of course, you know, given the president's usual motivations and modus operandi, you won't hear him say that.”
And I am not hearing the conservative media say that, either.
But here is where all of the media, progressive and conservative, have really fallen down, in my opinion: accepting that there is also not a clear risk-benefit ratio to social distancing and mandatory closures.
Dr. Nevin lays this out clearly:
“Those who would demand that we do not use hydroxychloroquine or chloroquine in the absence of high quality evidence are being quite hypocritical when they profess allegiance and strong support for social distancing measures, for wearing masks, for essentially shuttering the economy. Because these non-pharmaceutical interventions themselves have not been subject to any sort of randomized control testing … What we're doing is essentially we're having an observational trial of the efficacy of nonpharmaceutical interventions on the basis of the individual choices made by states and countries over time. But it's not randomized and we can't conclude from this definitively that any reductions or perceived reductions in mortality or morbidity are actually due to our intervention.”
I will say I am happy to self-isolate. I am not contravening its effectiveness, and it’s true that we do have ample anecdotal evidence that it is working to curb the rate of infection, as NY State Governor Andrew Cuomo emphasizes in his daily briefings with the media. But, what is the actual risk-benefit ratio of shuttering the economy?
As Dr. Nevin points out, when the country does eventually have to grapple with the negative economic fallout, health outcomes will be much worse because it is wealth that helps a country keep its health. Put another way, be prepared for the onslaught of many, many poor public health outcomes as a result of the coming economic downturn, which will also mean there will not be enough resources to deal with them.
Dr. Nevin: “We can't, in other words, prove to ourselves that had we just allowed this epidemic to run its course, we wouldn't be seeing the exact same outcome. Very controversial conclusion, but I think most epidemiologists would agree.”
These are the larger, more nuanced arguments we’re not getting from a media that really is trying harder to fill 24/7 with content that upsets and excites us, than actually informs us.
One last piece from my conversation with Dr. Nevin to help give you the fuller picture from a public health perspective, and it’s to do with the question of moral equivalency.
What are the moral implications of sacrificing the future well-being of our younger generations, such as the Millennials, who will be left to deal with the lingering effects of this far longer than the rest of us older folks, for the sake of protecting not the “essential workers” but everyone else, which in actuality, statistics suggest is really only about one-third of the US population, most of whom are materially well-off enough to weather this?
What are the moral implications of how suddenly we clearly are okay with trashing our economy to the extent that we have to protect some of us, but perennially not to provide healthcare for everyone with a nationalized healthcare system?
What are the moral implications of consistently allowing inner-city murder rates to be as high as they are in Baltimore (Dr. Nevin makes this point) or Chicago, while going out of our way to prevent roughly equal death rates from a pandemic nationally?
People should be compensated if they're harmed by these drugs, but even at its worse, an epidemic of poisoning from these drugs will probably pale in comparison to the economic damage caused by our other responses to the epidemic.
I am not telling you the answer, but I am framing the questions using the actuarial science that public health officials use all the time. As Dr. Nevin suggests, we have ample evidence that we are constantly willing to risk lives we have the means to save, such as by not offering national healthcare. Why is this the case? The usual argument is that to do so would be too invasive, too much government, too much power being handed over.
But now, it’s hard to argue that old economic paradigm still stands. Going forward, we now have a precedent where we are willing to spend more money than ever before to save a life. How will this play out in how we reshape our nation post-pandemic, and in this election year?
I wish each and every one of you and yours the best of health.
Thank you for supporting docu-mental. Feel free to share this widely.
Whitney