ON March 17, 2020, Stanford University epidemiologist John P.A. Ioannidis, a highly regarded researcher, made waves on the internet with an op-ed titled ‘A fiasco in the making?’ Prof Ioannidis argued that we lack sufficient evidence to calculate the true number of global Covid-19 infections or to extrapolate how the pandemic would evolve.
After all, it is only the sickest who go to the hospital for testing and treatment, causing a ‘selection bias’. We simply do not know how many asymptomatic people are out there. Barring such data, calculations of mortality and morbidity rates are meaningless, he said. Ergo, all preventative measures we take are “a fiasco in the making” — knee-jerk political, healthcare and socioeconomic responses based on crippled evidence. Has the world gone too far in its extreme measures, he wondered.
His comments, understandably, led to outrage in the medical community, with eminent Harvard epidemiologist Marc Lipsitch firing back: “We know enough now to act decisively against Covid-19.” Prof Lipsitch retorted sometimes exhaustive evidence could not be collected in time to guide decisions. “Indeed, there is an imperative to act strongly and swiftly” as it was clear that “the number of severe cases … becomes fearsome in country after country if the infection is allowed to spread.”
It was a fascinating and, borrowing Lipsitch’s phrase, fearsome battle of convictions. Both had access to the same data, but the conclusions were radically different. In the balance? The fate of the world.
Misinformation is fuelling shortages of medicines for autoimmune diseases.
The fear that stayed with me, however, after speaking all week and weekend with my medical colleagues, especially those who watched these scientists lock horns, was about the extent of the fallout and collateral damage from the pandemic.
Take the medicines chloroquine and hydroxychloroquine (HCQ), for example. These are antimalarials that have, for years, been used in my field — rheumatology — to treat rheumatoid arthritis and lupus, two severe autoimmune diseases. These are bread-and-butter medications for us, especially HCQ.
But now, suddenly, my patients are endangered, because many in the world have gone mad.
Messages have been circulating on social media and WhatsApp stating only chloroquine and HCQ can treat Covid-19; only these can beat the bogeyman. The world’s mad are enraptured by their social apps. Consequently, their insanity dictates that they rush out and buy these medicines before ‘someone else does’. Their panic is an indictment of our social and healthcare systems: they trust neither the medical community, nor each other.
The medical guidelines are clear that these drugs may be helpful — and should be used only in hospitalised patients with at least moderate disease; these patients comprise less than 20 per cent of the total Covid-19 infected. Meaning, 80pc of these HCQ-chasers will never need this drug. Yet absence of evidence of medicinal efficacy in mild symptoms or in no disease (‘can I take it for prevention so I do not get the virus?’) does not deter the masses. Couple that with a highly unregulated prescription system, and we understand how they could completely empty the marketplace of these drugs. There are also reports now of individuals and companies hoarding chloroquine and HCQ.
None of these groups truly understand the irreversible eye, skin, muscle and heart toxicity HCQ and other antimalarials can cause if taken without a doctor’s guidance. Blindness, cardiac failure, permanent skin and tongue markings, even death in acute chloroquine poisoning —because of its narrow therapeutic window —are potential side effects.
Meanwhile, my rheumatoid arthritis, lupus, and other autoimmune disease patients are at risk of life or limb. HCQ is a life-saving drug for lupus patients; it is what we call background therapy. A pregnant lupus patient absolutely cannot go without HCQ; she can lose her life and her baby. A pregnant rheumatoid patient can flare badly if she loses access to her medicines.
Yet that is where we are now. The rheumatology community and our patients have bad days coming due to these shortages, and there is little we can do but hope that this madness, too, will pass.
I am glad the government has taken measures to counter the selling of non-prescribed antimalarials and is threatening severe measures for hoarders, but this is just one example of the many repercussions the world should expect from this pandemic and its workings. Never has the hollowness of systems been thus exposed.
Meanwhile, the rheumatology and medical community will continue to ask of the public: Please do not hoard and waste our patients’ medicines. You will likely not need them. They already do.
The writer is an American Board-certified rheumatologist at Shalamar Hospital.
Published in Dawn, March 26th, 2020