What do we want ? Hydroxychloroquine (update without Azithromycin) and Remdesivir. When do we want it ? Now

by
Robert Waldmann
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I will never forgive Donald Trump for saying something exceedingly controversial with which I agree. I hate to say this but I agree with Trump and disagree with Fauci on hydroxychloroquine and Remdesivir.

Update: But don’t mix the Hydroxychloroquine with Azithromycin
“Azithromycin: (Major) Avoid coadministration of hydroxychloroquine and azithromycin.”

Thanks Ted Lieu

I will discuss hydroxychloroquine here because there is no legal issue. It can be prescribed for Covid 19 under current law and regulation. As noted here, the FDA has no say in the matter — they regulate food, drugs, and advertising and do not regulate the practice of medicine.

Consider the different treatment of Remdesivir, Hydoxychloroquine, and sever control measures. Because it is not proven that hydroxychloroqine works, it is considered a Trump average level outrage to say it should be tried. The side effects have been known for decades (and are acceptable given the circumstances). It inhibits SARS Cov2 replication in vitro https://www.nature.com/articles/s41421-020-0156-0 . There is anecdotal evidence that it has saved lives.

This does not amount to proof. Therefore, it is argued (by many people I respect) that it is irresponsible to type the following: all Covid 19 patients should be given hydroxychloroqine now. There is no morally acceptable alternative to doing this now. Now.

In contrast, there is extremely limited evidence on extreme control measures. There is no control group. The sample size is maybe one or two. And yet, it is perfectly responsible to advocate extreme control measures. Indeed it is perfectly responsible to impose them by decree (I am in Rome and have been ordered by prime minister Conte not to leave this apartment without a good reason).

Note the contrast here
The NYTimes.com presents a model graphically on page 1. It shows estiamtes. It is, in fact, theory, forecast not fact. The effectiveness of “severe control measures” is assumed. The data on which the estimate is based isn’t presented (on page 1)

Consider this published the same day (no longer on page 1)

“Trump’s Embrace of Unproven Drugs to Treat Coronavirus Defies Science”

Notice there is no headline about how Cuomo’s, Newsome’s and Conte’s embrace of unproven public health measures defies science (and I absolutely don’t assert that — I think they are making reasonable policy choices given necessarily incomplete knowledge)

It is absolutely clear that there is no general rule for acting without proof or solid knowledge. Sometimes, the rule is to not do something new until there is proof that it works. Usually, the rule is entirely different.

I do not think that anyone can justify the current dichotomy. I don’t think anyone tries. It is just assumed that the FDA rules are laws of nature and must be accepted.

I am trying to understand why this is. There are many possible good explanations which I will try to consider over after the jump

OK so here I am defending Trump from criticism in the New York Times (as written by the terminally ballanced headline writers) . Definitely preferable to having Covid 19 anyway, but no fun.

First, advising people do do something does not defy science. Science gives predictions of outcomes. It doesn’t tell us what to do. Trump defies the current policy of the FDA and the Medical Profession. He violates medical professional ethics (he can he’s not a doctor) and gives advice on health care (he has a first amendment right to do that as do I).

But second, there is the assumption that, when one considers pharmaceuticals, there is a dichotomy between proven and unproven (a false dichotomy is the most common error of thought and more common than any valid method of thought). So hydroxychloroquine for Covid 19 which is supported by preclinical evidence and anecdotal evidence is like Goop (link is not endorsement).

Again, I don’t think anyone can come up with a rational for treating pharmaceuticals in a way which is fundamentally different from everything else. In that case, decisions are not made based on cost benefit analysis given necessarily imperfect information. In that case, the fact that one *might* regret an action with the benefit of hindsight is considered decisive. Of course this is always always true — “might” makes right, anything might happen.

OK so why.
1. History. The difference is based on law. Laws are passed based on specific circumstances, then are imposed and interpreted. The question of what the law should be is considered by few, the question of what it is by many. Lawyers treat their laws as physicists treat theirs. Normal people respect the law. Obedience becomes ingrained.

I think this is expecially true for people like Tony Fauci one of whose core competencies is an ability to get along with the FDA (here for a change I am not speaking from ignorance).

A problem with explanation 1 is that the rules are similar world wide. It isn’t all Upton Sinclair and Teddy Roosevelt. The US used to lead by example. The FDA was explicitly praised and admired. But, in the end, the policy can’t be the result of “The Jungle”, it is too universal.

2. Regulations are needed to stand up to powerful concentrated interests. Alphabet soup FDA, FCC, SEC. The pharmaceutical companies have a very strong interest in selling pharmaceuticals. Tight rigid rules are needed to stand up to them.

The is not relevant to off label use of an off patent pharmaceutical.

3. Malpractice liability. It is very important to MDs to have a standard of care and to have no obligation to provide care which works better than the standard care. This is very explicitly a limit on malpractice liability. Better safe than sorry is true for the doctor and the hospital. They can be safe even if the patient dies, so long as they followed standards of care. This is a very strong incentive for small c Conservatism.

Again, my hypothesis has a problem that, if this were the issue, it should be US specific. I think it should be US specific. It isn’t. I honestly don’t know why Italian doctors act as if Italian civil justice actually works, but they do.

I can’t think of anything else. The explanations are completely insufficient. I do not understand.

Also give everyone with Covid 19 hydroxychloroquine NOW.