HEALTH

Why Does the President Keep Pushing a Malaria

Drug?
What is actually known about hydroxychloroquine, the medication that Trump is
xated on recommending for COVID-19
JAMES HAMBLIN APRIL 6, 2020

THE ATLANTIC

Two weeks ago, French doctors published a provocative observation in a

microbiology journal. In the absence of a known treatment for COVID-19, the
doctors had taken to experimentation with a potent drug known as
hydroxychloroquine. For decades, the drug has been used to treat malaria—which
is caused by a parasite, not a virus. In six patients with COVID-19, the doctors
combined hydroxychloroquine with azithromycin (known to many as “Z-Pak,” an
antibiotic that kills bacteria, not viruses) and reported that after six days of this
regimen, all six people tested negative for the virus.

e report caught the eye of the celebrity doctor Mehmet Oz, who has since
appeared on Fox News to talk about hydroxychloroquine 21 times. As Oz put it to
Sean Hannity, “is French doctor, [Didier] Raoult, a very famous infectious-
disease specialist, had done some interesting work at a pilot study showing that he
could get rid of the virus in six days in 100 percent of the patients he treated.”
Raoult has made news in recent years as a pan-disciplinary provocateur; he has
questioned climate change and Darwinian evolution. On January 21, at the height
of the coronavirus outbreak in China, Raoult said in a YouTube video, “e fact
that people have died of coronavirus in China, you know, I don’t feel very
concerned.” Last week, Oz, who has been advising the president on the
coronavirus, described Raoult to Hannity as “very impressive.” Oz told Hannity
that he had informed the White House as much.

Anthony Fauci is not among the impressed. e day the study came out, Fauci, the
leading infectious-disease expert advising the White House’s coronavirus task force,
downplayed the ndings as “anecdotal.” e report was not a randomized clinical
trial—one in which many people are followed to see how their health fares, not
simply whether a virus is detectable. And Oz’s “100 percent” interpretation involves
conspicuous omissions. According to the study itself, three other patients who
received hydroxychloroquine were too sick to be tested for the virus by day six (they
were intubated in the ICU). Another had a bad reaction to the drug and stopped
taking it. Another was not tested because, by day six, he had died.

Nonetheless, the day after Raoult’s study was published, Donald Trump tweeted
about it: “HYDROXYCHLOROQUINE & AZITHROMYCIN, taken together,
have a real chance to be one of the biggest game changers in the history of
medicine.” In the days since, Trump has repeatedly returned to this claim. On
Saturday, he said that the term game changer wouldn’t even adequately describe the
drug: “It will be wonderful. It will be so beautiful. It will be a gift from heaven, if it
works.” After downplaying the value of ventilators and social distancing, measures
that experts overwhelmingly agree are needed to overcome the virus, Trump said
the country would procure 29 million doses of hydroxychloroquine for a national
stockpile. He said he may start taking the drug himself.

[ Read: All the president’s lies about the coronavirus ]

Over the course of these two weeks, the president of the United States has become
the world’s most prominent peddler of medical misinformation. While some very
early evidence has shown that hydroxychloroquine may in uence the course of
COVID-19, Trump is overriding his top medical adviser and minimizing serious
risks by encouraging Americans to try the drug right now. is brazen dispensation
of medical advice from the president is dangerous in ways beyond the potential
harm of the drug itself. A time of strict directives for personal behavior and hygiene
requires tremendous trust in those giving the directives—and understanding the
reality that this is a disease without a miracle cure. But instead of inspiring trust,
Trump has pivoted from downplaying the number of cases in the United States to
the extremely effective trick of quack medical providers: hyping an unproven
treatment that entices desperate people with false con dence and confusing
messaging.

It is unclear how hydroxychloroquine would work to treat COVID-19, but the

drug is one of many now being urgently studied for the treatment of the disease.
e drugs being tested include those that could block viral replication, such as
remdesivir, and others that may target the way the virus binds to human cells. Still
other drugs aim to modulate a person’s immune response, among them a class of
drugs known as IL-6 inhibitors. Hydroxychloroquine has the theoretical potential
to affect the virus itself or the immune response. In addition to treating malaria,
hydroxychloroquine is important in the treatment of autoimmune diseases such as
rheumatoid arthritis and lupus. In those speci c conditions, the drug effectively
serves to subdue an overactive immune response.

Slowing the immune system too far, though, could make people more susceptible
to infection. Other drugs that suppress in ammation—steroids and ibuprofen—
initially generated some enthusiasm as methods of controlling the immune response
in COVID-19. ey have since shown mixed results and are not widely
recommended. Even in people without the disease, hydroxychloroquine’s
potentially harmful effects range from vomiting and headaches to instances of
psychosis, loss of vision, and even sudden cardiac death. e drug is to be used with
caution in people with heart conditions and liver dysfunction—both of which the
coronavirus can itself cause.

Based on the limited evidence so far, giving hydroxychloroquine to people could

very well be—as with most drugs that modulate the immune system—of some
bene t in some circumstances. Some people will be made sicker by it, depending
on underlying physiology, other medications they’re taking, timing, and dosing.
Identifying who stands to bene t and why requires data, and several randomized
controlled studies of hydroxychloroquine are under way.

[ Read: How the pandemic will end ]

But Trump has plunged ahead. On March 28, amid his constant enthusiasm, the
FDA issued an emergency authorization allowing the use of hydroxychloroquine for
treatment of COVID-19. Even still, the agency urged that the drug should be given
only to patients “for whom a clinical trial is not available, or participation is not
feasible.”

Some hospitals in the U.S., including Massachusetts General Hospital, have begun
incorporating hydroxychloroquine into treatment protocols, at the discretion of an
infectious-disease specialist. Other institutions are more guarded. At the University
of Washington, doctors are advised in official treatment policy that although the
drug has been shown to inhibit replication of the virus in cultures of monkey
kidney cells, “it has not been shown to be an effective antiviral” in living organisms.
e University of Michigan Medical School advises its doctors that “the current
body of literature and local experience does not support the routine use of any
speci c treatment regimen, including hydroxychloroquine, for patients with
con rmed COVID-19 infection.”

Conclusions like these draw on the fact that the body of evidence remains small,
and the results are mixed. A randomized trial of 30 patients with COVID-19 in
Shanghai found no difference in detectable virus at day seven, with or without
hydroxychloroquine. Another recent study suggested that the drug may help with
COVID-19 symptoms, including coughing and fever, but it included only 62
people with mild cases of the disease, and excluded anyone with conditions that
could be exacerbated by hydroxychloroquine. In mid-March, Italian and Israeli
researchers concluded that there were sufficient grounds to continue doing research
with the drug, but that any use should be closely monitored. e scientists advised
against widely unleashing yet another medical variable during the pandemic.

In the U.S., Fauci continues to hold the same line as the rest of the medical
community—cautious optimism, with a close eye on the many ongoing clinical
trials. Trump, meanwhile, escalates as a peddler. “What do you have to lose?” the
president said in a press conference on Saturday. “I’ll say it again: What do you
have to lose? Take it. I really think they should take it. But it’s their choice. And it’s
their doctor’s choice, or the doctors in the hospital.” At a brie ng yesterday, he
intercepted a question for Fauci about hydroxychloroquine and told the reporter
that the doctor wouldn’t be answering it.

[ Read: Anthony Fauci’s plan to stay honest ]

What do you have to lose? is a dark sentiment from a president managing a crisis that
his administration failed to prepare for: It failed to develop testing, failed to
communicate, and failed to have enough face masks for doctors. ere is, in fact,
much to lose. Americans also need hydroxychloroquine to treat serious immune
conditions and parasitic diseases. Since Trump began promoting the drug, people
have been hoarding it, and it has been added to the growing list of drug shortages.
Two weeks ago, in an attempt to procure some, an Arizona couple ingested
chloroquine, which is meant to be used in sh tanks. e man died.

In such moments, the appeal of any treatment that could offer a glimmer of hope is
understandable. But even if hydroxychloroquine eventually proves to be safe and
useful to some people with the disease, touting it constantly distracts from the
immediate needs of the crisis. Now is not a time to abandon the tried and true
systems that keep people safe and create order. It’s a time to double down on the
systems developed over decades to help us nd the best treatments for diseases, and
make sure that they are safe and effective. What do you have to lose? follows the logic
of removing stop signs because they might slow people trying to get to the hospital.

In his capricious responses to this pandemic, Trump has given little indication that
he respects, or even comprehends, the reasons for the scienti c process.
Hydroxychloroquine could end up as part of the treatment approach that one day
saves lives. Outside of a proper testing process and clear messaging, it could cost
lives. Addressing a world in a collective state of despair, Trump offers exaggerated
hope and endangers people as he rambles.

On Saturday, Trump suggested research exists that shows people with lupus don’t
get the coronavirus, implying that their use of hydroxychloroquine protects them.
“ere’s a rumor out there that because it takes care of lupus very effectively, as I
understand it, and it’s a, you know, a drug that’s used for lupus,” he said, “so there’s
a study out there that says people that have lupus haven’t been catching this virus.
Maybe it’s true; maybe it’s not.”

ere is no such study.

Related Podcast
Listen to Dr. James Hamblin answer questions about coronavirus on e Atlantic’s
new daily-ish podcast, Social Distance.
 Social Distance
Trump’s Miracle Cure
What do we actually know about
hydroxychloroquine?
00:20:47

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