Is hydroxychloroquine really a cure for coronavirus?
Plus, results of the Tangle poll.
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Today’s read: 8 minutes.
Tangle’s poll results, a weekend update, the debate over hydroxychloroquine and a question about PPE.
President Trump interrupts as a reporter asks Dr. Anthony Fauci about the efficacy of hydroxychloroquine as a treatment for coronavirus.
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Nearly one thousand of you filled out last week’s poll. So many of you wrote in with incredible feedback about the newsletter and encouraging words about going paid. It was so rewarding after eight months of unpaid work, waking up at 5am and pouring my heart into this on top of my day job to see the results of that poll come in. Thank you. I’ll have an update in the coming week or two about what my plans are, but I just want to say this now to be clear: the core of this newsletter will always be free. The news should not be exclusively for the wealthy or those who can afford it. My goal is to make Tangle accessible for anyone who wants it, but to nudge readers who can financially support it to do so. Ultimately, I want to value my work, make a living and be sure people who want news like this can read it. I’ll have more about how I’m going to do that soon.
A weekend update.
Sometimes, between newsletters, there’s so much that’s happened it’s worth giving a quick rapid-fire update on the news that you missed. Today is one of those days.
The Supreme Court’s decision to postpone oral arguments due to the coronavirus means we may not get a look at President Trump’s tax returns until after the 2020 election. House Democrats had subpoenaed the tax returns, and the arguments over them were supposed to happen March 31st — meaning a decision was likely in June. But now SCOTUS has delayed oral arguments for the foreseeable future. Click.
Donald Trump fired the intelligence community’s inspector general late Friday night. Michael Atkinson had alerted Congress to the complaint that triggered the impeachment hearings. Conservatives say Trump is just getting started, and they believe Atkinson and other IGs like him are members of the “deep state” working to destroy his presidency. A columnist at The Federalist argued the firing was justified, while a writer at The New York Times said Trump was gutting our Democracy. The likely reality is Atkinson was doing his job by making the complaint known to Congress, but Trump has taken extraordinary steps to ensure loyalty to his cause amongst members of the federal government. Click.
430,000 people arrived in the United States on direct flights from China since the outbreak of coronavirus began. The count, conducted by The New York Times, said nearly 40,000 of those people arrived after President Trump’s restrictions on travel from China were imposed. It both illustrates the importance of travel restrictions but also how they are ineffective at times. Click.
A Navy captain who was removed from his post for speaking up in a leaked letter about a coronavirus outbreak aboard his ship received a standing ovation from sailors as he disembarked. Capt. Brett Crozier was making his way off the USS Theodore Roosevelt in Guam when sailors began cheering and clapping to the beat of “Captain Crozier!” The footage demonstrated a large contingent of support for Crozier despite his removal. Pentagon officials said he was fired for tarnishing the Navy’s image by going public with his concerns when internal actions were already being taken to address them. Click.
What D.C. is talking about.
Hydroxychloroquine. If you’ve heard of it, you probably know it’s an anti-malaria drug that is rumored to be a successful treatment for the coronavirus. President Donald Trump has repeatedly touted the drug and it is already being tested abroad and used here in the United States for coronavirus patients. Its potential has been spoken about so much that an Arizona man recently died by trying to treat himself with chloroquine phosphate, an additive commonly used in fish tanks that share some makeup of the generic malaria drug. Then, this weekend, Axios reported that the coronavirus task force exploded in disagreement in the situation room over the efficacy of hydroxychloroquine. Trump’s trade advisor Peter Navarro and Dr. Anthony Fauci, one of the leading epidemiologists in the U.S., had a heated argument over how much the White House should tout the drug as a way to treat COVID-19. Fauci argued the drug is unproven, while Navarro handed out folders with studies that he claimed showed a “clear therapeutic efficacy,” Axios reported. During back-to-back press conferences Saturday and Sunday, Trump first announced that 29 million doses of hydroxychloroquine were in the Strategic National Stockpile and then on Sunday encouraged Americans to try the drug. “What do you have to lose? 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. But hydroxychloroquine… try it. If you like.” Experts on both sides say you should consult a doctor before taking any medicine or treatment.
What the right is saying.
The right has been elevating every hydroxychloroquine success story there is. On Fox News, the drug is brought up as a potential life-saver on an almost daily basis. A Los Angeles doctor says he is seeing “significant success” in prescribing the malaria drug along with zinc to treat COVID-19 patients. In New York, as many as 4,000 seriously ill patients are being successfully treated with the drug, according to The New York Post. Some patients are already on an eight-week trial to determine whether the drug is safe or not. Trump has touted it as a potential life-saver. Some have celebrated studies out of France and China and said the data is clear: hydroxychloroquine works. On CNN today, Peter Navarro defended his argument with Dr. Fauci by saying that he has a Ph.D. and is a social scientist, noting that he understands how to read statistical studies and it is clear to him hydroxychloroquine works. Dr. Scott Gottlieb, who used to work at the Food and Drug Administration, says the FDA needs to step up and rapidly test the potential cures. Vice President Pence said on Sunday that the drug will be used in a trial of 3,000 patients in Detroit and the results are going to be tracked in a formal government study. An international poll of 6,227 physicians in 30 countries found that 37% rated hydroxychloroquine as the most effective therapy. “We don’t have time to go and say, ‘Gee, let’s take a couple of years and test it out,’ and let’s go out and test with the test tubes and the laboratories,” Trump said. “I’d love to do that, but we have people dying today.”
What the left is saying.
Pump the brakes. On Friday, Sweden had to literally shut down its treatment trial with chloroquine because patients were having seizures or experiencing vision loss (note: hydroxychloroquine and chloroquine are different drugs, but both have been elevated as potential COVID-19 treatments). When Dr. Fauci tried to answer reporters’ questions about the drugs on Sunday, Trump stepped to the lectern and cut him off. But Dr. Fauci has said repeatedly that there isn’t enough evidence to treat patients with hydroxychloroquine. Maybe we should be listening to the actual doctors and not the trade advisers? We’ve already seen the repercussions of false hope around this drug. The drug has serious side effects, including heart arrhythmia that can lead to cardiac arrest, and its use has been almost entirely for patients who are on death’s door and out of any real options. Just because it’s effective for some patients doesn’t mean it is the way out of this mess. The most commonly cited studies from China and France lacked a control group and or had other limitations that have left a lot of scientists skeptical about their results. We should wait until longer-term studies are done here in the United States with proper controls and methods before we start telling people this drug is safe to take.
My take.
I think the president’s comments are dangerous. Looking millions of Americans in the eyes and saying “you have nothing to lose” by trying a drug that literally has deadly side effects is just bonkers. That’s not to say I don’t understand the president’s desire to do this or his grasping for a solution. The challenge he’s facing is perhaps more difficult of a challenge than any living president has ever faced. But what’s the point of a coronavirus task force team of doctors if you’re just going to disregard them? Dr. Fauci was clear in his response on whether hydroxychloroquine should be considered a treatment for the coronavirus: “The answer is no… The evidence that you’re talking about… is anecdotal evidence.”
Look, there are signs hydroxychloroquine could work. Trump and his supporters aren’t simply making that up and it shouldn’t be dismissed. Doctors in China did report the drug was successful in speeding up recovery in patients who were mildly ill. Doctors in France were also encouraged by its use. And anecdotal stories from physicians across the U.S. are prominent. None of that is a lie or made up. It’s also true that, despite its side effects, the drug is “relatively safe,” as The New York Times put it. So if a patient isn’t responding to other treatments and is taking a turn for the worse, there is a perfectly good cause for trying it.
But none of that is reason to go buy this drug and take it yourself. None of that is reason to think this is the solution to the coronavirus pandemic. And expressing pessimism about it is not a sign of Trump derangement syndrome or a desire to want Americans to die. There are reasons drugs, vaccines and treatments go through rigorous months or years-long testing. And it’s because taking a drug like hydroxychloroquine for a week now, to treat this virus and in concert with other drugs, could lead to long-term side effects we don’t understand. There’s also the simple fact that the size of some of these studies is minuscule. Take the one out of China. Here’s an excerpt from The Times:
“Coughing and fever eased a day or so earlier in the patients who received hydroxychloroquine, and pneumonia improved in 25 of 31, as opposed to 17 of 31 in the controls.”
Did you catch that? They tested the drug on 62 people. And of those 62 people, there was a +8 difference in the folks who recovered quicker on hydroxychloroquine. That’s not insignificant but it’s also a statistically tiny representation. Which is why we need longer-term studies. The challenge, obviously, is that we don’t have much time. Hopefully, we can learn from the countries that are ahead of us in the pandemic and find ways to fast-track our own studies, but we shouldn’t be recommending the drug until we know what it’s going to do. I hope and pray that this drug is the way out and can be used effectively to cure the virus, but for right now we should be putting our faith in the doctors, epidemiologists and experts in the U.S.
Grading.
After I released Friday’s special edition newsletter and graded my own coverage of the coronavirus as a C or C+, my college roommates chimed in on our group chat to say they thought I was being too hard on myself.
Your questions, answered.
One of my favorite parts about Tangle is answering reader questions. If you want to ask a question, all you have to do is reply to this email.
Q: What is the government (or the private sector, for that matter) doing about the PPE shortage? Are factories being repurposed and outfitted to make PPE? Is the government working on contracts with companies who have the ability to do that? I’ve seen a few headlines of masks being donated, but it seems like those are just a drop in the bucket. I’m a nurse in an ICU, and I haven’t heard of any large scale efforts. We are now required to reuse our N95 masks for 4 shifts before we can get a new one. Going to work feels like staring down the barrel of a loaded gun, and it seems like people with the power to affect change don’t care. Whatever is happening, it isn’t happening fast enough.
- Courtney, Denver, CO
Tangle: First off, I just want to thank you. I said this in Friday’s newsletter when talking about how the world might change after this, but with any luck, our doctors, nurses and health care workers will be revered in a way military members are now. Shoot, even better would be if Americans just started to revere each other in general again. This pandemic should be building reverence for every kind of worker in our country — Uber drivers, nurses, teachers, front-line factory workers, delivery drivers, the national guard, legislators, journalists and a whole lot more. But I especially want to thank you for risking your own personal health and safety every day for the rest of us.
Onto your question: the first thing the federal government is doing is it stopped shipping Personal Protective Equipment (PPE) out of the U.S. to China and other countries. Yes, you read the right: our government was literally shipping the very equipment our own doctors desperately needed outside the U.S. until a couple of weeks ago. I covered that in Tangle last week, but you can read the story here if you want. Essentially, the United States Agency for International Development (USAID) was sending literal tons of PPE to countries in Asia to battle coronavirus. Somewhere in the chain of communication our task force responsible for handling the virus didn’t know. So when we called up Thai officials asking for PPE, befuddled representatives on the other line responded that they were awaiting two shipments of PPE from us to them that were already en route.
Trump also invoked the Defense Production Act, and began using it, which I wrote about last week in a reader question as well. The act will be slow to increase production and scale that production, but it does allow the federal government to redirect the masks and PPE that are already out there to the places that need it most. So, for instance, you’re in Colorado. That means Sens. Cory Gardner and Michael Bennett, who represent Colorado, could go to Trump and tell him that nurses like you are already reusing N95 masks and playing Russian Roulette at work. If they get through, Trump can point manufacturers who are shipping to the U.S. toward Denver.
We’ve also begun breaking into the National Stockpile, which temporarily gave some states hope. But that hope was dashed last week after Jared Kushner, the president’s son-in-law who is becoming increasingly involved in the response, said the stockpile wasn’t intended for states. After Kushner’s comments, the federal government abruptly updated the definition of the national stockpile on its website to conform to what he said, and then Trump began insisting the stockpile was a short-term backstop and not a commitment to ensure states get those supplies.
The Federal Emergency Management Agency (FEMA) is also getting involved now. They began overseeing the coronavirus response and said it is “working to meet demands for personal protective equipment (PPE) through new acquisition, [Department of Defense] allocation, or Strategic National Stockpile sources.”
In the CARES Act that passed Congress, there was a lot of language about increasing funding to manufacturers for PPE and giving hospitals more money to buy that PPE. Throughout the pandemic, the price of the equipment you’re asking about has predictably skyrocketed, leaving states and the federal government bidding against each other to get their hands on the life-saving PPE.
By some measures, the response has been massive. New York alone received 8 million masks, which sounds like an unthinkable number. But a Health and Human Services spokesperson said in early March that the U.S. would need 3.5 billion masks to handle a severe pandemic. There are conflicting reports that some hospitals here are going through as many 300,000 masks a week, though the numbers are still unclear.
And yes, the private sector is getting involved as well. Ford has vowed to 3D-print face shields. 3M is creating all sorts of PPE and getting pressure to manufacture more. Clothing and textile factories across the U.S. are now manufacturing surgical or N95 masks. The New England Patriots team plane flew over a million masks home from China. Operation Masks, a two-week-old nonprofit run by tech executives, said it had secured one million masks for New York City. Even small businesses in local areas being hit by the coronavirus have started making various kinds of PPE to donate or sell to hospitals in need. As The New York Times documented, the mask market is “bedlam” right now.
My take on all this craziness is that the response is disjointed, disorganized and desperate. If there is one criticism of Trump and the federal government’s response that should be held in front of them over and over, it’s as simple as this: how is it possible that a nurse from Denver, Colorado, is writing into my newsletter asking where her N95 masks are? How is it possible that New York City’s hospitals are desperately fighting for PPE for nurses and doctors? How could we have been sending that equipment abroad up until a week ago? Why weren’t we prepared when so many people knew this day would come?
It’s a question that should be asked by every American. And I’ll tell you right now the answer is that President Trump and others in his administration have spent the last two or three years tearing down parts of the federal government under the guise of cutting red tape and purging bureaucracy. And in some cases those purges may have worked out well; less spending and better efficiency. The reality, though, is that they’ve spent the last three years purging the federal government of the very people and agencies who have experience responding to situations like this — and now we’re scrambling to make things work without them. The result we’re witnessing now is predictable and sad. And even if the challenge we’re facing is one any administration would have struggled with — there are undoubtedly places where past administrations would have handled it better. If this ship doesn’t get turned around soon, the federal government is going to have a lot to answer for a few months from now.
A story that matters.
Tomorrow’s election in Wisconsin is quickly descending into “madness,” NPR reports. Despite pleas from mayors and lawsuits to try to postpone the election, the Republican-controlled state legislature held firm in its desire to hold the election as is. Now local leaders are trying to protect election workers with Plexiglas barriers, masks and gloves. Reusable writing utensils are being used for touchscreen electronic poll books. Department stores are being converted into polling places so people can maintain six feet of social distancing. And 7,000 poll workers across the state are still needed to run the elections smoothly. The chaos, and the precautionary measures, could be a preview for how Democratic primaries or even the November presidential election are run across the U.S. in the coming months. We’re still trying to figure out if and how we can vote during a pandemic, and tomorrow’s election could be our first look at an answer. Click.
Numbers.
60 million. The number of essential workers who are still going to their jobs on the front lines during the coronavirus pandemic, Brookings estimates.
47%. The percentage of the foreign-born population that arrived in the U.S. between 2010 and 2019 with a Bachelor’s degree or higher.
31%. The percentage of the foreign-born population that arrived in the U.S. in or before 2009 with a Bachelor’s degree or higher.
3.5 million. Of the 10 million Americans who filed for unemployment in the last two weeks, the estimated number of them who also lost their health insurance.
3 out of 4. The number of U.S. hospitals now treating COVID-19 patients, according to a new federal report.
38.1%. The percentage of Tangle readers who said the news coverage of coronavirus has had no impact on their mental health.
19.9%. In the March 20th poll, the percentage of Tangle readers who said they or someone they knew had been infected with the coronavirus.
43.8%. In last week’s poll, the percentage of Tangle readers who said they or someone they knew had been infected with the coronavirus.
74.5%. In the March 20th poll, the percentage of Tangle readers who said they or someone they knew had lost their job or faced reduced working hours due to coronavirus.
90.4%. In last week’s poll, the percentage of Tangle readers who said they or someone they knew had lost their job or faced reduced working hours due to coronavirus.
19.9%. The percentage of Tangle readers who said they would be less likely to pay for Tangle due to the coronavirus pandemic.
11.2%. The percentage of Tangle readers who said they would be more likely to pay for Tangle due to the coronavirus pandemic.
10.8%. The percentage of Tangle readers who said they would not consider supporting Tangle with a subscription or donation (SHAME! Just kidding, I love you no matter what).
99.2%. In the March 20th poll, the percentage of Tangle readers who said they had been practicing social distancing in the last week to reduce the spread of the virus.
99.2%. In last week’s poll, the percentage of Tangle readers who said they had been practicing social distancing in the last week to reduce the spread of the virus (an amazing statistical repeat).
45.8%. In the March 20th poll, the percentage of Tangle readers who rated their concern of coronavirus as a 5 on a scale of 1-5 with 5 being the highest level of concern.
55.2%. In last week’s poll, the percentage of Tangle readers who rated their concern of coronavirus as a 5 on a scale of 1-5 with 5 being the highest level of concern.
Have a nice day.
Brooklyn legend Mario Salerno announced last week that he was waiving rent for all the tenants in his 18 apartment buildings across the famous New York City borough. Salerno, who also owns an autobody shop in the city, is one of the local legends in Brooklyn for his family’s deep ties to the neighborhood. Last week, he decided to take hundreds of thousands of dollars of losses by telling all of his tenants that they could skip out on rent for April. In a note to tenants posted in each of the buildings, Salerno told them to “stay safe, help your neighbors and wash your hands.” While discussing the decision with the local news website Greenpointers.com, Salerno said: “I told them just to look out for your neighbor and make sure that everyone has food on their table.” His act of generosity has since gone viral. Click.
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About Hydroxychloroquine. The Chinese study was a tiny one (about 30 each in both the treatment and the control groups) and the entry criteria was that the patients did not have fever, that is that they were either asymptomatic or minimally symptomatic. In the treatment arm, about 5 went on to more severe symptoms (not described how severe), with about 15 in the control group. While this represents about an 80% v 50% outcome difference in this specific samples, as trumpeted by Peter Navarro this morning, the idea that these statistics provide even tiny support for opening the floodgates to its general use, is ludicrous. Similarly with the original French clinical study, with a French followup study showing no drug benefit. The original impetus for using this drug was based on lab, non-clinical research; there is currently not much more justification for its use.
And what is there to lose? For one thing, despite the the federal government encouraging an increase in the drug's production, there are already patients with rheumatologic disease who have worsened because they can't get the HC that had kept them well.
More than that, while its side effects can be fairly well monitored in the relatively small number of outpatients who had been using it, monitoring outpatients is a very different situation when it's being given out like it's Vitamin C. In the ICU patient, blood chemistry is complicated under the best of circumstances, with imbalances that can promote life-threatening heart rhythm disturbances. Hydroxychloroquine makes situation even more complex and therefore more dangerous.
Bear in mind that Hydroxycloroquine has now been used as a salvage on hundreds of patients in the last few weeks. Considering the crush of cases around the world, if it was a "game changer" for this infection, we would have not the very rare clinical supporter of its use, but a chorus of ICU docs screaming about its effectiveness.
Does Hydroxychloroquine have clinical utility as a prophylactic drug? Is it useful for mild, moderate or severe cases? If it has substantial utility, the professionals, desperate for actually useful tools, will make that clear in short order. Otherwise, it's hucksters selling fish tank cleaner.
Any redactions incoming?