Hydroxychloroquine has become a recent fixation of President Donald Trump, who has taken to promoting the century-old malaria medication in press briefings, brazenly overriding his medical advisers to suggest that it could work as a treatment for COVID-19.
How did conspiracy theories and desperation bring this drug to the president’s attention? What exactly does it do? And when will we know what treatments actually work against the COVID-19?
Katherine Wells and James Hamblin discuss on the latest episode of Social Distance, the Atlantic’s podcast about living through the pandemic.
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What follows is an edited and condensed transcript of their conversation.
Katherine Wells: What is hydroxychloroquine? Where’d it come from, and what’s it used for?
James Hamblin: The most dangerous animal in the world is the mosquito, because it carries this little parasite that causes malaria. And hydroxychloroquine is able to inhibit that parasite from effectively spreading. The World Health Organization has considered it one of the most important medications we have for almost 100 years now.
And then also we saw that it seemed to help people who had some autoimmune diseases—lupus and rheumatoid arthritis, specifically—because it seems to modulate immune responses.
Wells: With the flu, we have a vaccine, but we don’t have a cure or pill.
Hamblin: We have antiviral medications that, if given to people early on in the course of the illness, can modulate the course of the disease.
Wells: Is what we’re looking for, in addition to a vaccine, drugs that could help the disease either not really have an effect or have a much milder effect?
Hamblin: Right. There are two main things we can target here. You can try to stop the virus from replicating effectively—try to have it burn out more quickly—or you can try to change the immune response. So there are antivirals that are being looked at that change the way the virus might attach to cells in your body or change the way the virus replicates and block its replication within your body.
And then there are other drugs that could just change the way your immune system works, either make it more effective at getting rid of that virus or make it not go into this overdrive mode that kills you. Depending on what point you are in the disease, one type of drug might be more effective than the other.
Wells: So how did I start hearing about this malaria drug?
Hamblin: There were some reports that some people had tried it in China.
Wells: Is it a reasonable thing to try? Is it one option among many that should definitely be studied?
Hamblin: There’s not a clearly plausible mechanism for its attempted use, but people are so desperate that no one is against at least trying something that we’ve had for 100 years and has been generally extremely helpful in modulating the immune system.
Wells: So it’s definitely worth a shot, in a careful way?
Hamblin: Yes, I think most things are worth a shot. There are people trying an antibiotic, azithromycin, which attacks bacteria, even though this is a virus. People are trying all different sorts of immune-modulating drugs to just see what can be done. Hydroxychloroquine is just one of those.
There was a letter published of anecdotal reports in China of some people apparently benefiting from hydroxychloroquine, which led a team in France to try giving a very small number of people who had the virus this drug in combination with azithromycin, and they published those findings.
It was not a clinical trial. But it quickly got the attention of Dr. Oz, who’s been informing the White House. And President Trump became quite focused on those two drugs.
There have been other studies around the world that show mixed results. There’s some hope that maybe this combination of drugs could, in the early phases, modulate the disease a bit. But we don’t know. If this coronavirus is like other complex infectious diseases, it will likely be treated with a cocktail of drugs. The order in which the drugs are delivered, and the dose amounts, will depend on who you are, how sick you are, whether you have preexisting conditions—all kinds of factors.
In an emergency when people are scared, it’s very easy to sell the idea of, What are you waiting for? There’s no time to wait. Everyone should just be taking it. And that’s what the president has said. Just two weeks ago, President Trump told everyone to try it, and he tweeted that it’s a game changer and could be maybe the most promising drug in the history of medicine. And obviously, at a moment when people are desperate and terrified, that’s going to lead them to rush to their doctors and ask for prescriptions. But while this drug has been safely used with people who are generally healthy but who have lupus or arthritis, that’s different from someone who's on the brink of being unable to breathe. Every single thing that you do to their biochemistry, the effect is amplified in a moment like that.
Wells: For medicine, especially in a crisis, we want to be told what to do, how to fix the problem. We want the answer now. People are dying.
Hamblin: Right. You don’t want to have more people die or make it worse or have another variable in this equation, where you suddenly realize that this unproven drug can have a strange effect on people who have this brand-new disease.
Wells: You can blame people who should know better, like Dr. Oz, for peddling false hope, which could have damaging consequences. But can you blame Trump for wanting this to be true? Isn’t it a transparent Hail Mary?
Hamblin: Yeah. And he’s sort of right when he says, ‘It’s really bad when you get on a ventilator. We want to keep people off the ventilator; that’s why you should take this.’ He’s phrased it wrong. But I understand what he’s saying, that when you are in your 70s or 80s and you have to go on a ventilator, the statistics are bad.
But I think part of it is a political narrative that Dr. Oz and Sean Hannity have a part in.
Wells: When will we know how to treat this new coronavirus?
Hamblin: When we have clinical trials in coming months. And there is not going to be a drug that cures everyone. We don’t have that for the flu. We don’t have that for the common cold. What we do is modulate the disease.
Wells: So there may be some drugs that make it less likely for certain types of people to die in certain scenarios?
Hamblin: Yeah, that’s it.
Wells: People, myself included, are still having such a hard time coming to terms with that. We all want to know: When can we get the economy up and running again? When can we all go outside again? When is all of this going to be over? And the answer is still about a year. And I just keep trying to come up with new ideas so that the answer is not a year.
Hamblin: Well, there’ll be moments when we’ll be able to ease things a little bit, as we’ve seen in other countries.
But our society is forever changed. And we’re going to think about interactions with people in it differently for a very long time. Even when the risk is low, there’ll be a lot of people who will be wanting to avoid closeness in a large crowd.
Wells: Tell me how to maintain hope.
Hamblin: People are doing great work to investigate these things and to roll them out safely. Every day, doctors and nurses and everyone are getting better at developing protocols and knowing how to treat this disease and how to keep people alive. And a single drug may end up being helpful. But we’re learning this whole process of testing and triage, and it’s all getting better day by day.