Many commenters here (DKos) have expressed intense suspicion of any vaccine that might become available in a few months, claiming that it’s likely to be another dangerous Trump scam, rushed to market by emergency approval. (See CNN and NYT) After all, hydroxychloroquine got emergency approval due to political pressure, and we’re fond of ridiculing that here. I want to make two controversial claims here. 1. The negative reaction to rapid vaccine development is suicidal for individual medical choices, for the psychology of pandemic response, and for politics.
2. Our incessant ridiculing of hydroxychloroquine goes beyond what’s justified by current evidence, and may also set us up for political disaster.
(Readers of my last post will notice significant overlap, sorry, but this one is broader and better-sourced.)
On Rapid Vaccine Development
Operation Warp Speed is not a Trump invention. It’s a rebranding of an Obama initiative to develop new vaccine platforms capable of rapid response to the viral challenges that epidemiologists knew were coming. (see obamas-science-advisors-outline-plan-faster-pandemic-vaccine) Obama personally asked a group of scientists “if you guys are so smart, how come you’re still making this in eggs?”. (See how-donald-trump-walked-the-u-s-into-the-covid-19-era) Better plans emerged and were boosted by the Obama administration. The vaccine work of Moderna, the first US vaccine developer to get to Phase 3 trials, was jump-started under Obama by a $25M 2013 DARPA grant and a $125M 2016 BARDA grant. The current head of BARDA says: “Eight years ago, HHS invested in novel public-private partnerships to create three Centers for Innovation in Advanced Development and Manufacturing or CIADMs to help strengthen the nation’s biotech infrastructure to prepare and respond to emergencies, Leveraging the capacity available at the Bayview CIADM to speed development and manufacturing of COVID-19 vaccine is precisely how we envisioned these centers be used in pandemic response.” Eight years ago the president was Barack Obama. All these points were made effectively by Rep. Bill Foster (IL-11) in a discussion with Tony Fauci, available on youtube.
So the fear often expressed here, that the very rapid development of a vaccine is some Trump trick, is misplaced. The speed is a triumph of rational planning, initiated here by Obama. How would a Trump trick account for China, Germany, the U.K., Russia, India, etc. all planning on getting vaccines in use about as quickly or even faster than the U.S.? In some ways, we are used to getting vaccines developed within a few months- the annual flu vaccines, each aimed at the likely strains for the upcoming season. Of course, those are just modifications of a basic vaccine already developed. Some of the new Covid vaccines, likewise, are modifications of vaccines developed for the original SARS corona virus, but unused for that since it was crushed by non-pharmaceutical methods.
There are no guarantees that the Moderna vaccine will do as well in large-scale trials as it has in preliminary tests. Likewise there are no guarantees for the Pfizer mRNA vaccine (developed in Germany), or the Oxford (U.K.) adenovirus vaccine, or the Sanofi vaccine (also mRNA, I think), etc. Nevertheless, it is highly likely that several of the many vaccines under development will work pretty well, and should be distributed on an accelerated schedule, as is happening in other countries. It’s extremely important, of course, to make very sure that the vaccines used will not backfire by antibody-dependent enhancement or other immune-related enhancement of the disease intensity, but obsession with very rare side effects is not in the interests of people who are at serious risk from Covid-19.
Good treatments will be here sooner. Dexamethasone has just been found to be very useful in severe cases. Remdesivir is scarce now, but production is ramping up. Nebulized interferon, EIDD-2801, etc. are being tested. Monoclonal antibodies, probably much more effective, are coming next. Help is on the way. (I’ll discuss the controversial hydroxychloroquine separately below.)
Remember, currently about 5000 people a day are dying world-wide, about 1000 of them in the US. In the US and many other countries, people are getting exhausted with maintaining precautions and are becoming more careless. Psychologically that makes sense if the choice is simply to delay the inevitable or to start living normally now. It makes no sense if the choice is to hang on for a few months and then get back to normal or to throw caution to the winds and risk being one of the last people to die of Covid-119 before treatments and vaccines come.
We know Trump is a liar and a crook. We know he shows depraved indifference to human life. That is not sufficient reason to reject a life-saving medicine developed from an Obama program.
We know people are often unrealistically optimistic, and use that to justify recklessness. That is not a reason to promote unrealistic pessimism that also leads to recklessness.
We know that people are desperate for a technical fix, and might buy fake ones from an old snake-oil salesman. But when there are real technical solutions, the last thing we want to do is play the part of fuddy-duddy bureaucrats in an Ayn Rand cartoon, stalling progress while the heroic Leader acts decisively. Picture a vaccine approved for some select group under pressure in October, with heartwarming pictures of the Dear Leader overseeing the first shots for a diverse group of elderly people or hospital staff. If we’ve been looking for any excuse to quibble and oppose that, we’re setting ourselves up for defeat.
So here’s the bottom line on vaccines:
1.Vaccines that are coming pretty soon are likely to be extremely valuable, so to reject them for political reasons would be personally suicidal .
2.The realistic hope for effective treatments and vaccines soon is crucial for motivating people to hang on and keep being cautious now, rather than giving up. Therefore, for immediate public health reasons spreading unwarranted pessimism is suicidal.
3.Trump will falsely claim that he, not Obama, took the key steps to make vaccines available at “Warp Speed”. Quibbling and naysaying as effective vaccines come into view will play into his narrative and thus be politically suicidal. Instead, we should proudly take credit for the Obama achievments.
On Hydroxychloroquine (HCQ)
Pretty much everyone here is fond of ridiculing HCQ, sometimes claiming that it’s been “proven ineffective”. It’s hard not to join in when the advocates are clowns like Raoult, Trump, Hannity, Immanuel, etc. But I claim that there is nothing to gain from that sort of certainty, and there may be a great deal to lose, especially politically. (Yes, I know that this claim will stir up anger on DKos.)
First, what are the known facts? A series of randomized controlled trials (RCTs) on hospitalized patients, as well as large observational studies that attempt to match treated and untreated patients based on their prior condition, find essentially no benefit for HCQ in patients who are already fairly sick. Given the risks of HCQ (particularly combined with azithromycin) causing fatal arrhythmias in patients who are already often experiencing heart problems, kidney failure, etc., its use for such patients has generally been dropped.
The less-crazy advocates of HCQ, however, claim that its proper use lies elsewhere, as a prophylactic for exposed people or as a very early-stage treatment, like typical antiviral meds. What do we know about that? Is there any prior reason to suspect that HCQ would be useful in such cases? Yes, it’s known to inhibit the replication of some viruses in vitro. There’s nothing particularly exotic about a chemical developed for one medical use accidentally having benefits for other uses. (E.g. aspirin was not developed to inhibit blood clotting or to reduce long-term colon cancer risk.)
An epidemiologist I correspond with (emphatically not a Republican) recently sent me two papers on HCQ RCTs for such uses. No serious arrhythmia issues were found in either study. In both, the risks for the HCQ groups were somewhat lower than for the controls, although in neither case was the difference large enough to confidently rule out the possibility that it was due to random chance.
https://www.acpjournals.org/doi/10.7326/M20-4207
https://www.nejm.org/doi/full/10.1056/NEJMoa2016638
If you pretend that the protocols were similar enough to just combine the results, the net result would still be a bit short of the conventional “statistical significance” cutoff. In other words, it wouldn’t be shocking if the treatment wasn’t effective and the differences were due to chance. Still, that’s very far from being “proven ineffective”. (Sometime I’ll write about the problems with the conventional way of presenting statistics in such trials, which tends to encourage mistaking weak evidence for evidence that no effect is present. Meanwhile, see https://www.nature.com/articles/d41586-019-00857-9 for that argument.)
Didn’t Tony Fauci just testify that it has not been shown to be effective? Yes, those RCTs do not show that it’s effective. They do, however, hint that it might be. Fauci, appropriately, immediately followed by saying he would change what he said if the new data coming in showed it to work.
Why do I think this matters? I see absolutely nothing to gain by pretending to be certain about a medical question on which we are in fact in doubt. What happens if the next studies show it’s somewhat useful? What if it reduces progression to serious illness by 20%? Does anyone think Trump and the Republicans will refrain from crowing about how the far-sighted Leader was right all along, and the fuddy-duddy bureaucrats killed tens of thousands with their cowardice? They’re already saying that. What will we say if it turns out there’s a grain of truth to it? Is it worth risking losing the damn election, probably the last chance to stop the slide into barbarism, just for a few good laughs?
So let me go over the HCQ bottom line.
1. At the individual level, we just don’t know if it has some value at early stages, so we shouldn’t make any claims that would get in the way of responding rationally to whatever new research results show.
2. At the public health level, it’s true that the crazy pro-HCQ hype plays a very negative role, encouraging recklessness. We should counter that carefully, pointing out that based on what we know already it isn’t nearly effective enough to justify being lax about testing, distancing, masks, and ventilation.
3. At the political level, being loudly arrogant in ridiculing any possibility that HCQ has some value could set us up for an enormous disaster.
My recommended talking points:
On vaccines: Thank god Obama got this program started. Let’s hope Trump and his corrupt cronies don’t screw it up.
On HCQ: I hope it turns out to help, but data show it’s no silver bullet. We need rapid testing, distancing and masks.
We’re playing this one for keeps. So I’m begging you all, think about what you’re saying. Don’t just recycle wisecracks. Make sure that what you say about medical prospects won’t backfire, within the range of plausible outcomes.
