Four drugs and a deadly disease

Four drugs and a deadly disease

A COVID parable

Believe me, this is a serious post, despite the frivolous film reference in the title. In a previous piece (http://randomramblings2018.blogspot.com/2020/06/home-remedies-hydroxychloroquine-and.html) I had talked about how and why we are easily mislead by what we hear and see. And how all this makes us hold beliefs which may be both ridiculous and strong. If only we could disregard them, merely as the quaint eccentricities of human behaviour. Unfortunately, the problem is that there is a whole bunch of people, with a wide range of scruples (mostly towards the deficient end), who are out there to take advantage of our fallibility.

Over the last several weeks, it has been quite revealing to watch the promotion and the interest generated in four potential drugs for COVID-19. The four drugs that I am considering all have different levels of proof of efficacy in treating the disease. At one end, the benefits of hydroxychloroquine are merely speculative, with no credible data showing any benefit. At the other end, dexamethasone (a steroid) reduces deaths due to COVID-19. Compared to this, the antiviral drug remdesivir has some rather minor benefits for patients (such as reduced duration of hospital stay). Another antiviral drug favipiravir is still under investigation. The costs of these four drugs are also quite different. While dexamethasone is quite cheap, a course of remdesivir can cost several times the per-capita GNI in several countries. To gauge the general interest in these drugs, I looked at google trends (https://trends.google.com/trends) data for the last 90 days. Who promotes these drugs, the implications of promotion, and the resulting uptake by physicians varies by country and health system. So, I focused on three countries that have very different health systems.

A tale of three countries

The interest in the four drugs in the USA, UK and India, present a striking picture. (Figure) The relative interest in the most appropriate drug (dexamethasone) was greatest in the UK, with just a (deservedly) passing interest in remdesivir. The Brits also, it seems, rather disinterestedly followed the hydroxychloroquine data controversy (culminating in the retraction of papers from two prestigious medical journals). The drug itself garnered little curiosity (the tiny peak in April in the figure). Take heart (some of) my disillusioned British friends, you still do have one of the best health systems working for you.

Figure: Relative interest in drugs for COVID-19 during the last 90 days in three countries

Industry or populist politics (or both) become the drivers of decision making to varying degrees in the USA and India. The Americans went through a veritable hydroxychloroquine mania, which persisted through much of April. This is one surge in numbers that their president can rightfully take credit for. Remdesivir also competed for attention and then went on to hold all of the interest for a while. (This is where you express your outrage at the power of industry lobbies) The Americans were lukewarm about dexamethasone. In case you are naïve enough to wonder why, who in their right minds would go to the trouble of promoting a drug that costs just a few dollars for a full course?

The Indians, who have the unique privilege of not needing a doctor’s prescription for many medicines, hoarded up on hydroxychloroquine rather enthusiastically. But unexpectedly, they showed even less interest in dexamethasone than their American brethren. Didn’t they know that they could buy a course of the steroid for about 10 cents, that too without a prescription? On the other hand, they showed a great deal of interest in favipiravir, and some in remdesivir (Indian companies have been licensed to manufacture and sell the drug at a fraction of the international price). The explanation is not far to seek. In India, populist politics keeps unbridled profiteering at bay, but in the zeal to do the right thing, ends up trumping science. The whole decision making apparatus functions like one giant, emotional human brain. Prioritisation then becomes based on blind faith and gut feeling rather than on objective evidence of what really works.

Many of you might share my frustration. Like every sane person, I believe that countries should prioritise the best treatments based on considerations such as which ones work and which ones are inexpensive, preferably in that order. But who am I kidding. It’s never been that way. The pandemic is merely bringing the disconnect to the fore, for all to see.