IMPALPABLE SUSTENANCE

There are moments of clarity that in their tempestuous presence, far exceed in gains than the comprehension, prolonged excruciating and time-robbing pensive deliberations, when nothing moves or advances. These eureka moments arise indifferent to time or space. Like the zephyr filling the sails of a sloop on a quiet lake. 

Judgment inquires, about experience and knowledge in the same breath. It is not about theorizing movements, or ordaining trajectories of arrows in flight with indifference to wind or a gathering storm. Judgment requires a spate of intuition boiled in a vat of reality. 

Taking a certain object away from a child to prevent harm, is based on the past experiences of others under similar circumstances. Rubberizing a sharp edge has equal protective value for an infant. In the adult world of aviation, a preflight is meant to prevent the potential of a catastrophe. Checking the free movements of the control surfaces, draining the fuel or checking the oil before takeoff heed to the same convention of prevention. All stem from the experiences of others and self, about using the correct conduct prior to a flight. I remember upon embarking in an airliner, my son upon looking into the cockpit asked, why the pilot and the copilot had their pilot operating handbooks on their lap. “Are they learning how to fly the plane?” He asked with incredulity.

In medicine, judgment is an important determinant of a physician’s management of any illness. True care of a patient is not a repetitive mantra of this for that. It is not the guideline metric of “Less is More,” or “Choosing Wisely,” as envisioned by the wisdom of the ones who ordain the trajectories of their version of the medical discipline. It is as Rebecca Elson put it, 

“And purpose is a momentary silhouette

Backlit by a blue anthropic flash,
A storm on the horizon.”

It is a collective experiential reference based on knowledge and with that instructive modicum of intuition.

Ask any physician in the throes of a busy Emergency Room work-day, how he or she is able to keep the collective mob of ailing people from inundating their decision and judgment on the singular patient they are tending to? “I refocus on each one as I go along,” most will reply. But, how do you know what medicine or therapeutic option to offer? “I look at them and my knowledge and experience come into play, each time,” they respond. Exasperated, with these equivocations, you ask, “But how do you know what the right thing is to do. Do you follow some guidelines?” They stare back at you and then shake their head and head to the next patient moaning for their help. Is it intuition or judgment or an inkling? A fair question.

Walt Whitman squares this argument thus, “impalpable sustenance of me from all things at all hours of the day.” There is a flow of an ethereal transfer of information between humans, the kind that unifies us as humans. This flow ebbs and flows to the beat of human desire. Intuition, judgment and inkling are all words that imbue the essence of that “impalpable sustenance.”

Another example where such judgment comes to the forefront is in piloting an aircraft. The virtue of experience and knowledge is compacted into that tiny moment of decision-making when things go silent and fear shakes the bones. When the engines shuddered, while ingesting geese and the aluminum behemoth becomes a glider. Sullenberger, the pilot using his “impalpable sustenance” was able to glide the US Airways Flight #1549 an Airbus 320 into the Hudson River, NY and saved all the lives on board. Even second-guessing by armchair experts, of his decision, could not achieve the same fate.

A not dissimilar event happened in 1989 on a United Flight 292 under the command of Captain Al Haynes. The DC-10 aircraft experienced a catastrophic engine failure in its rear engine, which triggered a loss of hydraulic fluid. That loss of hydraulic fluid caused all control surfaces (rudder, flaps, ailerons) to malfunction. The flight was diverted to Sioux City, IA and after judiciously manipulating the two engines still operating and using thrust vectoring for directional control, he was able to crash land the aircraft and save 189 lives. 55 test pilots given the same scenario in simulators failed to achieve similar results. You may call it “experience” or “intuition” or “judgment” in those critical moments, but surely it transcended all written words in some manual!

As recently as yesterday a report from the COVID19 frontlines brought forth another example of human ingenuity and good judgment in an attempt to save a life, that has won over many other physicians. A patient developed severe shortness of breath after being infected by COVID19. Ventilatory support did not offer much help as the patient’s life continued to ooze away. The physician considering the possibility of multiple clots as the reason for the sudden shortness of breath gave an anticoagulant as a form of therapy. That therapy stabilized the patient for a short while, but she succumbed. However, the physician’s insight has led to a new therapeutic option for other severely ill patients with similar complicating features of COVID19.

One cannot always relegate human intuition/judgment/inclination to the back seat or to the written word from academic experts. There is a blossom of colors in the minds of each physician-scientist who faces extraordinary charges and must be allowed without the nitpicking of retrospective legalism, to use that kernel of “impalpable sustenance” however implausible it might seem in face of unparalleled adversity. To any future charges, the physician-scientist must also be able to answer such questions to the best of his or her ability as to why such actions were taken. Suppressing such “impalpable sustenance” would lead us all into the ocean of mediocrity and stagnation and soon that sustenance will wilt and die, leaving us as nothing more than a non-thinking collective, what Star Trek called the “Borg.”

And I, being you, “Just as you feel when you look on the river and sky, so I felt,
Just as any of you is one of a living crowd, I was one of a crowd,
Just as you are refresh’d by the gladness of the river and the bright flow, I was refresh’d,
Just as you stand and lean on the rail, yet hurry with the swift current, I stood yet was hurried,” (Walt Whitman stated), we all rush to the same shore but each with a different voice and understanding.

It is fitting, therefore, to leave you with this short Walt Whitman poem:

WHEN I HEARD THE LEARN’D ASTRONOMER
When I heard the learn’d astronomer,
When the proofs, the figures, were ranged in columns before me,
When I was shown the charts and diagrams, to add, divide, and measure them,
When I sitting heard the astronomer where he lectured with much applause in the lecture-room,
How soon unaccountable I became tired and sick,
Till rising and gliding out I wander’d off by myself,
In the mystical moist night-air, and from time to time,
Look’d up in perfect silence at the stars.

COVID19 SHUTDOWN & its COSTS

In all post-war aftermaths, a reckoning is inevitable. Even though we are still in the midst of this pandemic, there are certain corollaries that seem to fill in some of the blanks. These are the blanks that wake us up in the dark of night with a thought that cannot be easily reconciled; A scratch that cannot be itched. 

Before we go hunting for the culprit of this current pandemic, let us visit the age-old annual irritant to our existence. The Influenza virus. There is something quite sinister in this micro-beast. The Influenza virus rears its ugly head every year to raise Cain among the young and the old. The virus has developed an art form in its sneaky attacks. Winter brings with it the cold. With the cold, everyone cordons themselves to the indoors. The virus starts the breeding process in schools where young children congregate. From there it gains access to the parents and thence to the commercial tracks across the world. 

INFLUENZA...

Influenza is a very contagious illness. It affects approximately 9% of the population infecting roughly 1 billion people annually. Of those around 30%-50% develop fairly significant illness requiring some form of therapy and management. And of those around 10% die as a result of the illness. The Case Fatality Rate is 0.15% for the Influenza illness. The numbers are staggering and this happens every year, but no specter of “the world is coming to an end” is in the daily news broadcast. If we are to look strictly at the United States population, 15-20% of the population is affected each year or 50 million people in all are infected by the Flu virus. Of those 250,000 are hospitalized and around 10-20% succumb to the illness. The variations in the severity of the illness and the fatality rate depend on the mutational features in the Hemagglutinin and Neuraminidase surface antigens of the virus and the efficacy of the vaccine. If the antigenic drift (Antigenic drift results from the accumulation of point mutations in the Hemagglutinin (HA) and Neuraminidase (NA) genes) is significant (and not anticipated by the vaccine producers) then the infection rate and the fatality rate is fairly extensive as evidenced by the H1N1 viral infection of 2008-2009 period. According to CDC estimates, between 43 million and 89 million cases of novel influenza A (H1N1) occurred from April 2009 to April 2010. Between 195,000 and 403,000 individuals were hospitalized, and between 8,870 and 18,300 people died. Of those patients who died, 90% had underlying medical conditions. Given the vulnerability of the elderly population with multiple comorbidities such as Diabetes, Hypertension, COPD, Kidney disease and Heart Disease, the elderly makeup almost 15% of the U.S. population but represent 65% of the hospitalizations and 90% of the deaths associated with influenza. (1,2,3)

ECONOMIC BURDEN OF INFLUENZA

In regards, the economic burden of the Influenza infections specifically in 2003 alone was the estimated economic burden of influenza totaled $87.1 billion, with $10.4 billion spent in direct medical costs. Most of the costs were directly related to the care of the 65 years and older patients. (10,12)

FATALITY RISKS FROM INFLUENZA

The mortality from the Influenza virus is enhanced by comorbid states such as COPD after making adjustments for age, sex and risk status. Any person with a history of hospital admission three years prior, or a chronic condition such as cirrhosis, Heart disease, pulmonary disease, kidney disease, Immuno-deficiency, HIV infection, and long-term residence in an Extended Care Facility (Nursing Home) were considered high risk for the Influenza. (4,5)

COVID-19, SARS COV-2, CHINESE CORONAVIRUS

Now let us turn our attention to the current miscreant; the SARS Cov-2 or COVID-19 or the Chinese Corona virus. The current data on this virus as of this writing today suggests that a total of 1.48 million people across the world have been infected and 87,444 people have succumbed to the disease. In the United States the estimates are that 1 in 994 people are infected with different regions showing different penetrance. In February 12, 2020, 4,226 COVID-19 cases were reported in the United States; 31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths occurred among adults aged ≥65 years with the highest percentage of severe outcomes among persons aged ≥85 years. (6). The incubation period of 2-14 days makes the exact number infected (diagnosed) difficult unless testing for IgG and IgM antibodies is done. Although the number prevalent in this discourse, based on China data, is that an estimated 81% of the population is asymptomatic, this number is probably much higher (86-90%) given the nature of illness in asymptomatic people. The difference of the severity of infection in the Hubei Province and other parts of the world is discussed in this article at length.

“One of the most perplexing questions regarding the current COVID-19 coronavirus epidemic is the discrepancy between the severity of cases observed in the Hubei province of China and those occurring elsewhere in the world. One possible answer is an antibody-dependent enhancement (ADE) of SARS-CoV-2 due to prior exposure to other coronaviruses. ADE modulates the immune response and can elicit sustained inflammation, lymphopenia, and/or cytokine storm, one or all of which have been documented in severe cases and deaths. ADE also requires prior exposure to similar antigenic epitopes, presumably circulating in local viruses, making it a possible explanation for the observed geographic limitation of severe cases and deaths.”

Furthermore, data from Wuhan presented in the journal Science, “This estimate reveals a very high rate of undocumented infections: 86%. This finding is independently corroborated by the infection rate among foreign nationals evacuated from Wuhan.

Additionally, Michael Farzan, co‐chair of the Department of Immunology and Microbiology at Scripps Research, states, “once a vaccine for COVID-19 is developed, it would not need regular updates, unlike seasonal influenza vaccines” Those infected and recovered have active immunity and are firewalled against future infections as well. The British Medical Journal states that the COVID appears less mutable than expected. The Case Fatality Rate for the COVID-19 is between 0.15%-1% with an average of 0.6% based on results from across the world vs. SARS or MERS, which have had case fatality rates of 9 to 10% and 36%. 

Most countries are already showing a “flattening of the curve.” (By “flattening” we mean that the rate of infection and recovery equalizes and then as the rate of infection falls, the curve turns downwards) In some of the countries, the flattening of the curve has occurred spontaneously preceding the Social Distancing, while in others it has followed. Several questions arise as a consequence of this finding and need further elucidation. Remember the estimates of infection rates and death rates are based on an arbitrary multiplier as done for the Swine Flu previously and was grossly overestimated. “We estimate that the total number of pandemic (H1N1) 2009 cases in the United States during April–July 2009 may have been up to 140× greater than the reported number of laboratory-confirmed cases.” The worst aspect of all this “estimated scientific data” is what most Journalists sensationalize to get their ratings and cause fear and panic among the laity for the sake of viewership and some busy experts feed off the journalists to get more exposure on television as well. Experts like journalists are, after all, human. The R0 or Reproducible Rate of the virus has also become an issue. The common flu R0 is 1.28 while the COVID-19 was estimated at 2.2. The difference is of significance because the +0.92 difference is the difference between an epidemic and a pandemic. Hence the deployment of the “Shelter in Place” mandates. However, if one considers this a bit further, a conundrum becomes evident. The advocated “Social Distancing” does limit exposure but might it prevent the youth from getting the asymptomatic infections and thus restrict enlarging the herd immunity pool and thereby because of this prevention might inadvertently later be exposing the risk to the vulnerable elderly and thereby cause a secondary peak?

OBFUSCATION

The management of the present COVID19 virus has been of serious concern from the beginning. In China, the real data from the Communist country remains hidden. The issues related to suppressing information and delaying the transmission of pertinent information from the Chinese Authorities and the World Health Organization are in discussion presently. Both are being questioned for disinforming the virulence of COVID19, the actual number of cases and its easy transmissibility between humans. Why this obfuscation was attempted, will need to be reconciled in the near future.

LIES, DAMNED LIES, AND STATISTICS

Another more interesting but likely dubious statistical modeling data done by the Imperial College of London by Neal Ferguson suggested that the deaths from this virus would amount in the millions globally. That initial model became the benchmark for all countries and threw everyone into a tailspin. No one, no leader or otherwise would ever want such a debacle on their hands. Experts clogged the television and Radio waves to highlight the Armageddon that was upon us. “Shut everything down,” they cried, and the leaders listened. The initial impact of the virus on humans was a cause for concern, accented with the statistical modeling. The dye was cast. The world would pay a huge price if it did not listen to these sages of science. The initial event can be traced down to the Hubei Province and Wuhan in particular on Chinese soil. Images of the shutdown of the Province from the rest of China, while simultaneously allowing world travel by millions of the Wuhan citizens came to pass. Images of Street spraying and lock-down and citizens forcefully separated from their families played out on the Western media daily. At the same time, the virus was being carried to points far and wide, WHO Director Tedros Adhanom maintained that the virus only was transmitted from animal to human and there was no evidence of human to human transmission. Simultaneously WHO’s Tedros and some other politicians suggested that any restriction on incoming travel from China would be considered xenophobic. The rest of the world let their guard down because of these assurances and collectively with political correctness the journalists cast the net of confusion. The influx of the infected Wuhan citizens into the world community gathered steam and intensity without a question. 

Once the virus had taken hold in a country, the images of the Wuhan lock-down and street spraying, social distancing, shelter in the home became the call from the experts. Focusing on the population needs based on the IHME modeling and other such experts, estimates of the devices, including ventilators, hospital beds, and PPEs appeared grossly below the needs. Calls for the government to take action rose in unison by the political crowd. “We need more!” Yet in a mere period of 2 weeks, they needed less!

THE ECONOMIC DEBACLE

Meanwhile, the economic engine of the world, the economy of the United States was brought to a standstill by a select few individuals. The economy that produced $21 Trillion a year shut down. The US government was forced to pay the companies and individuals a total of $2.5 Trillion (at last count). The money was shepherded to keep the economic engine on life support and workers on the payroll. From an $80 billion loss for the Flu to a staggering $2.5 Trillion and counting loss for the COVID-19. But there were some dishonest and shameful politicians who wanted to secure a fiefdom by giving freebies to their constituents and wanted more. Together, the damage was done across the world and especially to the most productive nation on the globe. But the experts were not done yet. They promised that this virus was going to be rearing its ugly head annually, (contrary to known information that this particular RNA virus’s virulence via the spike was immutable and that a potential vaccine would mitigate that risk entirely), therefore we must get used to “social distancing” as a way of life and just to add fuel to their rhetoric they advocated the need for “Contact Tracing” as a means to contain the spread. The fix was in and the population could be controlled easily under the guise of “public good.” Meanwhile, the technocrats at Google, Facebook, Apple, and others were busy working overtime to make this happen. These technocrats already know what your next desire is, why not know where you are or where you are going to be every second of the day. 

Liberty seems to be on a ventilator these days.

But getting back to the illness-related loss of human life from the COVID19, seemed to mimic that of the annual Influenza but the death rate was higher by a factor of 6-10 of an average Flu season but similar to a highly evolved Flu virus with a larger antigenic drift. The Economic loss however as a consequence of the shutdown is and will be astronomical. It might contract the greatest economy into a Recession. The experts continue their rant to keep everything shut down. One such “expert” wants the shut-down to last for 18 months. Perhaps these fanatics believe their rhetoric, perhaps their need for self-importance exceeds their capacity to understand or tell the truth, but there is a willingness to obfuscate reality in the United States equal to that what happened in China. Only in the US that obfuscation comes from biased modeling, fear-mongering, while in China it comes from Authoritarianism and Control. An important study  from John Ionnadis, MD., “People less than 65 years old have very small risks of COVID-19 death even in the hotbeds of the pandemic and deaths for people less than 65 years without underlying predisposing conditions are remarkably uncommon. Strategies focusing specifically on protecting high-risk elderly individuals should be considered in managing the pandemic.” The study suggests that selective high-risk group distancing is the more appropriate measure.

Meanwhile, did I mention that the “Wet Market” where supposedly the virus originated is now open for business? The previously safety-breached Wuhan Level IV Biosafety Lab (the other possible source) remains shut down for the present as far as the world knows.

WHAT IS THE VIRUS TO DO?

All of this begs the question, “What is this virus going to do?” In answer, one can only say with the most humility that it will do what viruses do. It will infect humans as many as it can to propagate itself. When a certain number are infected and attain a degree of immunity to it, one of three things will happen: 

1. The Selection pressures from the immunity will slow the virus down both as the temperature rises and people start to stay outdoors with pockets of infection scattered intermittently. 

2. The virus mutates, and that antigenic drift creates a more benign version that behaves like the common flu. 

3. The virus mutates with a significant drift that creates another monster. 

The current Social Distancing has had an impact. Perhaps only selective distancing measures for the vulnerable with comorbidities going forward might be appropriate and not the entire country. The economy needs to rev up again so a further loss of life from starvation, depression, and suicide does not engulf us in the future. 

Vaccine innovation against the COVID19 is in full bloom( 13). Meanwhile, mitigation strategies including the cheapest therapeutic version of Hydroxychloroquine and Azithromycin plus Zinc are being used with some success, but simultaneously being derided by the experts. Newer drugs probably at much higher prices are being touted as potentials, including Remdesivir (anti-viral agent) and EIDD-2801 as a prophylactic. Time exposes everything from the antisepsis of the sun. 

This time too, it will tell a tale, worthy to learn from.

 References:

1. Estimates of deaths associated with seasonal influenza—the United States, 1976–2007. Morb Mortal Wkly Rep. 2010;59:1057–1062. 

2. Girard MP, Cherian T, Pervikov Y, Kieny MP. A review of vaccine research and development: Human acute respiratory infections. Vaccine. 2005;23:5708–5724. 

3. Lambert LC, Fauci AS. Influenza vaccines for the future. N Engl J Med. 2010;363:2036–2044

4. Simonsen L, Clarke MJ, Williamson GD, et al. Impact of influenza epidemics on mortality: introducing a severity index. Am J Public Health. 1997;87:1944–1950. [

5. Simonsen L, Fukuda K, Schonberger LB, Cox NJ. Impact of influenza epidemics on hospitalizations. J Infect Dis. 2000;181:831–837. 

6. Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA. 2004;292:1333–1340. 

7. Centers for Disease Control and Prevention (CDC) In: Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th ed. Atkinson W, Wolfe S, Hamborsky J, editors. Washington, D.C.: Public Health Foundation; 2011. Available at:  www.cdc.gov/vaccines/pubs/pinkbook/downloads/table-of-contents.pdf. 

8. Keech M, Scott AJ, Ryan PJJ. The impact of influenza and influenza-like illness on productivity and healthcare resource utilization in a working population. Occup Med. 1998;48:85–90. 

9. Simonsen L, Clarke MJ, Schonberger LB, et al. Pandemic versus epidemic influenza mortality: A pattern of changing age distribution. J Infect Dis. 1998;178:53–60. 

10. Szucs T. The socio-economic burden of influenza. J Antimicrob Chemother. 1999;44:11–15. 

11. Kochanek KD, Xu J, Murphy SL, et al. Deaths: Preliminary data for 2009. Natl Vital Stat Rep. 2011;59:1–69. 

12. Molinari NAM, Ortega-Sanchez IR, Messonnier ML, et al. The annual impact of seasonal influenza in the U.S.: Measuring disease burden and costs. Vaccine. 2007;25:5086–5096. [

13. Wang CS, Wang ST, Lai CT, et al. Impact of influenza vaccination on major cause-specific mortality. Vaccine. 2007;25:1196–1203

PHYSICIANS FIGHT AGAINST CORONAVIRUS

Physicians are a sturdy lot. They come in all shapes and sizes, yet they all have a common goal; to find means to heal and comfort the sick. Ask any doctor, in an Emergency Room filled with patients; where some are crying in agony, others are gasping for air and still, others are infirmed into total silence. These physicians never let the trauma of life and living alter their sense of being. One by one, each is given the remedy he or she seeks and while most withdraw to their homes in comfort, some remain under the vigil of others within the walls of the hospitals till recovery. It is not only the ER doctors but most, in all different specialties who carry the same burden. Ask a bleary-eyed surgeon awakened in the middle of darkness, with adrenaline coursing through his veins, while he rushes to suture a gaping wound, an aorta, or a ruptured viscus all without a peep of self-doubt or self-pity. Or ask a family physician who sees a patient in the fit of a coughing spell calmly administer relief without a pat on the back. No, physicians by their very nature are destined to quietly move through society and life, bearing the burdens without calling attention to the burden itself or to themselves. 

If further proof was needed, look at the 136 physicians who have quietly given up their lives in the wake of this Coronavirus pandemic. Called to arms, they, the physicians, have gathered up their collective selves and hurled into the maelstrom with both feet. Like wilted twigs of winter turning into the stout blossoms of spring, physicians are by their very nature blossoms of humanity for all seasons. Quick on the learning, even quicker on the healing.

Their wisdom is derived from past leaders in medicine. When their science is carefully cogitated with their experiential references, voila a bouquet of therapeutic offerings emerges! Looking back at history, several notables took their cue from the human interaction with nature itself. Look for instance at Edward Jenner, after observing the benefit of cowpox stemming the risk of smallpox, he ventured into a trial vaccination of an 8-year-old boy delivering immunity to the child in Gloucester in 1757. He might have been vilified in this day and age for not doing a randomized controlled trial, but he manifestly saved millions of lives from the disabling and deadly disease. Another stalwart who lived in the same venous tributary of a thinker and doer named Barry Marshall. After many attempts to educate his fellow experts about the cause of peptic ulcers as not emanating from too much acid in the stomach but from a bacterium named Helicobacter Pylori, he failed to gain their support. He was ignored, then laughed at and finally given the gravity of his findings he had to drink a glass full of the H Pylori and develop an ulcer to prove his findings when organized medical science was forced to take notice of the causal nature of the disease.  He did receive the Nobel Prize for his findings eventually. 

Deep in our most convincing organ called intuition, there are many valves and levers of balance. The valves open to input from nature, from observations and the levers of balance, are the risks and benefits of using those observations as therapy. Doctors have long deployed this intuitive-complex, in their armamentarium to ascertain the best possible therapy for their patients. But over time a steady stream of complexity has overshadowed this modus operandi. The complexity craves for unending and at times valueless research that does little to advance the hypothesis but only to prove at the outset what was envisioned. We have come to a time where even large meta-studies are filled with the bias of the offering author. In the field of Oncology alone, for instance, data from one meta-analytic study revealed that only 11% of the “Landmark” studies were reproducible, verifiable or could be validated. That in itself is a damnable smudge on the progress of scientific evidence. But having said that, not all scientific data is reproachable. There are valid reasons to conduct studies in an organized manner so as to prove the benefit and lack of harm to the patient. That rigor, however, takes time. 

In the time of such panic when lives are being lost as now while facing a pandemic, the automatic response of RCT (Randomized Control Trial) as the only form of control to the use of potentially life-saving medication must need to withdraw. Even Anecdotal data that may reduce illness or thwart the disease from gaining a foothold and claiming more lives should be considered as an intuitive reason to forgo the strict complexity and delay of published “evidence.” If physicians in the battlefield against the pandemic are seeing the benefit and perhaps even through the colored lenses of their viewpoint, it is imperative that hurdles not be placed in their decisions. They are the frontline soldiers, not the commanders in a tent 100 miles behind. They see the ugliness of the fight; lives won and lost daily, while the commanders plot in the distant background. The wars are never won if the soldiers and their battalion leaders are forced to take a course of action that negates their intuition of the ebb and flow of the nature of the incoming fire. 

Hydroxychloroquine is a classic example of this new(old) potential armor against the current COVID19 pandemic. Several small “anecdotal” studies seem to validate the findings of this drug in conjunction with Azithromycin and possibly Zinc as having an influence on attenuating the course of this COVID19 induced illness within a human body. The data is mostly gathered in observational form and lacks the RCT of this vs. that to fit the Kaplan Meier curves. But this limited data even when viewed through rose-colored glasses suggest a potential benefit to some. When one adds the past common literature, which is found in abundance, that these drugs by themselves have few side effects, the common-sense test would be to use it in the earlier cases where the pulmonary cytokine storm has not yet overwhelmed the patient. Using it in late stages where the body’s immune surveillance has been overwhelmed, would be counterproductive and again looking to confirm biased belief. If Hydroxychloroquine (HCQ) can thwart the entry of the virus into the cell and within the cytoplasm, reduce the pH and prevent entry into the endoplasmic reticulum to prevent the replication of the virus based on basic scientific data, then it must be given the go-ahead as a treatment choice, especially when nothing else is available. Waiting for Godot is a fool’s paradise as is waiting for the results of a placebo-controlled trial. Waiting is not a wartime battlefield strategy given the urgency of the need. That these drugs are effective against COVID-19 has been proven in laboratory experiments. And now evidence is mounting that these drugs are working to decrease viral load in patients . Decreased viral loads mean patients not only avoid the hospital but are less infectious to others. This will decrease the burden on the healthcare system and upon the doctors and nurses that bear the ultimate responsibility of the patient’s care. In fact, India is officially considering health care professionals and family members of sick patients prophylactically take HCQ. The New York Times reports of a recent study: “Cough, fever, and pneumonia went away faster, and the disease seemed less likely to turn severe in people who received hydroxychloroquine than in a comparison group not given the drug.” More recently a Randomized Trial shows similar benefits as well.

Certain State Officials in various States have been misled into thinking that using HCQ + Azithromycin is removing the HCQ from the stockpiles needed to treat Malaria, Lupus or Rheumatoid Arthritis. For one, Malaria does not exist in the US, for another, the numbers of RA and Lupus patients do not require millions of doses that are already stockpiled. Officials should understand the urgent need of the patient and not the fancy of the stockpiled biases that exist when considering policies. For instance, the New Jersey Governor has placed a restriction on the use of HCQ, which is unfortunate. It bears on the thinking that perhaps using these relatively non-toxic medications by the physicians, nurses and first responders as a precaution just might prevent the loss of these front-line soldiers also. Empty virtue signaling of “for the public good,” while placing unnecessary constraints leads to harm and loss of life for both patients, their physicians, and nurses. As mentioned above, early treatment is crucial for keeping patients out of the hospital and off ventilators. Delaying treatment results in the opposite, more sick patients ending up in overburdened facilities. Besides, other State Governors of Nevada and Michigan, who formulated similar mechanisms of restrictions to the use of Hydroxychloroquine quickly reversed course, when seeing the burgeoning loss of life. If the restriction is to prevent hoarding of the medication, then perhaps using the Texas model of limiting the drug dosing for 10 days might be more appropriate. It prevents harm to our vulnerable, sick and infirmed patients and potential loss of life. 

In keeping with the oath of Hippocrates and in keeping with the welfare of our patients foremost, we physicians must not have arbitrary and capricious hurdles placed in front of us while treating and managing the patients who are struggling to gain a foothold on their lives against the Coronavirus. It is time to unshackle the constraints and allow physicians to heal the sick as they are trained to do.