I want to cover my eyes and ears for the media and political shit show that's going to come from this. It's true that a certain politician shouldn't be trumpeting unproven treatments, but the media seemed to celebrate when that politician was "proven" wrong. Did we forget that we should all be rooting for treatments to work?
I hoped during this pandemic science would move fast and sacrifice some accuracy for speed. But I didn't expect (a seemingly) complete fabrication could go so far with so many eyes. Now I worry the overreaction toward accuracy-over-speed will cause significant slowdowns in published data.
We shouldn't over-punish honest mistakes when we value speed over accuracy... but this just feels awful. Would think prison is likely to come.
A good read: http://freerangestats.info/blog/2020/05/30/implausible-healt...
Similarly, the complete disregard by the medical community of playing their role in reminding others organizing protests to take steps to prevent participants from spreading the virus has been equally disturbing. I've heard literally nothing from the medical community about tips, methods, or instructions for ensuring protestors do not cause a new outbreak. There does not seem to be any innovation happening in helping people organize and protest while keeping social distancing in mind. I don't know what that would look like, but it's a moral failure that the problem hasn't been worked whatsoever. I haven't even heard stories of people just handing out masks. Things are quite dire.
I think this is a typical example of the medical community's method of communicating with the public - until they've studied something to death, they're too afraid to say anything, and if pressed, will just tell you to keep doing what you're doing, even if emerging evidence to the contrary and widespread anecdotal counter-examples are starting to surface.
Think about the whole mask fiasco at the beginning of this mess. The CDC actually told Americans that wearing masks might make them more likely to get the virus, despite masks being an effective preventive measure against all other known respiratory viruses to my knowledge, plus the widespread usage of masks by literally billions of people in Asia is a pretty good indicator that it can be done safely.
During "normal" times, this general approach may be 100% right, you need to be very sure you understand even low-incidence side effects before you tell 8 billion people what is good for them and what isn't. But that's simply the wrong approach in the face of a fast-moving pandemic - you need to be able to do basic risk/reward analysis quickly and recommend the path that is most likely to work, even if you're not 100% sure, and you're operating on some educated guesses in the absence of hard data.
Basically, they need to operate more like engineers and less like doctors, at least for a little while =)
Yeah, or they just say stuff anyway. Yesterday Slate reported  that a large body of the experts (I refrain from scare quotes, but they seem apropos these days) are saying the protests take priority over the public health emergency.
Last month when people were protesting the shutdown itself I recall the predominant response was that protestors were violating social distancing protocols, endangering public safety, and should desist.
For people that are against the shutdown, this reaffirms the purely political nature of the policy.
> For people that are against the shutdown, this reaffirms the purely political nature of the policy
What does that mean? What is the nature of the policy and how is it purely political?
(Obviously any policy is political, because it's a choice effecting the population)
It's clear by now that many of the so-called "experts" are ideologically driven. For instance the highly influential Professor Ferguson told governments around the world they needed drastic lockdowns, which he then repeatedly violated himself to sleep with his left-wing activist girlfriend.
One of the other 50 "experts" in the UK government's advisory group (SAGE) is not only a left-wing political activist who made huge donations to Labour but is actually a life long member of the Communist Party. That's totally absurd given the tiny membership it has, but somehow the government managed to recruit a literal communist to make policy.
Lockdowns have been designed by these people and are a nearly pure implementation of hard-left policies, of the sort normally only found in communist states. Censorship is rife, a pass is required to go outside, protest is banned, the private sector is being destroyed. Maybe it shouldn't be a big surprise when you look at who's been coming up with them.
Any scientist can tell you that it's hard to keep up with the literature, and it's very likely that many of them spoke out against make without reading the papers. I was taught as an undergrad that they don't work. Many of these things are passed down uncritically.
This issue demonstrates that we need to improve science communication. Many scientists and public health professionals declared outright that make don't work. This shows that they are either unfamiliarity with the totality of the literature or that they feel the need to give definitive statements. When some people provided evidence in favour of masks, some of them switched to saying that make are needed by medical professionals and that improper usage can increase your risk. A better approach would be to acknowledge that there is uncertainty at that in their view the evidence against masks outweighs that in favour. If they took this approach, it wouldn't seem like they just flip flopped when they started recommending make. Also, it's not hard to train people to use them, and condescending to treat people as being too stupid to wear them.
Given the risk/reward, and the high stakes nature of what we were about to go through, stating "no comment" on masks was pants-on-head stupid, because when medical folks say "there is no evidence to support" the press inevitably spins it to mean "this doesn't work." It highlights just how behind the medical field is when it comes to understanding how to incorporate human psychology, risk management, and other areas mastered by other industries to minimize harm.
I mean I agree that science community should consider some aspects of communication, but every participant in this chain should act responsibly.
Once we put the blame squarly on the scientists, we absolve the actual bad actors.
With the situation you describe above, the fault is with the press for not doing due diligence. Not with the scientists telling the facts.
- It is truly agonizing that one must choose between civil disobedience and protecting the health of your loved ones, but that is a choice we are now all forced to make.
- Large public gatherings, even if outdoors, have heightened risk of transmission, especially if people are gathered together closely as they are certain to be at most protests.
- As such, the risk of contracting COVID-19 is high at protests, if the disease is present in the local population. Here is data to help you decide if that is the case for your local area: XXXX
- To understand the risks involved, based upon your own circumstances, here is data on the mortality and other health risks to those who you may transmit the disease to: XXX. If you choose to protest, consider adjusting other factors to minimize your exposure to these individuals. If you cannot, try to find ways to participate in the protest that minimize your own risk of becoming a vector. Or, if possible, quarantine your self for at least 7 days or at most 14 days from friends and family members who are at the highest risk.
Of course, stuff like this hasn't been written, and it takes not being paranoid of being labelled as not supporting the protests to write it. It should be culturally acceptable to say clearly and without risk that if you see your actions as a potential risk of killing your relatives, perhaps the right choice is in fact to participate in the protests without physically gathering. Given this message was not shared, we are basically relying for the most part on luck and on-site countermeasures, vs people choosing to not go, since the response so far implies that is not a moral choice to make.
I'd say you should ask somebody who lived during the AIDS epidemic denial years of the early–mid '80s, but most of them are no longer with us for some reason.
There are two worst case scenarios here - Firstly, politicians pushing unproven drugs on the general population, causing unnecessary deaths. Secondly, treatments which may have some efficacy being abandoned because of a reaction against those politicians, potentially causing a failure to bring an effective treatment to bear.
Both of these can be true at the same time.
Where you personally draw the line between "authority figure spouting off about something in official capacity" and "pushing" is up to you, but it's hardly delusional. It's also a hypothetical worst case scenario, if you read what I actually wrote.
It's "unproven" as a treatment for COVID but pascal's wager would say that there is no harm in taking it.
That's nonsense, plenty of approved medicines have pretty crazy side effects, and can do more harm than good if taken when they aren't needed.
Pascal's wager, about the existence of god, is also incorrect FYI. It posits that you should believe in god because you have nothing to lose. Amongst other criticisms it fails to take account of the negatives of adhering to a belief system, and it fails to take account of the possibility of choosing the wrong god(s).
Looking at some of the specifics, these don't look like "honest" mistakes, and I'm doubting any integrity on the part of the peer reviewers and the Lancet too with how blatantly false some of their data are. It doesn't even pass the smell test:
I don't think you can blame the media here.
They reported on extremely important and relevant scientific research that was credible by any kind of reasonable journalistic standard. How could they have done otherwise?
Contrasting the research claims against the claims of "a certain politician" would be a natural and necessary part of that.
Some commentators went too far -- some always do, often the same ones -- but the failing here wasn't generally the media.
> Did we forget that we should all be rooting for treatments to work?
I don't think that's being forgotten that outside the lunatic fringe. Notice that this story is getting wide coverage, just like the coverage of the original finding.
The issue of bring Trump into this is tougher. I'm not an American, and don't follow his speeches. I've seen many articles start out with "the drug that Trump irresponsibly hyped up has been proven not to work". To me, it feels like Trump is their main focus instead of the science. Now, if Trump has repeatedly hyped this drug I think that it would be reasonable. Is that the case, or is it the case that the media continue to bring up something he said weeks ago?
Trump pointed to doctors publishing reports of how they were using it in China and Korea, amongst others. That regimen, incidentally, seemed to involve a loading dose, followed by about five days, taken in conjunction with azithromycin and zinc. Innocuous, except for extreme edge cases (source: I took HCQ for years and am overly familiar with its health risks, zpacks and zinc speak for themselves). It was suspected (confirmed, I think) that he ended up taking this regimen himself.
Trump may also have known then (as do any of you smart folk) that the odds of a working vaccine for any coronavirus are long, to be generous. So antiviral treatments become pretty important when you know there's probably no vaccine coming. 
He also called in a favor to Modi when India (HCQ's primary producer) put a hold on all exports of the drug, and got millions of doses shipped to the US.
So the media treated this recurring talking point as him irresponsibly endorsing the drug and stories started coming out to make it a "gotcha" moment, including the ludicrous story of a retired engineer who drank pool cleaner containing chloroquine phospate, implying he did so only because of Trump's "endorsement" . Further, any story of a retroactive analysis showing inefficacy of HCQ or better - health risks - got an inordinate amount of coverage (inordinate, considering such studies were no better than the evidence promoting it, or made claims of unrealistic health risks).
If you didn't watch the source material of Trump's statements, but relied on new reports, you'd be forgiven for thinking that he has been giving medical treatment advice this whole time and causing deaths from people drinking clorox. It stands to reason, though, that the same sources that pushed Russiagate  for years may not be the best authorities on what Trump has or has not said.
People ask the question "how can I use this to help me politically?" versus "how can this help fight the epidemic?".
There is, to say it mildly, a bit of controversy about them in the academic world.
But we should still make sure these behaviors are not rewarded. Science was right when they called against "Pandemic Research Exceptionalism". I think at this point in time, where available knowledge has increased a little, we can afford to be stricter than before.
It’s really frustrating that the theorized mechanism of HCQ effectiveness as a prophylactic is its ability to transport zinc across cell walls (zinc interrupts the viral RNA replication), yet these trials don’t include zinc supplements.
Check the supplementary data. There were confounding factors, but a group of patients took zinc, and there is no difference between the two groups.
Bear in mind that this study has no say on the use as a treatment.
Sorry for my language.
I have a feeling that choice of words was deliberate. ;-)
We're hoping for _a_ treatment to work. Trump's motivations were largely self-interest, financial investments and other.
We didn't celebrate because Trump was wrong. There was skepticism about the treatment, but he (not a physician) was up there pimping it. Even he didn't necessarily believe it was the cure. For all he said that, he said "Hey, take it anyway, why not? Can't hurt!" (when indeed it can). Finally came conclusive evidence that "You are wrong. Be quiet." Though Trump being Trump, that didn't overly work.
It's no different to "Pharma Bro" Martin Shkreli, who once lodged an appeal / protest against a drug being approved...
Not because it was dangerous. Or less effective. Or more expensive.
No, in fact it was safer than treatments out there. And more effective. And cheaper.
And all those reasons meant he opposed it. Because it wasn't _his_ drug. People who say "Big Pharma is holding the cure to cancer", etc., all those conspiracy theories? Shkreli literally opposed a better drug because it would cost him and his company profits.
He has three trusts who have holdings in Sanofi, the manufacturer. For one of the trusts, Sanofi is the single largest holding.
> a generic $0.04 drug.
Not sure where you're getting that. GoodRx: "The lowest GoodRx price for the most common version of hydroxychloroquine is around $14.95, 91% off the average retail price of $174.01." https://www.drugs.com/price-guide/hydroxychloroquine has it at around $0.63-$0.80 per dose.
It's also 5 doses of that drug dose per person per 48 hours. The standard dosing regime is 14 days. Seven million confirmed cases and we're in the realm of $200M. Prophylactic dosing is the same, for how many millions of people, and now we're talking a lot of money and a lot of financial interest.
It's the same with people that were applauding healthcare workers but now have no issues with protesters that don't take any COVID measures.
It's terrible that health is politicized, it should be above all parties.
I also have a bit of an issue with your statement about Trump's motivations.
Just these presumptions are why some people didn't want the medicine to work, while in reality we can all only just guess about his motivations.
I also think you are trying to say there is some inconsistency between applauding health workers for doing necessary work that put them in danger of catching and spreading covid, and applauding protesters for doing necessary work that put them in (much less) danger of catching and spreading covid?
Three of Trump's personal trusts have investments in Sanofi, the manufacturer of HCQ. In fact, in one of the trusts, Sanofi is the largest holding. So I don't think it's entirely unwarranted to question motivations.
Celebrating someone being wrong is, agreed, wrong.
The words of this certain politician have a lot of weight and probably caused a lot of attention to be diverted from real research into looking into this. We can’t chase every crackpot theory only because it’s coming from somebody powerful.
We still have no idea whether hydroxychloroquine works or not for COVID19. And the hype is rather harmful and misleading as even if it did work, it is exceedingly unlikely to be a game changer but a small incremental improvement.
This is also certainly a failure of peer review. Though that has always been rather weak for cases of outright fraud and scientific misconduct, it still relies on the researchers to be honest about the data they represent.
The most infuriating offenders are the media, who have been irresponsible with the presentation of clinical study results. They'll take the results of an observational study and herald it as some revolutionary insight, when in reality the doctors, nurses, and pharmacists interpreting these results are saying "hmm okay, well let's be cautious in our approach and wait for other studies to be done".
Clinical practice should never change, and has never changed (to my knowledge) from the whims of a single OBSERVATIONAL study. But outside medical circles, people will see the results they want to see, and never look past the first 10 words of a headline.
That's been going on for a while, it reminds me of this: https://kill-or-cure.herokuapp.com/
Epidemiologists appear to frequently take un-reviewed, un-published papers straight to the press and politicians specifically to change government policy.
Actual doctors, not so much.
What's the difference between an expert in infectious diseases and an expert in treatment of infectious diseases, to the layman? Hardly any.
The media plays a part. Journalists routinely conflate doctors, academics and political activists under the rubric of "experts". Sometimes this is deliberate and overt. Guido Fawkes has had a long running campaign where they expose TV news presenting left-wing activists as neutral experts, without telling anyone about the interviewees backgrounds. As can be seen in this particular incident, that campaign has started to have a small effect, but some journalists don't like being exposed that way!
For people to get better at interpreting studies the first step must be to de-conflate different kinds of "expert". In particular academics need to be referred to as such and separated from the type of practical expert who practices their craft in the real world every day.
Don't we know to a first approximation that it doesn't work? This because it has been widely tried and there wasn't an "Awakenings" experience where the patients obviously got better. So if it works at all, it only does so at the margin. So hard to tell that it's necessary to gather a large statistical sample to know one way or the other.
I was trying to keep objective when writing that, there simply wasn't any really well-designed trial yet. Though from what I read just an hour ago or so there is a new trial that is said to be randomized and well-designed that hasn't found an effect, but I haven't looked beyond the headlines there yet.
As for the malaria drugs, these were not in routine use, at least not prior to the current epidemic. Moreover, recently Russia seems to place its bets on a Japanese broad-spectrum antiviral drug Favipiravir .
I wonder if we are heading for an AI winter soon. AI has been heavily hyped, but is having a lot of real world failures and is becoming associated with a bunch of fraud. At this time, I am less inclined and I believe a company if they invoke “AI” or “machine learning”.
Sure, businesses will still use machine learning for problems where it makes sense, but the hype of AI will die down and funding will dry up.
AI, specifically deep learning is far more than self driving cars. The industry is in its infancy and we are building ML solutions for a multitude of industries. You don't hear about any of it because none of it is sexy (or even accessable) to the layman - but rest assured, the industry is growing exponentially (like the research) and we are finding much more in the way of success than the high profile failures of self driving.
You only need one or 2-3 competiting Neuronal Networks for cancer detection and if you look how expensive it is to train that stuff, not many can actually do it anyway.
But what tripples down are pre learned networks you can easily reuse for your small use cases which are specific and have plenty of data and only need to outperform the existing solution.
This is just wrong. You can train a cancer discriminator on a low end gpu on your desktop. The hard part is getting quality [often annotated] data - and thats why data brokers like Google are positioned to dominate.
I don't mean running them, i mean training them.
There are a couple potential reasons. Powerful GPUs accelerate research and iteration. Some state of the art problems have hit the limits of current theory and make up the deficit by building massive nets - but even there we already have multiple automatic pruning/optimization algorithms to shrink those nets so that they work with smaller resources.
Make no mistake, the field is advancing exponentially. The state of the art googlenet/inception that arguably kicked off the whole craze with image recognition are laughably obsolete now and easily outperformed by simpler nets.
MNIST was the gold standard for recognition problems just a couple years ago, and now it's considered a solved toy problem.
"This study had some limitations. Mammograms were downsized to fit the available GPU (8 GB). As more GPU memory becomes available, future studies will be able to train models using larger image sizes, or retain the original image resolution without the need for downsizing. Retaining the full resolution of modern digital mammography images will provide finer details of the ROIs and likely improve performance." https://www.nature.com/articles/s41598-019-48995-4
Here they use a Nvidia V100 https://www.researchgate.net/publication/336339974_Deep_Neur...
Which yeah okay is more reasonable than i thought. But the advantage will still be at who ever has the hardware and thats just cheap for google.
You wouldn't need a market for models, you would just use whatever research delivers from whoever has the most accurate data & hardware.
Anyway, the larger point is that these established journals have failed us. Their added value, already low, has dropped below zero in this pandemic. They are slow, opaque, rent seeking parasitic entities seemingly run by individuals who don’t grasp basic statistics. The combination of preprint servers + twitter has proven far more effective in looking after humanity’s best interests.
The Lancet is one of the most impactful journals in medicine, and has played an important role in shaping how medicine is practiced. It is rigorous in its process, but it's not foolproof. So yes, there are some bad studies that come through, but that is why healthcare professionals are TRAINED to interpret studies--we separate all the bullshit from the legitimately useful stuff.
You should see some of the crap that comes through in some of the lower-impact journals.
> The combination of preprint servers + twitter has proven far more effective in looking after humanity’s best interests.
This view is incredibly false and dangerous for so many reasons.
Also, can we all stop describing any view or information as "dangerous"? It sounds like my mom, or religious people from the 80's.
False is one judgement and objectively proven.
"Dangerous" smacks of a censorious nature, which is subjective and, sorry, often based on a conflict of interest/agenda.
Encourage everyone to read Matt Taibbi's recent article about the recent rise of "virtuous" censorship as food for thought: https://taibbi.substack.com/p/temporary-coronavirus-censorsh...
So healthcare professionals are trained to separate the wheat from the chaff, but peer reviewers are not?
Thank goodness that "healthcare professionals are TRAINED to interpret studies."
Here's the thing - The Lancet is not impactful. Researchers choose to publish their impactful research in The Lancet. Other researchers donate their time to peer review this research. It is the researchers that have shaped how medicine is practiced, not The Lancet. It is the researchers and the peer reviewers that are rigorous. The Lancet itself is none of these things, it is a business run by people who don't do research. Without the people who actually do the work, or the patients that volunteer for the research, it is nothing. The Lancet, like all top tier journals, has long forgotten this distinction.
The problem isn't healthcare professionals lacking training. Take the Wakefield study. Did any doctor decide to stop offering vaccines because of that study? No. But it had a large impact on a the anti-vax narrative. These top journals have influence far beyond the professional sphere. This is why your suggestion we should give them a free pass is dangerous.
I think it is clearly true that rapid publication and out in the open discussion and peer review is very healthy. I don't see how you could argue otherwise? Why wouldn't I want to be able to read the opinion of someone I respect intellectually eg Andrew Gelman, on a study they have decided to comment on? How is that 'dangerous' if I am a healthcare professional who should be able to critically review a published paper as you suggest? Why do I need to rely on the reviewers the journal has chosen? The Journals want to keep things as they are to maintain their importance and their bottom line. We suffer as a result.
A major issue with this is the political and hierarchical benefits of publishing. It encourages professionals to focus on that, to the point that clinical work is now looked down upon and producing loads of shitty papers will propell you to the forefront of the academic star system and make you rich. It's truly cancer for our healthcare system.
There's no easy answer to which sources are reliable, but it helps to look at what reputable organizations say. They typically base their advice on the majority opinions of relevant experts. Scientists are human, so they are bound to make mistakes, but in the whole they have made demonstrable progress in a variety of fields.
As for what science lay people can rely on? I'm not sure there's a simple answer to that question.
That said, there are some good heuristics. Good scientists are able to show their reasoning process and explain why X is bad/good science. Bad ones handwave everything and push credentialism or rely on fallacious reasoning.
For example, I remember long ago when Ars Technica posted a detailed explanation of both what homeopathy is and how we know that it's completely bogus, why "water memory" doesn't and cannot exist, etc.
Meanwhile, in another failure of peer review, Nature published nonsense on "water memory" back in 1988:
Pre-print servers are great for getting results out quickly, but the level of quality control is extremely low. Journals are slower, but have a higher level of quality control.
There is a trade-off between speed and quality control, and both pre-print servers and journals sit at useful points in that trade-off.
Given the pressure to get information that might help fight CoVID-19 out quickly, journals have probably shifted towards the "quick/low-quality" end of the spectrum in the past few months. They'll move back when things calm down.
Preprints are not perfect, but I'd wager that anything free and truly open to review is better than what we have now.
The harm done by bad research in the Lancet is colossal because the results are widely read and disseminated, that is obvious isn't it? Pre-print servers are still quite obscure. Anyway, arxiv has been running for a long time with much success in certain fields, and hasn't been overwhelmed with nonsense, so your characterisation of pre-print servers is poorly calibrated and hyperbolic.
Also the Lancet charges money for its products, and can therefore expect to be held to greater account.
> arxiv has been running for a long time with much success in certain fields, and hasn't been overwhelmed with nonsense, your characterisation of pre-print servers is poorly calibrated and hyperbolic
I just said that the level of quality control on pre-print servers is extremely low - which it is. They check for very little beyond blatant plagiarism and obvious junk (determined within minutes).
I didn't say that pre-print servers are useless. They're very useful, but it's undeniable that prestigious journals apply an additional filter, which is much more exacting.
If you were to pick a random study from a pre-print server, and a random study from the Lancet, which do you think is more likely to be reliable? Which do you think has undergone more thorough peer-review?
Would you care to name some others?
In that case it's not really clear why you decide to stop reading the Lancet, rather than any other journal? Or have you stopped reading all journals
Filtering noise with noise?
It had 12 co-authors so that's a lot of peer review to start with, before whatever the Lancet applied.
“Here we are in the middle of a pandemic with hundreds of thousands of deaths, and the two most prestigious medical journals have failed us.”
There should be prison time if an investigation determines that this was done to increase certain drug sales.
See, if you can skewer HCQ, that means you get to take a shot at a certain politician too.
There were a number of researchers who criticized the study's structure and numbers from day 1. Over 100 researchers wrote an open letter about how skeptical they were.
I understand journals make mistakes, but this was egregious and smells like agenda to me.
It's probably more obvious how much he's been using this pandemic as a political thing from this side of the Atlantic, since that's where his energy has mostly been focused.
How can you criticize the editor's behavior here? Would you rather he remain silent while the US president lies about the Lancet?
"This is America?"
"It says something about the state of global political leadership that Gordon Brown must remind Presidents and Prime Ministers of their duties. The world needs international action now."
"Tony Fauci and Debbie Birx—You have to resign. You can’t lend your credibility to a President who is doing frightening violence to a system of international cooperation you have spent your lives working to protect and strengthen. Please resign now. Don’t support this President."
And, of course,
"Whatever one’s views about this government, public trust is essential for public health. Was protecting Dominic Cummings really worth it?"
Public trust is essential for public health, indeed.
Most of the opinions (with the exception of the tweet from two days ago) are about health policy. It makes sense that the editor of The Lancet is upset about Trump's attempt to wreck the WHO, for example. If the editor of The Lancet can't speak up about that, what can they speak up about?
For clarity, and I'm sure you agree: Trump's boosting of this drug as a "miracle" and "greatest breakthrough" was absolutely irresponsible even if the drug actually works, for the simple reason that we didn't know if it did (frankly we still don't), and that it is known to have significant risks (it still does, even usingly only baseline data and ignoring this study).
This was a bad study. It's possible that the editors at the Lancet hate Trump. But... you're simply reading too much here. Bad science gets published all the time. In particular, bad science gets published in circumstances like we have now where there is desperate need for "fast science".
Not everything has to be an "agenda" by global elites to damage your favorite politician.
But even granting your framing: why are you so concerned about the Lancet boosting bad data as an "agenda" but not with Trump doing exactly the same thing, with even less evidence? Why is it an "agenda" only when your enemies do it?
Also would take issue with "significant risks". HCQ, especially in the temporary loading dose being used in COVID cases, is largely, largely, largely benign except for edge case patients. I do remember Trump saying multiple times in the briefings that people shouldn't take the drug without their doctor's prescription. Presumably prescriptions being given out to people in the edge case risk category would have their doctors to blame, not Trump.
I'm all for calling out shaky medical advice, but the dangers of HCQ being published in the media were overblown, especially considering the context of a pandemic. To pretend otherwise is just rhetoric. Like with autoimmune diseases, the doctors say that while there's risk from long term use of HCQ over a certain daily dosage, considering it may prevent you from dying via organ failure, the narrow and reducible risk is worth the payoff. If you're dying of COVID and a doctor decides it's your best chance, you're not going to give a shit about long-term usage risks, and let's presume your doctor will weigh short term risks accordingly.
We should hold science to a higher standard. Politicians lie all the time, and exaggerate all the time.
Just because Trump does a thing that is despicable doesn't mean we give everyone else a pass too.
I could go on, but I think you get the idea -- literally everything you wrote can be flipped right around, which is why you need to consider whether or not your own sleeve is maybe a little decorated.
Seriously: I agree with you. I'm pointing out, however, that you're jumping in to claim "bias" by the "media" in a context where the "other side" very clearly already had blood on its hands over the same issue. And treating one side and not the other is helping no one.
Umm.... right here...
"It's possible that the editors at the Lancet hate Trump. But... you're simply reading too much here. Bad science gets published all the time. In particular, bad science gets published in circumstances like we have now where there is desperate need for 'fast science'"
Not everyone who objects to frauds being used to bring down Trump likes Trump. Some people are very, very upset about how things like this hand him easy, unambiguous wins, and make it seem as if he can be trusted to the same degree as nominally legitimate sources of information. Also, whatever extent that those institutions compromised their own processes in the name of these attacks, for what other interests are their processes compromised?
Should we just trust these institutions because they've been labeled "trustworthy" or instead turn our trust to institutions whose processes are more transparent, responsive, and formally isolated from outside interests?
edit: It's important to note that this means that a majority of Americans will never believe that this drug is not a legitimate treatment for the virus, no matter what further studies say. That's an abject failure for the scientific establishment, and a victory for the anti-vaxxers of the world.
I don't think that's true at all, and I'll be the first to say it:
I don't think there's any good evidence for HCQ at all, I think it's junk science, I don't believe a word about it that comes from this administration or anywhere in the right wing media. It's all pure spin to cover for some outrageously irresponsible rhetoric.
But show me a real, controlled study with significant results, and I'll recommend this drug to everyone who needs it.
But you have to show the data. And that means, yes, sometimes you discover you've published bad data and have to correct it. THAT is what science is about, not proving the absence of political bias.
Are you sure about that? I was sure about that ("there's no way Trump can win") last election, and I was utterly wrong.
As far as his chances of winning - I personally did see had a fair shot in 2016, because the issues he was talking about mattered to a lot of people that had been disempowered over the past 8 years. I personally believe in LGBT rights, but it was obvious that there was going to be a horrid backlash from the gloating of projecting a rainbow on the White House. But since being elected Trump has addressed very little of what he campaigned on - the swamp has been further packed, and he's basically golfing and shitposting instead of leading. At this point he's coasting on favorable propaganda from Faux news, and the middle of the country will have that illusion shattered as we blow past 200k deaths.
Typical flu seasons: https://www.cdc.gov/nchs/data/health_policy/influenza-and-pn...
Covid-19 death counts as of ~2 weeks ago: https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm
In the US, three times as many people have already died of CoVID-19 as die from influenza in a normal year.
The number of deaths from CoVID-19 continues to rise, and nobody knows what number it will eventually reach. With a 0.5% mortality rate and an R0 of 2.5, the expected death toll (before herd immunity is reached) would be ~1 million people in the US, or the equivalent of 30 years of influenza deaths.
Competing on-patent drugs, like Remdesivir, would make someone a great deal of money if they work better than HCQ.
What if it was "just" done to dunk on Trump after he touted the drug? The media sure did love the narrative that his favorite drug might be killing people.
This study always smelled bad. The media was so quick to champion it everywhere though. Why might that be I wonder? Where are the retractions now? The whole thing is disgusting.
The media in the US is doing everyone a disservice. Because of this less people are going to believe "science" and more people are going to just retreat to their echo chambers and believe whatever they want. I know I'm not going to trust the Lancet or the NEJM ever again. It's all political now.
What a mess.
COVID patients are different from the patients that normally receive chloroquine and the chloroquine doses used for COVID are also higher. There is also the issue of how chloroquine interacts with other drugs such as azythromycin.
This particular study has its problems but other studies on chloroquine were also starting to suggest that chloroquine could have dangerous side effects.
Aspirin is one of the most widely used drugs and generally considered safe. But you should never give it to a kid with chickenpox, because doing so is a risk factor for developing Reye's Syndrome, a serious and potentially fatal disease.
It's not that aspirin "becomes more dangerous" in general, but it is more dangerous for those particular patients. And we don't really know why, either; but the data is clear on the correlation.
We don't yet know all the ways that the novel coronavirus makes people sick. Heck we don't even have a reliable inventory of possible symptoms yet.
So it's really not fair to pretend that it would be silly or unreasonable to suspect the possibility of some sort of negative correlation with a particular drug or class of drugs. This sort of thing happens all the time in medicine.
This is a dangerous view and not a fair take. Drugs CAN become more dangerous when used in a different context. The sheer permutation of prior/current medical conditions, interacting drugs, demographics, genetics, medical procedures, and a bunch of other factors all play into the equation that determines a drug's safety and efficacy profile. This is why we continue to do research. This is why guidelines are constantly shifting. This is why medicine requires years of study.
> The media was so quick to champion it everywhere though.
I definitely agree with this point. The media has caused harm to the population by taking the results of a single observational study, and parading it around like it was some new concrete medical certainty. This is not how professionals operate. We don't flip our practice on the whims of a single OBSERVATIONAL study.
And I emphasize OBSERVATIONAL because most people here don't understand what that entails. Most people here who comment on clinical trials are not even trained to interpret them. Is it randomized/non-randomized? Double-blinded? What did data collection look like? How were results analyzed? What was the patient population? Timelines? Control arm? Placebos? Previous findings? Primary/secondary endpoint? Do you know the difference between a meta-analysis and a systematic review? NNT? Hazards ratios? Odds ratios?
Too many people outside of medicine think they know how to interpret a study, when in reality they have no idea what they're looking at and cherry-pick the interesting sentences that they're looking for.
> I know I'm not going to trust the Lancet or the NEJM ever again.
This is not a fair take. The journals are responsible for reviewing and publishing the most influential clinical research in the world. Occasionally a bad study makes its way in due to falsified data or other illegitimate factors. Health care professionals are well-aware of this, which is why we are trained to interpret studies, and be conservative in the face of radical findings like this.
If anyone has a problem with the Lancet or NEJM, they should see some of the mess found in lower-impact journals.
The lesson I learned is that I will always scrutinize papers I read with a more critical eye, regardless of where they were published in.
a) a grammar/spelling check
b) a gut check to make sure it "makes sense"
c) validation of the math/analysis
d) validation of the underlying experimental procedure used to collect the data
e) validation of the underlying selection criteria for inputs/candidates in the experiment
f) reproducibility of the experiment and results
g) something else?
h) all of the above
My impression is that "peer review" generally includes a & b and sometimes c & d.
The fact that the lancet was able to determine that there were validity concerns with the data and issue an expression of concern in less than 2 weeks is proof that the system works.
Science is never 100% certain. The media has never been a good source of scientific information and probably never will be.
edit: also, if you "don't trust the Lancet or NEJM" then you don't trust a huge number of the treatments available to you at the hospital. These are two of the most important and eminent medical journals in the world and many life-saving treatments began as articles in these journals.
It is later when other scientists start working to replicate or expand on the study that they request access to the data, and dig into the details. This is when most instances of scientific misconduct are found, and this paper is no exception.
In science, publication is the start of the peer review process, not the end.
I was quite surprised at the newfound fatality. Given that it was the Lancet, I took it at face value. Their political biases made them overlook the sheer flimsiness of the study.
Rather than a mess, it is showing us the messy humans behind the veil of "science". There is no platonic scientist - just humans doing imperfect science.
Aspirin has a long track record and well understood safety profile, but it can still cause life threatening complications like Reye syndrome in certain viral infections.
He also quotes the CDC website saying it is quite safe.
> “CDC has no limits on the use of hydroxychloroquine for the prevention of malaria. When hydroxychloroquine is used at higher doses for many years, a rare eye condition called retinopathy has occurred. People who take hydroxychloroquine for more than five years should get regular eye exams.”
I guess this way at least they can point the responsibility somewhere else, and say it's not their fault.
On top of that, there is no patent money to be made by big pharmaceuticals on this drug. It makes me wonder where the funding really came from in this Lancet study.
The next fiasco-in-the-making to watch is the 'evidence-based' criminal justice reform sure to come to a lot more American cities soon.
You're throwing around an awful lot of poo. Nothing concrete at all but all in very emotive terms. Not constructive - but was that the point?
 (note scare quotes)
I’m all for being skeptical, but I think they went overboard, especially given the alternative of having no medicine.
When an existing drug is intended to treat some new disease it needs to be reevaluated for that disease again, because even if it can save lives for one disease it can be deadly for another.
So the fact that it is given to thousands or millions does not mean much in this context.
That's true. There are people who want to discredit science as a whole. Reality tends to get in the way of most hidden agendas - that's why they're hidden.
Because our president was idiotically and irresponsibly championing a drug for which there was no good evidence of efficacy at all.
This is an absurd reaction and I suspect you know it. There isn't a single scientific journal in the world not subject to some bias, trend, or failure of one form or another. To dismiss an entire platform because of an imperfect record amounts to an abdication of your own responsibility to form your own opinions about scientific matters. This is a responsibility for which journal reviewers can only ever take partial responsibility for both practical and intrinsic reasons.
Peer review is not a rubber stamp which blesses anything which passes through it as "TRUTH." It is a minimal standard and subject, at any rate, to all the uncertainties and biases implicit in any human endeavor. It is entirely possible this paper represents a political bias. Almost everything does. It still falls to us to make reasonable judgments about science. What doesn't make sense is to reject the entire process because it fails to meet some unreachable expectation of perfection.
Can you provide examples? I'm sure it'll be hard, if not impossible, to provide an example that's as emotionally satisfying as directly contradicting Trump, but I'd love to see which studies you're thinking of.
Don't forget, The Lancet is also the journal which published the paper that kicked off the anti-vax movement: https://en.wikipedia.org/wiki/Lancet_MMR_autism_fraud
> ACE2 can also be increased by thiazolidinediones and ibuprofen.
The closest thing I could find  to a source for that was :
> NSAIDs [Non-Steroidal Anti-inflammatory Drugs, which includes ibuprofen] might affect how Covid-19 binds to human cells, according to Dr. Yogen Kanthi, assistant professor of cardiology at the University of Michigan, who studies inflammation.
> “There is data from basic science studies that have shown that Covid-19 itself binds to a protein at the surface of cells called ACE2,” he said. “There is a hypothetical risk that giving NSAIDs like ibuprofen could increase levels of ACE2 shown in animal models, but not in patients.”
 - https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600...
 - https://kvia.com/health/2020/03/17/france-says-ibuprofen-may...
 - https://news.ycombinator.com/item?id=22611363
Why? They knew the data was fake when they published it, but they published it anyway to boost sales of Remdesivir.
They're literally trying to make money by killing people. If you wouldn't trust someone if you saw them run over someone else with their car, why would you trust Lancet?
Peer Review gone wrong -> https://www.youtube.com/watch?v=wLlA1w4OZWQ
Precisely the way trump himself behaves, but you don't point that out.
You illustrate my point by assuming that I'm supporting him, just because I'm not criticizing him.
So what you're saying is we should never fully trust these journals? We should always be skeptical?
That's what I'm saying too...
YES, you should be skeptical, but mostly not at the journal-level. You need to be skeptical at the article-level. That is why it's so important to be actually TRAINED to interpret the studies.
The abstract of a trial is like an "advertisement" for the study. You quickly scan it to see if the study is worth reading. If it is, you make multiple passes of the article, identifying biases, understanding the study context, calculating ratios and numbers, reading through the lens of your own practice, and a bunch of other things.
So yes, I'd argue that brand names are a big problem. You just have to see how proud people are when they are accepted in one of the major publication venues, and the prestige that results.
I think you are not being objective.
"No, the real scandal is that the respected medical journal Lancet aids and abets in poor research practices by serving as a kind of shield for the authors of a questionable paper, by acting as if secret pre-publication review has more validity than open post-publication review." 
HN isn’t the ideal venue for hyperbole.
One should always be skeptical of research and have dicsussions on the reported data and to what extent and in what context it makes sense. The media outlets summarizing the research papers very often fail to do that so as to skip the details and keep the readers happy because they assume "readers just want to know the superficial abstract knowledge, they can't possibly be interested in the critical analysis of the figures and the numbers so let's exclude that".
I think that exactly how good scientists proceed. This isn't my field, but my understanding is that research groups don't "fully trust" peer reviewed research, so they usually attempt to replicate the key results they plan to cite in their new research.
In fact, scientists often say, somewhat tongue-in-cheek, "It's published in Nature, so it's probably wrong" (the more revolutionary a result, the more likely it is to be wrong, but also the more likely it is to get into one of the top journals).
If your implication is that the media and the science community conspired to make the president look stupid, I think you've got a big hill to climb to prove that.
...and I think it's possible that's what we see here. An emotional decision to publish, and then no one wanted to contradict because no one wanted to be viewed as a Trump sympathizer.
This incident comes in the middle of the replication crisis, with 50%-70% of studies failing replication, including in the medical sciences field. Furthermore, many suspect that BigPharma pushes inconclusive garbage as peer reviewed science to promote commercial interests. Then there is the response to covid19, which, justified or not, some regard as catastrophic overreaction. The BigScience enterprise is in peril of losing public trust. Which is a terrible loss.
Lancet / NEJM editors failed. There are no excuses. The right course of action is to apologize, not to further antagonize the public. Try humility for a while.
Who can you trust these days?
First, there are some really good science reporters out there, doing excellent work. I recommend Ed Yong at the Atlantic, Helen Branswell of STAT News, Jon Cohen at Science, Amy Maxmen at Nature. There are others (it's a team effort and those are all great publications), but if you just read all of the articles under their bylines, you will get a good overview of what's going on. They will not let you down.
If you have a little bit more time and energy for this stuff (as I do), then there are many experts on Twitter who freely share their analysis, and among them are some excellent communicators. When controversial stuff comes out, you can get a good sense very quickly what the flaws are and what seems to be the consensus. If you want to dip your toes into these waters, I recommend Angela Rasmussen, Trevor Bedford, and Marc Lipsitch. For critical analysis of bullshit published by seemingly reputable academics, I highly recommend Carl Bergstrom (his takedowns are highly entertaining as well as informative).
It's frustrating for me to see such pearls of knowledge and expertise so freely available, yet the vast majority of people snarfing down huge quantities of information swill.
 human-to-human transmission doesn't happen; masks are ineffective; HCQ is horribly risky; a vaccine is coming;
And this: "Before the Covid outbreak, remdesivir was a drug for which Gilead had failed to find a use." (Barrons 6/2/2020)
It’s going to take a long time to recover from what the media has done here. HCQ isn’t even allowed as a treatment in a lot of places, or require hospitalization (funny for a drug on the market for 60 years and over the counter in some places).
Other countries are ramping up production and we’re still dealing with the yet another casualty of culture war.
- NEJM and the Lancet published (and "peer reviewed") this article, or apparently just rubber stamped it.
- The company doesn't have any semblance of having the capability of doing the work it purports to do.
- The article has severe inconsistencies, for example, do you really have data on 98k hospitalized patients? http://freerangestats.info/blog/2020/05/30/implausible-healt...
- The company apparently was founded in 2008 but no data from them was used in any peer-reviewed journal until this year. https://www.theguardian.com/world/2020/jun/03/covid-19-surgi...
And governments and the WHO bought this, hook line and sinker?
An important lesson here about the limits of peer review and science. A lot depends on the original authors not being frauds or simply making mistakes as we’ve seen time and again with scandals.
1. Seems to be saying there isn’t currently a health risk posed by the continuing of their trial.
2. Says they tried using HCQ and PPE together and found health providers were catching the virus less. Nothing in the article attempts to break out whether HCQ or PPE was responsible for it - obviously it’s common sense that using PPE would reduce the risk of catching the virus.
This is hardly a truckload of evidence at all. Also the original study from France was about using HCQ for patients who had already caught the virus, not prophylactic use. HCQ proponents shift around between possible uses of the drug as it becomes clearer that there is a lack of evidence for one way to use it.
Could evidence be found in the future that the drug has some small beneficial effect? It’s possible - but what’s clear is that claims that it was a miracle cure are completely unfounded.
Statement from American Journal of Epidemiology,
Statement from Yale
The older study on SARS
My guess right now is that at best it will be as effective as remdesivir, but really until an actual RCT is conducted there is no proof either way.
The only thing I’m sure of it isn’t a “100%” cure as was touted by some politicians since if so, that would be obvious by now as the drug has been tried since January/February and yet patients treated with it are still dying.
By now, it also matters when you give it. Lopinavir/ritonavir were called ineffective in NEJM, but a recent publication (in Lancet, ironically) says that perhaps (no placebo, blech) that given within 7 days of symptom onset they may be beneficial.
Remedisivir looks best in patients with moderate (requiring oxygen) but not critical disease.
And as for RCTs on HCQ, one of those (for post-exposure prophylaxis) from UMN should be apparently be published soon (no idea when or how: their PI is being, IMO rightly so, tight-lipped), and another is under review. A third one is ongoing.
Another very different thing is to misrepresent the source of the data, or worse.
If you dig into Surgisphere, you will see they have significant consulting engagements with Johnson and Johnson. Not saying that's necessarily bad, but so much bad science about Covid and HCQ seems geared towards promoting high-priced treatments like Remdesivir, and not low-cost preventative measures like making sure you're not D deficient. All these studies need to be evaluated based on who's funding them or the political agenda behind them.
HCQ seems like it's been targeted for destruction. Every study I've read on it shows you shouldn't use it in late stages of disease. Fair enough, but the theory of its effectiveness (as a Zinc ionophore) hasn't been fully studied, although there is a good amount of anecdotal and country-level evidence it works well if taken early (with Zinc).
These garbage studies are dangerous and should be called out loudly.
"A third COVID-19 study using Surgisphere data has also drawn fire. In a preprint first posted in early April, Surgisphere founder and CEO Sapan Desai and co-authors conclude that ivermectin, an antiparasitic drug, dramatically reduced mortality in COVID-19 patients. In Latin America, where ivermectin is widely available, that study has led government officials to authorize the drug—although with precautions—creating a surge in demand in several countries."
Surgisphere is producing studies based on data they don't actually have, according to researchers, Australian hospitals, etc. It could be for self-aggrandizement, or pay-for-publish or something else. I don't know, but it should not be tolerated for any reason.
The actual track record of whether the OTC zinc tablets you can buy in a store work is quite uncertain though. Lots of studies coming down one way or another, and uncertain levels of statistical rigor. https://www.mayoclinic.org/diseases-conditions/common-cold/e...
It is easy enough to make a video with what seems convincing but many of these neat explanations don’t actually work once you get into the human body.
Some US states have blocked pharmacies from filling doctor prescriptions for HCQ, instead of advocating for increased manufacturing capacity within US factories that make HCQ/ingredients. Meanwhile, we boosted ventilator production,
where hospitals received $30K for each late-stage patient placed on ventilation, with only 20% chance of survival. We blocked early treatment that worked and we funded expensive late-stage equipment that did not work.
All this with more global information sharing than ever before in the history of humanity. Since we were collectively unable to filter/parse data generated by wildly different economic incentives, where the consequences were DEATH, how can we design new systemic incentives to avoid repeating such mistakes?
> Neil Ferguson, who became known as “professor lockdown” after convincing Boris Johnson to radically curtail everyday freedoms, acknowledged that, despite relying on “quite similar science”, the Swedish authorities had “got a long way to the same effect” without a full lockdown.
> Sweden’s chief epidemiologist and the architect of its light-touch approach to the coronavirus has acknowledged that the country has had too many deaths from Covid-19 and should have done more to curb the spread of the virus.
> Sweden’s death rate per capita was the highest in the world over the seven days to 2 June, figures suggest. This week the government bowed to mounting opposition pressure and promised to set up a commission to look into its Covid-19 strategy.
> Sweden’s 4,468 fatalities from Covid-19 represent a death toll of 449 per million inhabitants, compared with 45 in Norway, 100 in Denmark and 58 in Finland. Its per-million tally remains lower than the corresponding figures of 555, 581 and 593 in Italy, Spain and the UK respectively.
The specific shortcoming its government is looking into, according to the article, was inability to "protect care homes where half of all Sweden’s Covid-19 deaths have occurred."
Sorry, don't need a society-wide lockdown to protect nursing and group homes, which are highly regulated and often government-operated.
Lies, bad lies, and statistics.
> Belgium has surged to the top of the grim leaderboard because authorities decided to be radically transparent, if perhaps a bit speculative, about the toll from the novel coronavirus. They include not only deaths that are confirmed to be virus-related, but even those suspected of being linked, whether the victim was tested or not.
> As of Wednesday, Belgium, with a population of over 11.4 million, has counted a total 6,262 deaths from COVID-19 — roughly 540 per million citizens — and more than half of those deaths were in nursing homes. Of those 52%, just 4.5% were confirmed as having been infected, yet all are counted in the national tally.
I don't recall ever reading how Sweden's hospitals were overwhelmed so the injection rate never increased beyond what they could handle.
As for total infections, If you look at the graph of cases by country normalized by population, highlight Sweden, and then select show all, Sweden is about in the middle.
They're right there in the mix, it's not like the Swedish model was perfect but Sweden certainly didn't devolve into rivers choked with the dead either. They're having about the same problems as everyone else but didn't add to their misery by completely destroying their economy.
This was done because of a run on HCQ by people who had no business prescribing it such as dentists and others who were abusing their prescribing authority. Meanwhile patients who have depended on HCQ for decades were facing withdrawal because the drug supply had suddenly choked up.
> Meanwhile, we boosted ventilator production, where hospitals received $30K for each late-stage patient placed on ventilation, with only 20% chance of survival.
The 20% chance of survival on a ventilator was a clickbait and has been proven false. https://www.npr.org/sections/health-shots/2020/05/15/8567680...
> The mortality rate among 165 COVID-19 patients placed on a ventilator at Emory was just under 30%. And unlike the New York study, only a few patients were still on a ventilator when the data were collected.
It’s almost the exact opposite - 70-80% of vented patients are surviving.
Meanwhile HCQ/zinc therapy has not shown any benefit despite a rush across the world to try and use it.
Good. Patients with lupus and other diseases were experiencing shortages of what for them is demonstrably life-saving medication. There's not an infinite supply, and there are folks who need it for more than speculation and self-administered home prophylaxis.
I don’t think you’ll like the answer here.
Financial incentives have been known to cause perverse outcomes where moral hazards occur more often than not. I think financial incentives work well in a lot of cases, but healthcare and media have been so perverted by financial interests it’s become untenable.