COVID-19, hydroxychloroquine and the eighth alternative

Editor – The duty of a physician has been proposed as ‘cure occasionally, relieve often, comfort always.’

‘Comfort always’ relates to the art of medicine. The scientific underpinnings of medicine evolved over centuries and is currently founded upon evidence-based medicine (EBM). EBM is data driven; stratified into a hierarchy with meta-analysis of randomised controlled trials at the top.¹ Seven ‘alternatives’ to EBM in the absence of evidence are eminence, vehemence, eloquence, providence, diffidence, nervousness and confidence-based medicine.² The eighth and the latest entrant to this august group is ‘propaganda-based medicine’ (PBM). The rise of PBM has been driven by the ubiquitous presence of social media platforms which influence popular opinion and the main vehicle for the dissemination of information in today's world. Healthcare and beliefs are very much an integral part of this social media driven information society. These platforms have far reaching influence, significantly more than the conventional peer-reviewed scientific publications and websites in shaping public opinion. Claims of efficacy of drugs or other interventions based on questionable scientific data are posted, gain traction and propagated without fact checking. They may often go ‘viral’ to a global audience – who accept it as received wisdom. Political patronage gives it greater validity. PBM allows an item to transition from quasi-science to almost an element of faith with significant unintended consequences.

An example of PBM in the context of the COVID-19 pandemic was witnessed with the drug hydroxychloroquine. Despite conflicting results from small studies, with no or little evidence regarding prevention discussed in different reviews, it has been adopted as a therapeutic option and made its way into national guidelines.^3–5 The drug flew off the shelves causing a global shortage for lupus patients who actually would benefit from it.⁶

This was a classic example of the triumph of PBM over EBM. It reinforces the concept that there can be no shortcuts in science, particularly when so much is at stake. The inefficacy of hydroxychloroquine for the treatment of established COVID-19 infection has now been demonstrated in the large prospective RECOVERY trial.⁷