The malaria drug chloroquine was developed from quinine, an alkaloid found in the bark of the cinchona tree, which grows in the tropical highlands of South America. The Incas passed the bark cure to Jesuit priests, who transported it to Europe in the mid-sixteen-hundreds. The National Institutes of Health calls quinine “the most serendipitous medical discovery of the 17th century,” but its side effects—diarrhea, vomiting, partial deafness and blindness—could be devastating. A less toxic derivative of chloroquine, hydroxychloroquine, was developed in the nineteen-forties. Doctors and pharmacists call it HCQ.
Against malaria, the drugs, which are taken as pills, essentially defend red blood cells against a parasite that is transmitted by mosquito bite. Lately, some doctors have been trying it against the novel coronavirus, which causes COVID-19. Attention to chloroquine and hydroxychloroquine—and to a third drug, the antibiotic azithromycin, a common brand name of which is Zithromax Z-Pak—intensified in mid-March, after researchers at Aix-Marseille University, in France, released a preliminary study saying that, in a clinical trial, the combination of hydroxychloroquine and azithromycin had quickly reduced the amount of the virus in COVID-19 patients.
On March 18th, on Fox News, Tucker Carlson opened a three-minute segment about the study by saying, of the United States, “This is a country of science.” He then introduced a lawyer, Gregory Rigano, whom he identified as an adviser to Stanford University’s medical school. Rigano had self-published a white paper about chloroquine, on Google Docs; his connection to the French research was otherwise unclear. He was appearing remotely, wearing a suit and sitting in front of a cold fireplace. When Carlson asked him why he thought the study was important, Rigano responded, “The President has the authority to authorize the use of hydroxychloroquine against coronavirus immediately. He has cut more red tape at the F.D.A. than any other President in history.”
According to his Web site, covidtrial.io, Rigano has experience “advancing various pharmaceutical assets through laboratory, animal, formulation, manufacturing, clinical trials,” and was hosting an “open data clinical trial for Covid-19.” (The wording on the Web site has since been changed.) He told Carlson that the French study “was released this morning on my Twitter account,” and showed a “one hundred per cent cure rate” against the coronavirus. Carlson called the revelation “remarkable.” Rigano, after a bizarre reference to hepatitis, said, “What we’re here to announce is the second cure to a virus of all time.”
Charlie Kirk, the founder of the conservative nonprofit Turning Point USA, tweeted the segment, exhorting his nearly two million followers to “RT If President @realDonaldTrump should immediately move to make this available.” Most media outlets, though, quickly challenged the credibility of Rigano and that of his white paper’s co-author, James Todaro, a cryptocurrency investor who has tweeted about having a medical degree from Columbia. HuffPost called them “hucksters.” Joan Donovan, who studies “media manipulation and disinformation campaigns” at the Shorenstein Center, at the Harvard Kennedy School, called them “bitcoin entrepreneurs” and pointed out that “neither do research on viruses.” She wrote, “This is dangerous because people are now tweeting about trying to get their doctors to prescribe anti-malaria drugs. Worse, thousands of people think they can cure coronavirus by drinking tonic water.” (Tonic water contains quinine.) Stanford Health Care posted an “IMPORTANT NOTICE” on its Web site: “A widely circulating Google document claiming to have identified a potential treatment for COVID-19 in consultation with Stanford’s School of Medicine is not legitimate.”
Donald Trump, however, ran with it. Last Thursday, at a press conference, he declared that chloroquine had “been approved” by the Food and Drug Administration as a treatment for COVID-19. (It hadn’t.) On Friday, he said that he is “a big fan” of the drug. (The F.D.A. commissioner, Stephen Hahn, issued a cautionary statement about spreading “false hope.”) On Saturday, Trump tweeted, “HYDROXYCHLOROQUINE & AZITHROMYCIN, taken together, have a real chance to be one of the biggest game changers in the history of medicine.” He added that the drugs should be used “IMMEDIATELY” to treat the coronavirus. HCQ is also used to treat rheumatoid arthritis and lupus, which are autoimmune diseases; at one of his pressers, Trump had said, “If you wanted, you can have a prescription,” adding, “What the hell do you have to lose?”
Physicians responded instantly and publicly. Sam Ghali, an emergency physician in Lexington, Kentucky, tweeted that the President’s recommendation involved “a DANGEROUS combination of drugs with tons of side effects,” and that “together they can make your heart go into abnormal rhythms and even KILL you.” Rob Davidson, an emergency physician in western Michigan, who chairs the Committee to Protect Medicare, tweeted, at Trump, “Leave the medical advice to doctors. You can’t even do your own job correctly, stop trying to do ours.”
The American Society of Health-System Pharmacists soon reported a shortage of HCQ. By Sunday, at least four state pharmacy boards—in Idaho, Ohio, Nevada, and Texas—had restricted prescriptions. (The list has now grown to include Kentucky, North Carolina, and Oklahoma.) At least one board also restricted azithromycin. Katherine Rowland, a pharmacist in Eugene, Oregon, tweeted, “Well it finally happened to me. A dentist just tried to call in scripts for hydroxychloroquine + azithromycin for himself, his wife, & another couple (friends). NOPE. I have patients with lupus that have been on HCQ for YEARS and now can’t get it because it’s on backorder.” A lupus patient in Maryland told a reporter for Undark Magazine that she never worried about a drug shortage but was now terrified that, without the medication that protects her organs from inflammation, her immune system would turn on her. “I’ll suffocate,” she said.
In recent weeks—as the number of coronavirus cases escalated to what is now half a million worldwide—the F.D.A. and the Federal Trade Commission have sent cease-and-desist letters to at least seven sellers of products that are being marketed as cures for the coronavirus. On March 6th, one such warning went to “The Jim Bakker Show,” in Blue Eye, Missouri. The television program, which is fronted by a televangelist who spent nearly five years in prison, in the early nineteen-nineties, for fraud, had been touting survivalist products, including Silver Sol Liquid, a silver solution that was purported to “mitigate, prevent, treat, diagnose, or cure COVID-19 in people.” Viewers were told that they could put the liquid “in a nebulizer which then creates a steam and you breathe it in, and it will go directly into your lungs where that virus is.” Another letter went to Herbal Amy, an L.L.C. in Nampa, Idaho, the Web site of which was selling “Coronavirus Protocol” products: Coronavirus Boneset Tea, Coronavirus Cell Protection. The suggested regimen was “rather extensive,” because “the particular corona virus that is now spreading world wide is exceptionally potent,” the Web site noted. The herbs in the protocol were “specific in one way or another” for the virus, and worked “for acute infections.”
Anthony Fauci has directed the National Institute of Allergy and Infectious Diseases since Ronald Reagan was President. As a medical professional, he has faced H.I.V., SARS, MERS, Ebola, and now Trump. At press conferences, Trump speaks of hunches (“I feel good about it”); Fauci delivers information that has been vetted by experts. On Sunday, Science magazine asked Fauci how he can tolerate statements that “aren’t true and aren’t factual”; Fauci replied, “I can’t jump in front of the microphone and push him down.” Fauci carefully explained that any clinical successes related to the cocktail that Trump was praising were anecdotal. He said, “My job is to ultimately prove without a doubt that a drug is not only safe but that it works.”
As the coronavirus continued to spread, Trump made one troubling declaration after another. A vaccine was coming “relatively soon,” he said. (It takes at least a year to develop a vaccine.) “We were very prepared” for a pandemic, he said. (The country’s hospitals were caught with such a shortage of basic protective gear that front-line health-care workers are reusing, by necessity, potentially contaminated masks). The virus “miraculously goes away” as the weather warms, he said. (Robert Redfield, the director of the Centers for Disease Control and Prevention, has said, “This virus is probably with us beyond this season, beyond this year.”) The number of coronavirus patients would be “close to zero,” Trump said. (At least a thousand people have died of the coronavirus in the United States, thirteen of them in one twenty-four-hour period, this week, at a single hospital in Elmhurst, Queens.) By Wednesday night, on Twitter, #DoctorsOnlyPressConferences was trending nationally.
Ryan Marino, one of the doctors tweeting about the dangers of Trump’s messaging, is a thirty-one-year-old medical toxicologist at University Hospitals in Cleveland. His specialty involves “the poisoned patient”—a drug overdose, lead exposure, “things that bite and sting.” Call a poison-control center and it is usually a clinician like Marino, as opposed to a laboratory toxicologist, at the other end of the line. A podcast host recently told him, “You are right out at the tip of the spear,” treating “patients at the point of care.”
A few years ago, Marino noticed rumors about fentanyl, the potent painkiller which in an illicit form, usually a powder, is often found in street drugs such as heroin. On Facebook, a Texas man warned everybody to sanitize the handles of Walmart’s shopping carts because “one drop” of fentanyl could “cause death”—“all you have to do is rub your nose or touch your child’s mouth.” (The post has been shared more than thirty thousand times.) In Grove City, Ohio, after law-enforcement officers seized three kilograms of fentanyl, one network news affiliate described that amount of drugs as “enough to kill 1.5 million people.” Law-enforcement officers and other first responders had heard that they could fatally overdose by simply inhaling or touching fentanyl during drug busts. In one town, a police officer brushed an unidentified white powder off his shirt after searching a drug suspect’s car; he fell unconscious and received naloxone, a drug that can reverse an overdose. The officer was recovering shortly thereafter, but his chief spoke to “Inside Edition” and described the potential danger, as he imagined it: “He leaves and goes home, takes off that shirt, throws it in the wash. His mom, his wife, his girlfriend goes in the laundry, touches the shirt: boom, they drop. He goes home to his kid: ‘Daddy! Daddy!’ They hug him: boom, they drop. His dog sniffs his shirt: it kills his dog.” A fentanyl-industrial complex appeared—gloves, sprays, masks, hazmat suits.
In late 2017, Marino started a hashtag, #WTFentanyl, to dispel the myths that fentanyl can be easily absorbed into the skin or inhaled after becoming airborne. The rumors had, at first, struck Marino as humorous, then absurd. Then he decided that there was “serious potential for harm.” He worried that first responders would ration naloxone for themselves, and that people would die. His tweets, though, could be darkly funny. In a news interview, the C.E.O. of an alcohol- and drug-treatment center said that anyone who “enters a room with someone who might be having an issue with fentanyl” could “instantly” become addicted. Health-care workers tweeted about it, one telling Marino, “I became addicted to fentanyl by reading this tweet.” Marino replied, “Now you’re dead,” and attached a GIF of Stewie, the baby on “Family Guy,” tossing a red rose into an open grave. After someone else tweeted about fentanyl patches that had been in her bathroom cabinet for “nearly a year,” Marino responded, “Everyone who has been to your bathroom became instantly addicted and then died.”
Poisoning, in any form, is no joke to Marino—he became a medical toxicologist partly because he lost a beloved cousin to an overdose. On a podcast, he recently said that his “end game” is “to insure that there’s less harm.” After Trump’s comments about hydroxychloroquine, Marino began tweeting about the coronavirus. Whereas before he had dispelled gross exaggerations about fentanyl, he now found himself urging politicians and the public to take the risks of HCQ more seriously. He told me, “There’s very few things that make me clench up inside, and hydroxychloroquine is on the short list, because it’s so toxic.”
HCQ can cause cardiac arrest, low blood pressure, hypoglycemia, seizures, and an altered mental state. Marino warned his nearly twenty-four thousand Twitter followers that Trump, by making “unsupportable recommendations,” praised what was in fact a combination of “extremely toxic drugs with a long history of lethality and complications that are difficult to treat in even the most advanced settings.” Retweeting Trump, he wrote that it is “a crime in all 50 United States to dispense medical advice without a license.” Later, he tweeted, “Don’t listen to the President. Listen to all the experts around the world who are in consensus that we need to continue to distance/isolate.”
Marino publicly shared a memo that he had sent to his emergency-department staff: the research paper that related to Trump’s comments sounded “promising on the surface” but involved “flawed” and “limited” science. The French study that Fox News had touted had ultimately involved a treatment group of only twenty patients. Six dropped out. Three went to intensive care. One died. In a clinical trial, “dying, and doing worse, are important outcomes to measure,” Marino told me. “When they say it was ‘a hundred per cent’ successful, they’re ignoring the fact that patients were cut out of the results.”
Something else worried Marino: sick people may hear about Trump’s “hunches” and treat their coronavirus symptoms at home with a dangerous, unproven drug. That has now happened. In Lagos, at least two people have overdosed on chloroquine. The Nigeria Centre for Disease Control tweeted that the World Health Organization had “NOT approved” the compound as a treatment for COVID-19, and exhorted, “Please DO NOT engage in self-medication.” On Monday, a man in Arizona died, and his wife was in critical condition, after ingesting the kind of chloroquine solution that is used to clean fish tanks. Marino tweeted, “ ‘Fake news’ is a term that I hate to use, but when White House press briefings are causing people to poison themselves needlessly then I can’t think of a better way to describe that.”
By Thursday morning, Kaiser Permanente had stopped filling “routine” prescriptions for chloroquine, in order to “ensure access” to the drug for “severely sick patients, including both COVID-19 and those with acute lupus.” Doctors in New York, the outbreak’s epicenter, are experimenting with the drugs; days ago, Governor Andrew Cuomo announced the impending arrival of seven hundred and fifty thousand doses of chloroquine. Physicians elsewhere have tried the medications in cases of “compassionate use,” when nothing else is working. Clinical trials are underway in Minnesota and elsewhere. Alison Bateman-House, a professor of population health at New York University, told the Washington Post that the F.D.A. is “caught between saying it wants good science, and good processes, and what evidence-based medicine requires, and this is what our bosses, the people and the president are telling us they want.”
Marino heard about New York’s experiments on Thursday, when at least two hundred and thirty-seven people died of the coronavirus nationwide. That night, Trump called “The Sean Hannity Show,” on Fox News, and repeated his claims that “there’s no risk” in using an anti-malarial drug for COVID-19 “when it’s already out there in different form, for a different purpose.” He bragged about getting “such fast turnaround,” saying, “Why would we wait?” But, seconds later, he said, “If you were a betting man, I guess you’d have to bet against it.”
Marino told me, “While superficially it seems prudent to just try anything in the face of an overwhelming crisis, there is no reason to believe that these meds will help,” unless they are proven to do so. He said, “If our response to a crisis is to ignore the scientific method that has gotten us this far, then we are setting ourselves up for additional and preventable problems.”