Statistical Medicine, Chloroquine And Hypertension In The Era Of The Coronavirus

Medicine has long relied on statistics for its predictions. Doctors have long communicated with their patients and family members by calculating the cure rate once the disease is diagnosed and its rate of development. One no longer suffers from an evil, with all the negative charge that clinical semantics entails, but the mathematics favorable to healing is valued.

Communication between medical knowledge and patient fear has always been difficult. Among the latter there are those who blindly follow the decisions of their trusted doctor, there are also those who do not want to know anything, but there are many others who try to understand their state or that of their loved ones. This last segment is on the rise as corroborated by the fact that some very successful television series have clinical debates in hospitals as a narrative element of interest, from ‘Emergencies’ to’ House ‘,’ The Good Doctor ‘,’ Grey’s Anatomy ‘or’ The Knick ‘, to name just a few of the most relevant fictions.

However, statistics applied to medicine had not had such a central role as in the current coronavirus epidemic. Between the curve and the peak, mathematicians and government spokespersons go out every day to count cases and deaths, including acceleration or braking rates along the lines of evolution of the epidemic, with more and more abundant detailed calculations and infographics by country, autonomy, time zone age and gender, etc.

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Four weeks after the alarm decree and absorbed by statistics, it is already evidence that, with the current chaos in the methodology of counting the data provided, it is not possible to predict anything; not even carry out a minimal approximation to the course of events. Get used to the idea, because on the way to the 200,000 infections announced by the Spanish health authorities, some international computer centers – from Imperial College to the University of Oxford – speak of millions of infected people in Spain, around 7 according to their average calculations being optimistic.

As any seasoned person will be able to verify, the measurement of infections and deaths has been very different from one place to another for some time, the accounting method has even been modified depending on the control or lack of control of the epidemic. And in countries where healthcare has been federalized, such as the United States or our own country, it is even more complex to get a good idea of ​​what is actually happening in numerical terms with the virus. Furthermore, China is under suspicion that they have not provided as much information as possible about its original outbreak, trying to avoid penalizing its prestige as a nation. So the data, let alone the data comparisons, are chaotic right now. In this context, it is possible that only the figures on people admitted to hospital intensive care units are relatively reliable to know the evolution of the epidemic.

Western Health offside

That is one of the debates that arose around the pandemic. The other is the lack of foresight by political and health authorities in this regard. The countries of the Far East, the so-called Pacific dragons, have understood it at first because they had the experience of the previous SARS and the fact that China is often the origin of a good part of the known coronaviruses, which include some pathogens that cause the usual winter constipates and have their reservoir in wild animals, especially in bats.

In countries where healthcare has been federalized, such as the United States or our country, it is even more complex to get a good idea of ​​what is happening

The hypotheses about the supposed success of Asian countries in their fight against the coronavirus are diverse, invoking both the disciplined spirit of the community derived from the philosophical teachings of Confucius and the authoritarian character of the Chinese Communist Party. Perhaps the Orientals, as selfish as the Westerners, believe more in the group as a protective agent against individualism than the freethinking autonomy of the West has fostered in our advanced societies.

But it should also be borne in mind that China, as we have mentioned, is a permanent and original source of viruses that are transmitted from animals to humans, among other reasons for the exotic culinary customs of some of its territories, where they continue to practice the dangerous consumption of wild animals without sanitary controls. In this sense, it is worth remembering the advances in food hygiene that have occurred in recent decades in the West, with measures such as controls on food handling or the prohibition of products such as animal blood, certain viscera or unpasteurized milk.

What is clear is that Western Health has had no insight regarding the Covid-19. Despite the fact that most of the best international medical journals very soon released access to new articles on the coronavirus, many from the Chinese scientists themselves who warned about its distinctive characteristics, for too long there was no study to foot of field – in Wuham – of western scientists or of the WHO. For weeks, Western health authorities – and not only Spanish – compared the Covid-19 to a simple flu, scorning its fatality rates – which we now know were weighted inappropriately – thinking it was too far away and that, In any case, it would be relatively easy to isolate and attenuate it as it did with influenza A, SARS, or even Ebola.

But two factors completely collapsed the forecasts: around 80% of those infected were asymptomatic but, at the same time, they transmitted the virus, and in a world more globalized than ever and with a capacity for interconnection with China that has multiplied in the last years. Not all of the medical community reacted this dismissively. In Italy, as soon as the first infections that caused the confinement of Codogno and other small populations near Milan in Lombardy were known, a prestigious Italian virologist with medical practices in the United States compared Covid-19 with the Spanish flu of 1918, the pandemic that killed 50 million people. Most of his colleagues refuted his omens and called him apocalyptic and seeking prominence in the media. In our country there have also been medical scientists who have mocked the forecasts of the National Center for Health Alerts and Emergencies, whose spokesman is the well-known and criticized Fernando Simón, the doctor of the jersey. Some of these criticisms, however, have been ideologically interested since they come from people closely linked to the political opposition, and even to Catalan nationalism.

Health personnel during their work day in a plant of the Puerta de Hierro Hospital in Madrid. (EFE)

The truth is that Simón and the advisers in the first moments of the Ministry of Health did not have any plan B. They trusted in the prestige of the National Health Service – now scattered by the autonomies and with little coordination capacity, as has been verified -. They did not even notice that the Spanish pharmacies had been completely short of masks and disinfecting gels throughout the month of February and that there were even hoarding phenomena. Almost at the same time, another prestigious doctor, a Spaniard at the head of the Institute of Emerging Pathogens at the Monte Sinai Hospital in New York, Adolfo García-Sastre, warned of the dangers that the collapse of the health system could produce. It was a question of averaging the infections – which they already considered inevitable – given the Covid-19’s high capacity to transmit itself and its extremely rapid multiplication in the upper respiratory tract. For García-Sastre, it was evident that no current health system would be able to bear the stress of a massive spread of coronavirus in a few days, as it has finally been happening first in Wuhan and then in Lombardy, Madrid, New York itself and now in France and England.

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By the time this has happened, both medical and political authorities have discovered that the western industry, including the health industry, has been delocalized for years, precisely in China, and that it operates according to ‘just in time’ criteria, that is, it buys daily upon request and no longer has the storage capacity of raw materials for its manufactures: neither alcohol nor plastics, nor special fabrics … with which to produce emergency items in this crisis: masks, gels and, especially, respirators and personal protective equipment for toilets. The criminalization of plastic, essential for making latex gloves, goggles, and breathing tubes, has done the rest. García-Sastre himself, who predicts the recurrence of major viral epidemics every 20 to 30 years in the near future, exonerates Western health systems of the current disaster, as none were prepared for the rapid spread of Covid-19.

Only an adequate research and hospital implementation policy could more effectively combat future pandemics. For this, in addition to the obvious increase in investment in these areas, there must be a greater flow of specialized information, more coordinated clinical trials and much more collaboration between different medical areas, since an expert in public health and epidemiology is not the same as a biochemical researcher focused on knowing the genetic chain of a virus or bacteria, much less an internist, a pulmonologist or an intensive care doctor. And all of them are protagonists in the current Covid-19 pandemic.

Medicine to the rescue

We have already seen that public health experts and even many epidemiologists, including those at the WHO, have been outspoken by the pandemic. Neither they nor the politicians they were advising had to know the moral of the tale of the Hindu prince and his subject Sissa, thanks to which it is easy to understand how fast and how much more exponential growth can increase. Authorities and health officials have seen in just two weeks go from having an outbreak confined in a small circle of people to runaway with thousands of infected and hundreds of deaths. So is exponential growth.

With the population becoming infected at breakneck speed due to the high transmission that characterizes Covid-19, and with microbiologists still studying substantial parts of the behavior of this new pathogen, and beginning a busy race to develop research that will find a vaccine or Some effective pharmacological treatment (there are more than 50 global vaccine projects and nearly a hundred international therapeutic studies at the moment), the battlefield soon moved to hospitals. And yes, in the main line of fire against the deadly action of the virus, medicine, the Eastern and Western, have shown an unusual courage and ability to work, to the point that citizens have originated —in our country – an unprecedented formula of recognition: the ritual of collective applause from windows and balconies as a sign of gratitude to the army of restrooms who have been working in less than optimal conditions against the great microscopic enemy. The part of casualties in the toilets is also overwhelming, and is still not sufficiently justified for medical reasons.

The residents of Santa Cruz de Tenerife go out to the balconies and windows of their houses to applaud the toilets who care for the coronavirus patients. (EFE)

It is true that Chinese doctors in emergency hospital centers, the main trenches of this health war, have been leaving clues about the problems and solutions they were encountering. However, the epidemic in Europe had not yet escalated when a medical controversy occurred in France that has caused rivers of ink to flow in French healthcare: From the prestigious university hospital in Marseille (the IHU), the director of the Institute unit Infectious Mediterranean, the renowned virologist Didier Raoult announced in a video “the end of the game” against Covid-19. Raoult, with a certain aspect of druid, echoed some Chinese and Korean recommendations and had used in her patients a medication that was recommended against malaria, chloroquine, of which there were also many and cheap stocks. Raoult was answered by the French Ministry of Health and Inserm (the official health research institute), the same ones that alerted against ibuprofen. Recommending chloroquine was premature and there were risks involved.

To complicate the situation, other French hospital doctors added a second therapy to antimalarial medicine: azithromycin, an antibiotic widely used against pneumonia. While in France the controversy has continued, which has now moved to the United States, with President Donald Trump defending the use of chloroquine against the opinion of his own health advisers, in Italy and Spain the Ministry of Health itself has recommended this therapy. So in Spain, antimalarial hydroxychloroquine is being administered despite its side effects because, it seems, it works, and even more so combined with the aforementioned antibiotic. Perhaps this medical daring explains the high rate of cures that Spanish hospitals have, or perhaps it is the self-denial and the value of their human resources, since the materials have been out of control for weeks, for which half the country has had to start looking for masks or making respirators.

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In any case, in Spain the UCI battle is being won, also having unprecedented levels of social collaboration. Spanish doctors have also cleared the development of Covid-19 pneumonic disease and have adapted their therapies to it. Apparently it is not the infection itself that causes the death of the patient but rather the overacting of the immune system once the virus multiplies in both lungs. That immune excess would cause widespread inflammation of vital organs and lead to an irreversible situation. The Spanish pulmonologists and emergency internists have understood, however, that in the phase of infection, the virus must be fought with chloroquine, but once it passes or is close to passing into the inflammatory phase, one must forget about the virus and proceed to deflate the patient with corticosteroids. Knowing how to manage the times and the medication would be the key to healing the seriously ill with the virus.

Why the big outbreaks in Italy and Spain

The last question we would like to raise is not intended to explain any of the abundant conspiracy theories circulating around the SARS-CoV-2 coronavirus. Some are widespread, such as those that indicate the existence of a military biological laboratory in Wuhan, from where the bug may have escaped. Or others, more specular and related to alleged microbiotic wars between the US and China, in addition to those that assume that Bill Gates is a kind of guru with powers in the afterlife because after the Ebola crisis he tried to make humanity aware of the risks of viral epidemics. There are even more incredible theories, such as those of the American doctor Thomas Cowan, who at the recent health and human rights summit in Tucson, Arizona, came to explain the close relationship between viruses – a biological excrescence as defined – and contamination radiological. For Cowan it is no coincidence that the 1918 Spanish flu occurred at a time of strong expansion of radio emissions, or that Covid-19 now coincides with the arrival of 5G in telecommunications.

Much more significant than such conspiracies is the knowledge that is being acquired regarding the behavior of the specific coronavirus that Covid-19 causes, of which we had no idea but its similarity to other previous pathogens – SARS or MERS – but little plus. It is true that very soon its primary composition was deciphered and it was learned that it used its protein “crown” to bind —coarse, apparently— with the enzyme ECA2 —ACE2 in English— thanks to which it penetrated into human cells from where it reproduced by the millions. But fundamental aspects of the virus are still unknown, so many that it is understood the general confusion that public health groups in the world have suffered. Once again, statistics are the one that throws a cable to medicine: the data show that the virus is mostly asymptomatic, that it presents with mild symptoms and that it affects more seriously older people, men more than women, and patients with previous pathologies. like heart disease, hypertension or diabetes. But it is not yet known why these traits, or the causes for which exceptions occur, as well as the repercussions of overexposure to the virus or the so-called viral load of infected droplets that an individual can transmit or for which it can be known. be infected.

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The case of hypertension is particularly opaque. During the first great wave of the virus in China, a Mexican virologist interviewed by a prestigious national media came to say that the problem of hypertensive patients stemmed from their hyperactivity, which facilitated their spread. Some time later it was concluded that the problem was not high blood pressure, but medication to moderate it. Specifically, it was alerted to the fact that some medicines inhibited the enzyme ECA2, the same one that the coronavirus uses to penetrate cells and is present in the lungs, which could accelerate the severity of the viral infection.

Faced with this news, both the French and the Spanish Ministry of Health were positioned to stop the conclusions against antihypertensive medication: there is no clinical study that corroborates such assumptions. But many doctors, when in doubt, have been choosing to change their patients the therapeutic group with which they control blood pressure. Until Chinese hospital doctors and renowned Harvard internist Leo Galland have ruled quite the opposite: hypertensive patients treated with BRA drugs that block angiotensin II – a vasoconstrictive hormone – that is produced thanks to our friend the enzyme ECA2 from the lungs, would be in better conditions to improve against Covid-19, since the virus causes the enzyme “depletion”, and the more enzymes the less depletion. Quite a mess in a passionate medical debate right now.

And something similar happens with the thermal and geographic hypotheses. At this point, for example, we know little about the possible transmission of the coronavirus through water, food, or even sexual activity. The heat is supposed to mitigate its activity, but nobody is sure of it, nor of the seasonal nature of the virus, while everyone prepares for a second wave of Covid-19 once the quarantines are over, the second wave that in the case of the 18 flu was the really deadly one. A North American university study, also statistical, concluded a month ago that Covid-19 showed much more intense outbreaks in a geographic strip of the northern hemisphere coinciding with temperatures between 6 and 22 degrees and humidity below 60%.

Several people in the empty Times Square in New York due to the confinement measures decreed in the USA. (Reuters)

None of this has been demonstrated, even though Chinese Wuham, Italy, Spain and the United States coincide in that strip, as well as many other countries with a much lower incidence of infections. Another geographical study, this one from the University of Alicante, concludes that the virus is not transmitted by air, since if it were so, the main current from China would take the east direction and not the opposite, as has happened with the Covid-19: then it would be the direct contagion between people that acts in this disease. Some people, on the other hand, attribute to the social culture of Latinos the persistence and intensity of the viral outbreak in Spain and Italy. More sociability, a better quality of life thanks to the Mediterranean diet, a more immunological genetics, a demography with pyramids of an older population also thanks to the healthy attitude towards the existence of Spaniards and Italians … all this separately or at the same time, would be playing against both countries. But it is also contradictory that it only occurs here, and that countries such as Greece, Portugal or Malta, as Mediterranean as us, have very low rates of Covid-19 disease.

Neither New York nor New Jersey, where the virus is now attacking with greater virulence, are too similar to Mediterranean ways of life, and it is time to see, in the same way, how Covid-19 behaves in countries such as the United Kingdom, Germany, Russia or the Scandinavian territories, peripheral to the health crisis to date.

As you have seen, a whole ocean of doubts. And that is the main current conclusion of the pandemic caused by this coronavirus: that science is not all-powerful and that it needs time and resources to reach complex knowledge of things, and that no matter how much we have turned the planet into our vacation villa , we continue to be at the mercy of the gods of nature and suffering from a certainly inevitable biological fragility. Every time man faces the drama of existence, he receives a lesson in humility.

* Juan Lagardera is a journalist and editor.

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