Reliable information is key to tackling any outbreak and nowhere is it more crucial than in the management of the ongoing pandemic. However, the sheer volume and variety of information being thrown at us make it difficult to judge which bits are true and which hyperbole. Leave alone the common man, even the so-called experts are at sea. The consequence of all this is impaired judgement, misplaced beliefs and distorted priorities. The run on pharmacies for hydroxychloroquine (triggered by mere speculations) that we witnessed a few weeks ago is a prime example.
I am prompted to write this article because of another irrational obsession that has gripped us at the moment. Almost every television channel and newspaper seems to be gushing over the miraculous effects of the antiviral drug remdesivir, and that other “cure”, plasma therapy. Barring a few honourable exceptions, even some of the so-called experts are not hesitant to overstate their benefits. It is not uncommon to hear exaggerated assertions such as “three patients were cured with plasma therapy”. Level-headed advisory from institutions like the ICMR, that plasma therapy is still an experimental treatment, are lost in the din. So, it is very likely that people are, in general, convinced that the only two currently available treatments for COVID-19 are plasma therapy and remdesivir.
Till about two weeks ago, there was no proven treatment for COVID-19. But that changed dramatically when a group of researchers in the UK released the results of their study of dexamethasone (an inexpensive, readily available medicine). Working away from the limelight, these researchers pulled off the unprecedented feat of completing a rigorously done clinical trial within 100 days of conceiving it. News channels in this country reported the story for a couple of days and then promptly went back to talking about plasma therapy, remdesivir and another as yet unproven drug, favipiravir. You may be forgiven for dismissing the results of the dexamethasone study as just another study — after all, no one is talking about it. But the results of this study deserve prominence for at least two reasons.
First, this is the first study to show an unequivocal, and large benefit in sick patients with COVID-19, on the outcomes that matter most — the risk of death and the risk of needing ventilator support. Among the sickest of patients, just eight patients would need to be treated for 10 days with dexamethasone (compared to not treating with the drug) to save one life. By any measure, this is a large treatment benefit in modern medicine. To put this in context, 25 patients would need to be treated with bypass surgery (compared to medicines alone) to save one extra life, over 10 years. In contrast, remdesivir merely reduces the duration of hospital stay by four days without any significant effect on dying from COVID-19. Plasma therapy is yet to be rigorously tested in people with COVID-19 and has shown little or no benefit in other types of flu.
Second, dexamethasone is cheap and readily available, with several “branded generics” available in the Indian market. A course of treatment at the prescribed dose would cost less than Rs 10 per patient. On the other hand, remdesivir, even the brands marketed by Indian companies, would cost tens of thousands of rupees per course. Likewise, the infrastructure and cost of acquiring and concentrating plasma from volunteers who have recovered from COVID-19 make plasma therapy an expensive proposition.
In the absence of adequate information, the price of a commodity serves as an indicator of quality for the consumer. Information asymmetry is most acute in healthcare, with the added disadvantage that the providers of care have far greater access to, and understanding of the information. It is naïve to expect that the pharmaceutical industry and for-profit healthcare providers will fill this information gap to their detriment. The responsibility to rescue the media, the general public and our policymakers from the “remdesivir effect”, therefore, falls squarely upon physicians and public health agencies.
The direct and opportunity costs of prioritising less effective and expensive treatments can have dire consequences both for health and the economy. It is critical that we focus on providing the most effective treatment to the largest number of people at an affordable cost. The message should be loud and clear, that for once, the inexpensive option is by far, the better option.
This article first appeared in the print edition on July 10, 2020 under the title ‘The remdesivir effect’. The writer is a professor of cardiology at the All India Institute of Medical Sciences, New Delhi. Views are personal.
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