Using Hydroxychloroquine (HCQ) for

Early Treatment 

of Outpatients  

Editing Notes:

1. Date of original blogpost: Aug. 18, 2020

2. Aug. 20, 2020: added Endnotes section in blue font. Any other edits (minor) within the original blogpostalso appear in blue font. 

     a. The point about "high risk" patients is critical. (See Endnote #1.)

     b. I added links to two interviews which may be a quicker way to convey the message. (See Endnote #3, Dr. Risch's follow-on interview to his CNN interview).

3. Aug. 29, 2020: added Endnote #6.

Blogpost:

On July 28, 2020, a Tweet and blogpost by Martin Armstong caught my attention. The blogpost contained a controversial video on the so-called America's Frontline Doctors. The doctors in the video claimed that a combination of HCQ taken in low doses and Zinc could help (a) in preventing coronavirus infection and (b) more importantly, in treating the disease in its early stages.

This video was subsequently banned by mainstream media with the reason, according to Fox News, being that it would "hurt the Biden presidential campaign" (i.e. help Trump's presidential campaign had it not been banned). An ER physician who had appeared in the video, Dr. Simone Gold, was fired from her job shortly thereafter. Source. (The implication is that "forces" behind Biden are more powerful than those behind Trump. Time will tell.)

To be clear, their message was that there is a simple and cheap way of treating Covid-19 patients at the early outset of symptoms. This was the message that has been suppressed by mainstream media.

Meanwhile, Dr. Anthony Fauci, the FDA and NIH have taken a hard stance against the use of HCQ for treatment of Covid-19. The say that not until RCTs (randomized controlled trials) are carried out should HCQ be prescribed. The benefit of an RCT is that it would establish without reasonable doubt whether or not HCQ was an effective treatment for the disease. The problem is that an RCT takes time, months or years. Meanwhile, more and more people are getting infected, many have died or continue to die, the health care system has been overloaded, and the global economy has taken an unprecedented hit. A Yale epidemiologist named Dr. Harvey Risch advocates the combined use of HCQ with AZ (azythromycin, an antibiotic) for treatment of early stages of infection in outpatients who are at high risk. I emphasize the words "early stages" and "outpatients". (More on "high risk" in the Endnotes.) His prescription does not apply to inpatients (those hospitalized) nor to those with advanced stages of the disease (i.e with severe respiratory issues). 

(See Endnotes re Dr. Risch's rebuttal of Dr. Fauci's stance on RCTs.)

I asked a few physician friends for their opinion. (I am not a physician.) I thought that their response would settle the matter. However, I received mixed responses. So I decided to investigate for myself by going to the source, which meant reading Dr. Risch's academic paper.

Side note: An article from MedPage Today dated July 31, 2020 is excellent in that covers the issue thoroughly and references many relevant sources including Dr. Risch's paper. If you'd like to get an overview and find links to major articles, this would be the go-to article. However here in this blogpost, my focus is something different. It is to look at Dr. Harvey's analysis directly instead of listening to other people's opinion or interpretation of it.

As a historical note, I started my investigation via this Google search: "dr harvey risch hydroxychloroquine". (If you click on the previous link, you'd be able to see the search results for yourself. The aforementioned article from MedPage Today was the second search result.)

So, let's look at Dr. Risch's academic paper, the one which leads him to recommend HCQ+AZ for early treatment of outpatients with Covid-19. But before we do that, let's check his credentials. They may be found on Yale's website. 

My opinion after checking him out is that he has not only credible but outstanding credentials as an epidemiologist, which is what counts. He is the author of 325 original research publications and has an h-index of 88. But what does an h-index of 88 mean? According to this source, "after 20 years of research, an h-index of 20 is good, 40 is outstanding, and 60 is truly exceptional." Risch obtained his PhD in 1980, so he has had more than 40 years of research under his belt. Second, according this Wikipedia article on the h-index, "among 36 new inductees in the National Academy of Sciences in biological and biomedical sciences in 2005, the median h-index was 57." Dr. Risch's index is higher than this median, and we are talking about the median among a select group of scientists. So far so good.

Dr. Risch's paper may be accessed here. It was published on May 27. (Note that at the top of the PDF file containing this paper, not to be overlooked are 3 critiques of Dr. Risch's paper and 2 rebuttals by him. I don't treat these other works here, but simply mention that Dr. Risch's 2nd response -- file "kwaa152" -- is worth checking out: See Table 1 on p.8 which summarizes 12 studies all with the same conclusion: "reduced risk". )

Excerpts from Dr. Risch's paper, with titles by me.

Is outpatient infection different from inpatient distress?

"Symptomatic outpatient infection is a pathologically and clinically different disease than the life-threatening inpatient acute respiratory distress syndrome caused by SARS-CoV-2, thus there is little reason to think that the same treatment would be useful for both."


What is the purpose of this paper?

"In reviewing all available evidence, I will show that HCQ+AZ and HCQ+doxycycline are generally safe for short-term use in the early treatment of most symptomatic high-risk outpatients, where not contraindicated, and that they are effective in preventing hospitalization for the overwhelming majority of such patients."

(HCQ = hydroxychloroquine. AZ = azithromycin)


What is the available evidence on the efficacy of HCQ+AZ?

"Available evidence of efficacy of HCQ+AZ has been repeatedly described in the media as “anecdotal,” but most certainly is not. The evidence is not perfect either."

Can lack of randomization be a weakness of the First Study (Marseille group, P. Gautret, D. Raoult)?

"If [this] study had shown a 2-fold or perhaps 3-fold benefit, that magnitude of result could be postulated to have occurred because of subject-group differences from lack of randomization. However, the 25-fold or 50-fold benefit found in this study is not amenable to lack of randomization as the sole reason for such a huge magnitude of benefit."

Side note: Both the first and second studies may be accessed via the above MedPage Today article.

Why is smallness not an issue with the First Study?

"The study has also been described as “small,” but that criticism only applies to studies not finding statistical significance."

What were the results of the Second Study (also Marseille Group)?

"A second study of the Marseilles group involved 1061 patients tested positive for SARS-CoV-2 and treated with HCQ+AZ for at least 3 days and followed for at least 9 days. The authors state “No cardiac toxicity was observed.” Good clinical outcome and virological cure were seen in 973 patients (92%). Five patients died, and the remainder were in various stages of recovery."

What were the results of the Third Study (Dr. Vladimir Zelenko, New York)?

"Of the 1450 patients, 1045 were classified as low-risk and sent home to recuperate without active medications. No deaths or hospitalizations occurred among them. Of the remaining 405 treated with the combined regimen, 6 were ultimately hospitalized and 2 died."

Side note: Dr. Zelenko's prescription may be found here. HCQ+AZ+Zinc, including dosage.

Are FDA, NIH and cardiology society warnings borne out in real-world usage of this treatment?

"This discussion thus shows that the FDA, NIH and cardiology society warnings about cardiac arrhythmia adverse events, while appropriate for theoretical and physiological considerations about use of these medications, are not borne out in mortality in real-world usage of them. Treatment-failure mortality will be much higher, but even that pales in comparison to the lives saved. It would therefore be incumbent upon all three organizations to reevaluate their positions as soon as possible."

Preamble to why differing scientific worldviews might be involved.

"Given that a detailed and dispassionate review of all of the available relevant evidence leads to conclusions about outpatient HCQ+AZ use different than those of the FDA and NIH panels (which comprise wider expertise than the cardiology societies), I address how different underlying scientific worldviews might be involved."

Are we talking about the same disease?

"For Covid-19, inpatient acute respiratory distress syndrome is typically a florid immune-system overreaction, whereas initial outpatient illness is a viral multiplication problem involving the beginnings of immune response. These are different diseases."

What are the facts?

"The fact that epidemiologic data to-date show strong evidence for efficacy of combined HCQ+AZ in early outpatient treatment, even if not “proof” yet at the level of several successful RCTs, is evidence that this medication regimen works in that context."

(RCT = randomized controlled trial)

What is Risch's point?

"It is my point to say ...that HCQ+AZ has been directly studied in actual early high-risk outpatient use with all of its temporal considerations and found empirically to have sufficient epidemiologic evidence for its effective and safe employment that way, and that requiring delay of such general use until availability of additional RCT evidence is untenable because of the ongoing and projected continuing mortality. No studies of Covid-19 outpatient HCQ+AZ use have shown higher mortality with such use than without, cardiac arrhythmias included, thus there is no empirical downside to this combined medication use."

How prevalent is the use of HCQ+AZ in the world for treating Covid-19?

"I strongly urge these panels [(e.g. FDA, NIH)] to reconsider the data and arguments discussed above. Substantial fractions of physicians treating Covid-19 patients in Europe and elsewhere report use of HCQ+AZ: 72% in Spain, 49% in Italy, 41% in Brazil, 39% in Mexico, 28% in France, 23% in the US, 17% in Germany, 16% in Canada, 13% in the UK."

What are Risch's concluding remarks?

"We have a solution, imperfect, to attempt to deal with the disease. We have to let physicians employing good clinical judgement use it and informed patients choose it. There is a small chance that it may not work. But the urgency demands that we at least start to take that risk and evaluate what happens, and if our situation does not improve we can stop it, but we will know that we did everything that we could instead of sitting by and letting hundreds of thousands die because we did not have the courage to act according to our rational calculations." [emphasis mine]

What is the main takeaway from this paper?

"Five studies including two controlled clinical trials, have demonstrated significant major outpatient treatment efficacy of treatment with Hydroxychloroquine + Azithromycin."

This concludes my excerpts from Dr. Risch's paper. You may want to read his paper firsthand or perhaps read the article that he wrote in Newsweek on July 23.

Housekeeping

Dr. Risch's 2nd rebuttal (file "kwaa152") contained an interesting reference ("5") whose headline said, "Media and Big Pharma are in lockstep to suppress a cheap, life-saving Covid-19 therapy in order to reap pandemic-sized profits." Time will tell.

Practical question for the reader

Would you take HCQ+AZ (+ also Zinc) if you were to develop Covid-19 symptoms? 

I know I would given that I don't have any existing heart conditions. (Crossed out and modified below during Aug. 20's edits.)

I would, but only if I was in a high-risk category (above 60, with coexisting conditions, high probability of mortality) but without any existing heart conditions. (Crossed out during Aug. 29's edits. The risk to people with heart conditions was quoted as either 9-in-10,000 or 9-in-100,000 by Dr. Risch. Citation needed.)


Endnotes

1. "High risk". In my original blogpost, I hadn't picked up Dr. Risch's point that his proposed treatment is suitable only for high risk patients. I picked this up from his interview (item #3 below). High risk means high probability of mortality (e.g. 10-15%). People older than 60 who have coexisting conditions are considered high risk.

2. Dr. Risch's interview on Fox News. Published Aug. 3, 2020

3. Dr. Risch's follow-on interview to his CNN interview. Published Aug. 3, 2020. Dr. Risch makes his case starting at minute 4:25. 

4. Dr. Risch mentions that historically many drugs that have been admitted for patient treatment haven't been subjected to RCT (randomized controlled trial). So it is rather strange that Dr. Fauci is now bringing up RCT as the requirement for allowing treatment with HCQ, in my opinion.

5. Disclosure: I am not a die-hard Trump fan by any means!

6. Dr. Risch answers questions on Fox News: part 1, part 2. Published Aug. 23, 2020.

Author's Tweet about this blogpost

Author is also on Twitter

Remaining Excerpts from 

Lyn Alden's Primer on 

QE, MMT, and Inflation/Deflation

Lyn Alden had written an article entitled "Quantitative Easing, MMT, and Inflation/Deflation: A Primer". Last updated on June 5, 2020.

I had started writing a series of Tweets to quote various excerpts. (That was a little over 2 weeks ago.) I had collected the remaining excerpts but instead of proceeding to present them as a series of Tweets, figured out that it made more sense to present them as a single document which is what I've done below. If anything in these excerpts doesn't make sense, it means that it's time to read the original article itself.

Recent History of Inflation in US, 2008-2020

“Broad money supply (M2) per capita increased by an annualized rate of about 5.0% [over 2008-2020].

Official consumer price inflation only increased by an annualized rate of about 1.6% during that timeframe.

So, trillions of new dollars were created on an absolute basis and a per-capita basis, with limited effect on many prices. This is unintuitive to many, but there are several reasons for this.

[T]his newly-created money from QE in 2008 to 2014 went up against several deflationary forces.”

What’s inflationary and what’s deflationary?

Increases in money supply are inflationary.

But, all of the following are deflationary:

Technology is deflationary. (E.g. smartphone as a tech Swiss Army knife)

Offshoring is deflationary.

Onshoring is deflationary. (E.g. cheap immigrant workers.)

Unprofitable businesses are deflationary. (E.g. Uber, WeWork)

Cheap commodity prices are deflationary.

Wealth concentration is deflationary.

Lower asset prices are deflationary.

Debt defaults are deflationary.

Aging demographics are deflationary. 

Trade surpluses are deflationary. (Corollary: trade deficits are inflationary.)

“Before monetary policy is factored in, deflation is the natural order of a productive economy.”

“[In the aftermath of the 2008/2009 GFC, t]he $3.6 trillion in totally new dollars for QE that came out of the Fed’s void and injecting into the economy was small compared to this total initial base of existing wealth ($71.3 trillion), and small compared to the amount of paper wealth that had recently been lost ($11 trillion). The new money just offset a part of what was otherwise a large deflationary shock.”

Current Covid-19 Crisis

“We’re currently experiencing another huge deflationary shock from the impact of COVID-19 on a highly-leveraged global financial system, as many people have lost incomes and asset prices have fallen, but large fixed debts remain, expecting payment.”

“The United States went into this crisis with total debt (government, corporate, and household) equal to about 350% of GDP or $75 trillion in absolute terms, which is a very deflationary force. We began the 2008 crisis with about a 350% debt/GDP ratio as well.”

“In the years ahead, the possibility for broad inflation is back on the table.”

“As pandemic lockdowns ease and ongoing government stimulus tries to get the economy back up off the floor, consumer demand can increase while the new money supply remains in the system.”

“Over the multi-year longer-run, if we see a trend towards bringing a portion of our supply chains back to the United States, that could further raise inflationary pressures because it would start to undo one of the major deflationary outlets (offshoring) that has been in place for decades.”

2020 Starting baseline

“At the end of 2019, total U.S. household net worth was over $118 trillion, U.S. GDP was just under $22 trillion, and U.S. broad money supply was about $15 trillion, as reported by the St. Louis Fed with sources to the relevant agencies that collect those statistics. The Fed’s balance sheet ended 2019 a bit over $4 trillion. That’s our starting baseline, rounded.”

(But note $75 trillion in aggregate debt too! That’s government, corporate, and household debt altogether.)

“

Almost $11 trillion in U.S. equity wealth was wiped away from the Wilshire 5000 full-cap U.S. equity market from peak to trough in Q1 of 2020, although as of this writing we’ve partially rebounded from those lows.

For every 5% of the $118 trillion in U.S. household net worth that was or will be lost in this crisis from peak to trough, that would be $5.9 trillion in wealth wiped away.

[T]he Fed’s balance sheet is expected by many estimates to expand from $4 trillion to $10 trillion this year, and is already up to $6.7 trillion within two months of the crisis and is still growing at a swift rate. If we reach a $10 trillion balance sheet this year compared to the $4 trillion that the Fed came into the year with, that will be $6 trillion in new capital injected into the economy ...

Would $6 trillion in new capital lead to massive inflation this year, in the face of such a deflationary shock and wealth destruction? Probably not. This money-printing would counteract some of the deflationary shock of so much debt and lost spending and income, but not necessarily spur a lot of new inflation right away, ...

What if the Fed boosts its balance sheet to $15-$20 trillion by the end of next year or the year after, meaning it injects $11-$16 trillion into the system from its starting balance sheet of $4 trillion, particular [sic] if a significant portion of that is to finance crisis-level helicopter checks, extended unemployment benefits and other Main Street expenditures by the government? Well now we’re talking large numbers, and the possibility for intermediate-term inflation is more on the table. Not hyperinflation, but inflation.

It’s the next few years in the future, where we really need to think about broad inflation after so much aggressive policy response and expansion of the money supply.

[T]he bottom 50% of Americans have very little safeguards against total insolvency. Specifically, the bottom 50% of Americans collectively have only 1.5% of the country’s household net worth, which is down from 4% in the 1990s. Their assets and liabilities are nearly equal, resulting in a very low average net worth, ...

So, the combination of the Treasury and the Federal Reserve is injecting a 5% annualized rate of the country’s GDP of new money into the economy in an MMT-like situation right before we found ourselves in this virus crisis.

Going forward, the United States has a structural rising 5% deficit and then some combination of crisis intervention (already projected to be $2.7-$4 trillion or more this year, or 12-18% of GDP) and potential stimulus (infrastructure renewal and continued checks, and so forth going forward in the years ahead) on top of that 5% baseline. After this year with a deficit of 20%+ of GDP, there is a decent probability of several years of fiscal deficits of 10%+ of GDP, and mostly funded by new money from the Federal Reserve. That’s $4+ trillion this year and $2 trillion+ per following year for a while after that in new money injection into the economy.

“

“The biggest variable in the near-term and intermediate-term to monitor for broad consumer price inflation in my view (outside of targeted areas of supply chain disruptions) is the total amount of QE-funded money that makes it to Main Street, meaning to the public, as well as their ability to come out of quarantine and spend it.”

“Outside of food, healthcare, and other essentials which have inflationary catalysts at the moment, the trend is likely to be disinflationary for many discretionary goods and services until a large amount of helicopter-like money ends up on Main Street.”

Author is also on  Twitter

List of Previously Pinned Tweets

In January 2020, I started the practice of pinning my Tweets. Pinned Tweets are somewhat more special, fundamental, or deeper than my other Tweets. They may be worth referring back to. So, it made sense to compile the list which appears here.

In April 2021, I added a sentence or two starting with "Why did I pin this?" in order to convey my motivation for pinning each Tweet.

----------------------------------------------------------------------------------------------

15. The Great Taking; Dec. 19, 2023

Why did I pin this? It explains a lot of things that I've been thinking about for more than a decade such as, why is global debt-to-GDP so high? Why does it keep rising? How come no one in leadership positions seems to express concern publicly? 

14. Insights into Federal Reserve policy; May 26, 2023

Why did I pin this? I'm fascinated by the Fed and its intentions. Michael Burry and John Hussman have both called it "willfully ignorant". 

13. Pacer's family of Cash Cow ETFs; Feb. 5, 2023

Why did I pin this? These ETFs are based on maximizing FCF/EV or the ratio of Free Cash Flow to Enterprise Value (which is Market Cap plus Debt minus Cash). This is a screen that makes good fundamental sense and provides conviction when allocating capital. The ETFs also involve periodic rebalancing which is also good.

12. [Allen Farrington] Bitcoin as Base Money ("Only the Strong Survive"), Farrington's writings, The people Farrington reads; Oct. 29-31, 2021

    

Why did I pin this? I was moved as much by Farrington's Only the Strong Survive as I was by John Pfeffer's 2017 article on Bitcoin. Up until reading Farrington's article, I thought that Ethereum was a "more evolved" cryptocurrency than Bitcoin. This article made me aware that there is a strong case in favor of Bitcoin in so far as base money is concerned. Also, all of Ethereum's features (e.g. smart contracts, transaction speed) can also be built as higher layers on top of Bitcoin (e.g. Lightning). I need to delve into these topics further.

11. Volatility Cycle; Oct. 14, 2021

Why did I pin this? The article makes it possible to better appreciate volatility.

10. [Steven Van Metre, Hoisington] QE: is it inflationary or deflationary? Tweet1, Tweet 2; April 4-6, 2021

Why did I pin this? Understanding inflation requires not only understanding the change in both demand and supply for the good in question, but also the change in both demand and supply for the currency in which that good is priced. When QE isn't accompanied by lending, it causes money demand growth to exceed money supply growth which is deflationary assuming no change in the demand or supply for the good in question.

9. [Harley Bassman] The Convexity Maven; March 10, 2021

Why did I pin this? A practical discussion of how to construct an investment position so that it has a convex payoff instead of a linear one.

8. [Doug Casey] Parallels between Ancient Rome and modern day US; Dec. 31, 2020

Why did I pin this? The problems of modern US are anything but simple and ordinary.

7. [Economist Magazine covers] Complete list of The Economist magazine covers; Dec. 31, 2020

Why did I pin this? An exercise in trying to detect any correlation between these magazine covers and aggregate stock market level.

6. [Logica] Quantitative Analysis of US Stock Market: Tweet 1, Tweet 2; Aug. 29, 2020

Why did I pin this? Interesting use of quantitative analysis in order to obtain an edge in securities markets.

5. CAPE Ratio by Country, Aug. 20, 2020

Why did I pin this? A low CAPE ratio country is not necessarily a good buy unless one expects it to rise during the holding period that one might have in mind; a rule of thumb would be to compare the low CAPE ratio to its historical average. The opposite kind of statement can be made about a high CAPE ratio country.

4. [Ray Dalio] Excerpts from his online Book entitled "The Changing World Order, Chapter 1", aka Cycles of Rising and Declining Empires, May 22, 2020

Why did I pin this? A multi-century study of the rise and fall of empires and major global powers is likely to contain useful insights for our future.

3. [Jim Rickards] How does it make sense for people to be making both a bearish forecast on gold as well as a bullish one?, aka "Deflation then Inflation", April 26, 2020

Why did I pin this? It's rational to simultaneously be expecting both inflation and deflation because the time horizons for each might be different.

2. [Jeffrey Gundlach] Selected Slides from his Webinar entitled "A Tale of Two Sinks", March 31, 2020

Why did I pin this? Can't recall what was going through my mind at the time ... The timing was a week after the trough in US stock prices in the era of Covid-19.

1. [Lyn Alden] Her Expectations for the Next Decade, Jan. 10, 2020

Why did I pin this? I thought it was important to point out Alden's bearish stance on US stocks and bullish stance on precious metals.

Note about "Likes": Likes are nothing more than bookmarks for me. They are a private matter and I'm not too pleased with Twitter's practice of broadcasting them.

Selected Slides from Mary Meeker's 2019 Internet Report

(without Commentary)

Mary Meeker's Internet Report was published in June 2019. A complete list of her annual Internet Reports may be found here. 

Previously, I had written a blogpost containing selected slides from Meeker's 2018 report which may be accessed here.

Why did I create this blogpost? It contains 60 slides. It's shorter than Meeker's 300+ slide deck so it is faster to go through them. I selected slides that resonated with me or which made personal sense or which I thought I would one day like to refer back to. 

These slides probably tell a different story than Meeker's original slide deck.

Author is also on Twitter.