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Should I advocate for people to not buy Ivermectin as a treatment for COVID-19 in the Philippines for now?

by BrianTan2 min read31st Mar 20218 comments

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Hey all, I'm from the Philippines, and there's a huge debate currently in mainstream Philippine media on whether Ivermectin is an effective treatment for COVID-19 or not. And I'm wondering if I should advocate for people to not buy Ivermectin as a treatment for COVID-19 in the Philippines for now. I also want to know if I should be advocating for the Philippine FDA to continue banning its use (or to approve its use). If anyone here has knowledge on Ivermectin, or has spent a bit of time looking at the evidence about it, I'd love to hear your thoughts on it.

For context, "Some doctors in the Philippines and abroad, as well as a number of lawmakers, urged the Department of Health and the Food and Drug Administration (FDA) to hasten the process of approving Ivermectin as a COVID-19 treatment in the country."

The Philippine FDA has not even approved Ivermectin for use by humans, and yet there are local doctors who prescribe it to patients. Some people find ways to procure it (and they may even be unintentionally procuring fake Ivermectin products sold by scammers). And yet, I've heard of some people in my network who are are thinking of buying it or have already bought it for themselves.

Currently, I sense that the majority of Filipinos are skeptical, and they think that there isn't good evidence for Ivermectin as an effective treatment for COVID-19. This statement, released by a group of multiple reputable health associations in the Philippines, does not recommend the use of Ivermectin as a treatment for COVID-19, and they cite what seem to be reputable studies (randomized control trials, though they may be small ~100-person samples) showing that Ivermectin has no statistically significant effect vs. control groups in treating mild or moderate cases of COVID-19. Meanwhile, "the World Health Organization (WHO) Representative to the Philippines Dr. Rabindra Abeyasinghe stressed on Tuesday, March 30, the need for "carefully controlled and planned" clinical trials of the anti-parasitic drug Ivermectin before it could be used to treat COVID-19 in the country."

I want to form better beliefs myself from the available evidence and figure out if I should be telling people in my network to not buy Ivermectin as a treatment for COVID-19. I'm leaning on doing that already, but am open to hearing others' views here on LessWrong. 

I also want advice generally on how one can form better beliefs about effective medical treatments. Based on reading Rob Bensinger's COVID-19 Overview on LessWrong and doing some of my own research, I think Zinc and Vitamin D3 should be taken by people with mild to moderate cases as a treatment for COVID-19. But I've seen some conflicting articles/studies/RCTs/meta-analyses out there on Zinc and Vitamin D3, with some saying there's a statistically significant effect on treating COVID-19 and some saying there's none, so I'm not sure what to do about my view in light of those evidence. Any thoughts on the effectiveness of Zinc and Vitamin D3, or how to form beliefs based on medical studies / journal articles, would be helpful. Thanks!

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3 Answers

To the question of whether Ivermectin is useful as a treatment: I don't know. A skim through Google Scholar certainly suggests it has some promise, and the side-effect profile is mild enough that the risk-reward seems likely to work out.

This question has gotten far too little attention from good intellectuals. A good distillation of the research would be very valuable.

To the question that was asked, about whether you should do advocacy on this topic (in either direction): No. You are not ready.

The COVID-19 pandemic has had a long string of incidents where prominent institutions look at something which has a complicated, messy and unclear evidence base, decide they need to take a stance, and either pretend to be confident, or pretend that cost-benefit analysis is impossible so their lack-of-confidence means no one should do anything. This happened with masks early in the pandemic, with the question of whether there's aerosol transmission, with the question of whether there's presymptomatic transmission, with the mRNA vaccines between when the study results came in and when the FDA finally approved them, with the AstraZeneca vaccine and phantom worries about blood clots. The WHO, US CDC, and US FDA all severely tarnished their reputations this way, and it's unlikely they'll earn back trust any time soon.

If the place you start from is that you're going to do public advocacy, but you need to decide whether you're advocating for or advocating against, then it will be hard to engage with a complicated/messy/unclear evidence base and remain honest. You'll be incentivized not to see the situation for what it is.

Suppose there's a 25% chance that Ivermectin works. If you convey that information honestly, that's a good thing to do, but it isn't an advocacy campaign--you're doing useful research, but not advocating a policy position.

Suppose the answer is that ivermectin definitely works, but only a little bit--eg, it reduces mortality by 10%. A big chunk of the public thinks it works a lot better than that, and is taking dumb risks on that basis. You'll be tempted to lie to those people.

To the question of how one can form better beliefs about effective medical treatments:

For questions that are not politicized and not fast moving (ie, most things other than COVID-19), use UpToDate to orient, then go to primary-source papers only when you have a specific question in mind, and only when you're kind of desperate.

For questions that are politicized or fast moving (ie, COVID-19 treatments), where you're doing original distillation work: use Wikipedia to orient on the relevant biology and terminology, then collect primary-source studies from PubMed, Google Scholar, and (for COVID-19 in particular) medrxiv. You have to be pretty systematic about it, since the number of usable studies tends to be small enough that accidentally omitting one is a big deal. You'll need to know how to reliably bypass the paywalls (mostly Sci-Hub), and how to judge reliability based on a methodology section.

This was really helpful Jim!

When I said public advocacy though, I mainly meant making a Facebook post communicating my beliefs about Ivermectin and whether people should take it or not, which 50-500 people in my network might see. So I could convey my beliefs honestly about Ivermectin in that post and at length, and I'm open to conveying I am uncertain about it.

That being said, from your comment, I realize that there's a large chance that whatever beliefs I communicate about Ivermectin will be wrong, and being wrong about it publicly can tarnish my reputat... (read more)

I just listened to a podcast talking about how great Ivermecin is, and fund this post because I was trying to find out what LWers though about this.

Here's a bunch of links from that podcast, which seems legit, but I've mostly have not looked into them. If you do follow up on this, let me know what you think.

The FLCCC: https://covid19criticalcare.com/

British Ivermectin Recommendation Development group: https://bird-group.org

The BIRD Recommendation on the Use of Ivermectin for Covid-19:

Executive Summary: https://bird-group.org/wp-content/upl...

Carvallo et al 2020. Study of the efficacy and safety of topical ivermectin+ iota-carrageenan in the prophylaxis against COVID-19 in health personnel. J. Biomed. Res. Clin. Investig., 2. https://medicalpressopenaccess.com/up...

Cobos-Campos et al 2021.Potential use of ivermectin for the treatment and prophylaxis of SARS-CoV-2 infection: Efficacy of ivermectin for SARS-CoV-2. Clin Res Trials, 7: 1-5. https://www.readkong.com/page/potenti...

Database of all ivermectin COVID-19 studies. 93 studies, 55 peer reviewed, 56 with results comparing treatment and control groups: https://c19ivermectin.com

Karale et al 2021. A Meta-analysis of Mortality, Need for ICU admission, Use of Mechanical Ventilation and Adverse Effects with Ivermectin Use in COVID-19 Patients. medRxiv. https://www.medrxiv.org/content/medrx...

Kory et al 2021. Review of the Emerging Evidence Demonstrating the Efficacy of Ivermectin in the Prophylaxis and Treatment of COVID-19. American Journal of Therapeutics, 28(3): e299: https://www.ncbi.nlm.nih.gov/pmc/arti...

Nardelli et al 2021. Crying wolf in time of Corona: the strange case of ivermectin and hydroxychloroquine. Is the fear of failure withholding potential life-saving treatment from clinical use?. Signa Vitae, 1: 2. https://oss.signavitae.com/mre-signav...

Yagisawa et al 2021. Global trends in clinical studies of ivermectin in COVID-19. The Japanese Journal of Antibiotics, 74: 1. https://www.psychoactif.org/forum/upl...

I’m not a doctor. This is not medical advice.

There’s an organization tracking this kind of stuff, see CETF. The most promising treatment they have listed is fluvoxamine. I would get that if you get anything, but it’s still not certain. https://www.treatearly.org/promising-drugs

You should also check Scott’s article on Vitamin D. I think Zinc and D in dosages below TUL daily are not a terrible idea (low risk, medium to high reward). The RCTs are mixed. https://astralcodexten.substack.com/p/covidvitamin-d-much-more-than-you

Thanks for linking both of those resources! I hadn't heard of CETF before. I'm not sure how much to trust CETF, but that's an interesting resource. Their website led me to the New York Times' treatment tracker though, and generally I find the NYT pretty reputable. I wonder why fluvoxamine, and to a smaller extent remdesivir, aren't talked about a lot yet in the Philippines as having promising evidence as a treatment for COVID.

Thanks also for linking Scott's article. I had heard of it but hadn't read it much until today. It's interesting that he only thinks... (read more)

4Matthew Elvey6moI contacted the maintainer of the New York Times treatment tracker when her Information about Ivermectin was sorely (months) out of date. The interaction led me to conclude it’s not a reliable source. She promptly blocked me and didn’t respond and didn’t update it. I’m new here (or misplaced my credentials) so I won’t link to the tweet of the DM but it’s public. I’ve read all the primary source clinical trial studies on ivermectin for Covid. (including the one that just came out on 6/2. ). Either the reporter hasn’t read most of them or she’s part of the disinformation campaign.
5Linda Linsefors6moMatthew, what's your current best guess about Ivermectin as Covid treatment?