Winston Churchill once said that “gin and tonic has saved more Englishmen’s lives, and minds, than all the doctors in the Empire.” Now, Churchill himself mostly drank whisky – 3-4 ounces at 11 am, teatime and bedtime. This strict health regimen was accompanied by some champagne, wine and brandy to wash down lunch and dinner. So, what made Churchill speak so glowingly about G&T?
The answer lies in what tonic used to contain in those days – it was a powder extracted from the bark of the cinchona tree called quinine. The powder not only treated malaria – that great scourge of the Indian colony – but also helped prevent it. But it was so bitter that the British officials began mixing it with soda and sugar, giving birth to ‘tonic’. Embellished with an ounce or two of gin, it prevented malaria and saved thousands of lives.
Now, an advanced synthetic version of the same malaria drug, called hydroxychloroquine or HCQ, could end up saving thousands of lives in the time of COVID-19. A few small studies done in France and China where coronavirus patients were given HCQ showed a significant improvement in a large number of them. Although two recent studies have challenged these claims, HCQ is being used widely by doctors across the world to fight the coronavirus. France allowed it for very sick patients, while the US FDA has allowed doctors to give it to hospitalised patients if they think it is needed.
The hydroxychloroquine drug is being tested on at least 1,500 coronavirus patients in New York
Since the world and their uncle has been googling furiously ever since COVID-19 became a global pandemic, HCQ has disappeared from most markets. The drug is used not just for malaria but also as regular treatment for auto-immune diseases like lupus and rheumatoid arthritis. India usually consumes 20 lakh pills every month to treat these three diseases. Ever since people got to know that HCQ might help fight the novel coronavirus, they began hoarding the drug, leading to shortages for people who need it right now.
That is one reason why India banned the export of HCQ on March 25. This came as a big blow to US President Donald Trump, who has been championing the drug as a ‘gamechanger’. India produces 70 percent of the world’s HCQ and accounts for 47 percent of what is sold in the USA. So when Trump learned that India had stopped all HCQ exports, he threatened to ‘retaliate’. The very next day, India lifted the ban, allowing the drug to be sold to our neighbours and to a few badly affected countries. The US, with the highest number of COVID-positive cases in the world, clearly makes it to that list.
The US has already stockpiled 31 million doses of HCQ of 200 mg each. But how many people will that cover? The early trials in France used three pills a day for 10 days for each patient, or a total of 30 pills per person. A randomized control trial in Wuhan involved giving 2 pills a day for 5 days, or 10 pills per patient. China’s multicentre collaboration group recommends a higher dose of a total of a 100 pill-equivalents to COVID-19 patients with pneumonia. Other trials recommend 14 pills to be give over two weeks.
Although there is no clear consensus on what the dosage should be, if one takes as the average required dose the relatively conservative 14 pills per patient regimen, the US can cover about 2.2 million people with the HCQ it currently has in its stockpile. That is just 0.7 percent of its population, which is hardly anything considering that various models suggest that over 150 million Americans, or nearly half of the country’s population, could catch the virus this year. So the US needs to import a whole lot more of HCQ from India.
How much can we export? Indian companies – IPCA labs, Zydus Cadila, Wallace Pharma among others – have the capacity to produce 20 crore pills every month. Although these companies say they can ramp up their capacities to 35 crore pills by end of May, it is easier said than done in the time of such supply-chain disruptions.
News reports suggest that the Modi government intends to keep a stock of 10-crore pills, and allow the rest to be exported. If we take a 14-pill regimen per person, India will be able to cover 71 lakh people with the pills in its stock. That is just about 0.5 percent of our population. If the US were to import 40 percent of the remaining 10 crore pills, it would end up with 71 million doses in its stock. That will help it cover 1.5 percent of its population. That means Americans could end up with three times the coverage with a drug that is mostly manufactured in our country.
One could argue that India doesn’t have that many coronavirus patients and therefore, we don’t need to keep so much HCQ with us. One could also argue that the idea that HCQ could prevent and cure COVID-19 is more about hope than real scientific evidence. So if Indian companies can make good money from Trump’s idiosyncratic optimism about HCQ and a few test studies, then why stop it?
The point is that the entire game of fighting the coronavirus is about anticipating the future and being prepared for it. HCQ could well turn out to be the gamechanger Trump believes it to be. For a country like India, which is short of hospital beds, ICU facilities and ventilators, there is no conscionable ground to export HCQ till we have built a stockpile that can cover a significant part of our population. The US wouldn’t have thought twice before banning HCQ exports if it were the world’s largest producer of the drug. After all, one’s own citizens must come first before we start talking about cooperation between nations.