'You don't need any of these 10 drugs'

'The vast majority of people are going to get better.'
'And the small fraction, who are not going to get better, unfortunately, there's no drug that we have that can that can alter the trajectory.'

Dr Lancelot M Pinto, a respirologist attached to the P D Hinduja Hospital and Research Centre, Mahim, north central Mumbai, belongs to that school of evidence-based pandemic-fighting Indian doctors, who knows there are very few -- or unfortunately, frighteningly, almost no drugs still -- that will make a difference while treating either the mild or the serious COVID-19 ill.

Most of the COVID-19 sick, especially everyone with mild attacks of the disease, will get better and there is absolutely no necessity for medication.

That is: You don't need any medicines if you have contracted a mild case of COVID-19 and your oximeter reading is not dropping.

Ninety-seven per cent plus people, with this abominable viral disease, who have no comorbidities, shall recover completely, by themselves, without requiring even a prescription.

This is a simple truth.

One that just about anybody should be able to understand and relate to, you would think?

But as is the case, the most self-evident of truths are somehow the hardest to comprehend. Let alone digest.

Especially when the truth about the right protocol for COVID-19 treatment is drowned out by the urgency of the cacophony in favour of the more discordant combination of ineffectual drugs believed to be 'necessary'.

For doctors like Dr Pinto, for whom less is more, minimalistic prescriptions for his patients in times like this, when the hysteria of fear is at its shrillest pitch, is actually a tough and not very popular job.

A respiratory disease specialist -- who earned an additional degree in epidemiology from McGill University, Montreal, Canada, and has fellowship of the American College of Chest Physicians -- Dr Pinto is a clinician and researcher with a special interest in tuberculosis, Chronic Obstructive Pulmonary Disease and smoking cessation.

But since last year has devoted most of his time to the COVID-19 afflicted and the puzzling concerns and overconcerns relating to this disease.

In the first of a multi-part interview, Dr Pinto talks about the dilemma of prescriptions drugs to Vaihayasi Pande Daniel/Rediff.com

What is the situation in Mumbai at the moment? And how does it look? Are both cases and deaths easing?

I think it's definitely better, for sure. In terms of both cases and in terms of the work in a hospital. So, my perceptions are skewed, in terms of what's happening at the hospital level, and, the number of patients getting admitted to both the ICU, as well as the regular beds, has definitely decreased.

So, it's looking considerably better?

Much, much, better.

How difficult it is to work in an environment where so many other fellow doctors are sort of bent on treating COVID-19 patients with many, many more drugs than required?
I have a sister, who is a psychiatrist in LA, and she was telling me that under-prescribing is one of the hardest jobs to do, but it's also one of the doctor's most important tasks.
It's also very difficult, she says, to just stick to your guns and say, 'No, I won't prescribe anything. It's not required'.
If it's that problematic in LA, in India it must be so much more difficult, where over-prescribing is rampant?

I couldn't agree more.

That's directly proportional to the paranoia generated by a disease, right?

So, if you are under-prescribing for something that is, preventive, patients are very, very happy, very often, because they don't feel a perceived need of treatment then.

But when it comes to a disease that's associated with the amount of paranoia that you're seeing right now (with COVID-19) -- where almost every patient has some sort of an experience in terms of their loved one, their friends, their family or somebody who's already been treated, and has been treated with a bunch of drugs -- in that kind of an environment, to stick to your guns and say, 'Yes, I know your friends have been treated with 10 drugs, but I really don't think you need any of these 10 drugs', is extremely challenging.

So, it's given the fact that A. There's a lot of paranoia all around; B. Most individuals have had some sort of experience with somebody they know, receiving polypharmacy. It's this combination of paranoia plus knowing somebody who got better with a bunch of drugs (which makes it worse).

Now, clearly, we don't believe that they (the patient's relative) got better because of the bunch of drugs, because we believe they would have gotten better in any case.

But from a patient's perspective, they got better, because they saw the 'right' doctor, who gave them a bunch of drugs. And then, if they come and see you, it's very difficult for them to digest the fact that you strongly believe that they can get better, despite the fact that they don't take any of the drugs, that the people they know, have been prescribed.

So, it's extremely challenging.

And tough?

Obviously the more junior you are, the more difficult it is, because India has a very hierarchical society, when it comes to even doctors.

So, if a senior doctor prescribes a bunch of drugs, and somebody who's younger (comes along and) says 'You know, none of this works', is very challenging and been extremely difficult.

The only good thing -- and I say 'good' in a facetious manner, maybe -- the only good thing is that people 'doctor shop' in India. If they aren't happy with you, they will just end up going to some other doctor, who will give them the 10 drugs.

It doesn't become confrontational in that sense. Unlike a public system, where had they come to me, I would be bound by the fact that it's a public system etc and patients could get confrontational with me, because they potentially think that they have a right to decide what I should be prescribing to them.

In my case, if they are not happy, very often, they will seek a second opinion and get the drugs anyway.

I don't want to ask this, because it's just sort of a dark question, but I should still ask it. In this particular COVID-19 situation, is there some sort of darker reason for doctors to keep prescribing these medications? They're all very expensive.

I don't think it's necessarily coming from there.

It would be impossible to know the answer to that question. Transparency, right?

There's nobody who's going to be able to answer a question like this.

I haven't been offered a kickback by any pharma (company). I can speak for myself that I haven't been incentivised in any way. But then that could also be because a majority of people working in pharma know that incentives don't work with me.

I don't know how that (incentive) system works. It's very difficult to know, because unless somebody confesses to this, it is going to be difficult to know whether that's the case.

I wouldn't want to speculate on that because it's difficult to know.

But I genuinely believe -- and I've said this before -- so COVID-19 is a disease where, in the worst-case scenario, 85 per cent people get better without anything (any drug). And in the best-case scenario, we think, probably 95 per cent of people get better without anything.

If you look at, for example, the antibody cocktail study, which was recently published, which is in a preprint right now, they had a rate of 3.2 per cent hospitalization, in the placebo arm (ie those who did not get the cocktail of the drug trial for this new REGN-COV2 drug combination). And these were individuals who had at least one risk factor.

So even if you have one risk factor, the risk of hospitalisation in that study was about 3.2 per cent, which means that 97 per cent of individuals got better even without being hospitalised, with possibly nothing (no medication), because this is not conducted in India and this was conducted in a place where nothing would be offered for people (sick with COVID-19) at home by and large, right?

If 97 per cent individuals are going to get better without any treatment, whatever the doctor gives, it kind of reinforces his belief that 95 per cent of his/her patients are getting better because of what he/she has given them.

If a doctor prescribes 10 drugs, and they get better that completely reinforces his confidence in those 10 drugs.

The only way you get confident in minimalistic or evidence-based medicine, that believes in minimalism, is if you practice it and genuinely get that feedback.

If you're not giving yourself the chance to practice that, it's very difficult for a doctor to step back, once he has done things and the reinforcement is that people are getting better (because of, he feels, his regimen of medication and not because they would have regardless)

This is why you have these whole schools of thought, if you speak to doctors across the city. For example, there will be one doctor who will swear by a favivirapir. There'll be another doctor, who will swear by doxycycline. They'll be a third doctor who will swear by zinc or whatever it is.

Everyone has their own cocktail, because those cocktails have been reinforced by the fact that 97 per cent of people got better.

Yes, I heard the same from my sister. She says her medical colleagues in India feel these huge prescriptions actually work and doctors are prescribing this complex cocktail of drugs for their own family too and they feel it is having some effect, which could also be, as you said, the fact that with COVID-19 most people get better anyway, whether they received a medication or not.

Exactly, exactly.

Which is why I think maybe there isn't necessarily a dark side to this. Maybe it's just the reinforcement of false beliefs, which has happened, by virtue of the fact that you've never ever tried not give too many medications to begin with.

So, the fact that, you rightly said, probably they would treat themselves or even their own family with the same cocktails that they are prescribing, would suggest that it may not be purely incentive-driven. It may be genuine belief that they are doing good.

IMAGE: Dr Lancelot M Pinto. Photograph: Kind courtesy Dr Lancelot M Pinto

It's very hard to persuade people, who are sick at home with mild COVID-19 and have no comorbidities, that they are erroneous to consider following enormous prescriptions, when they just need paracetamol.
How do you put it to them?
What is your most sensible advice to people, who are getting sick with mild COVID-19.

Fortunately, for me, lot of my referrals come to me by word of mouth. That really helps.

If that referral comes by a word of mouth, then the person has this inherent trust in the place, where it doesn't become that challenging for me to then even state things that they would find ordinarily ridiculous based on their experiences (with others who are being treated with more drugs rather than less).

With a good percentage of patients though it takes a little more time in terms of counseling, it takes a little more time in terms of explaining things.

And that's been my pet peeve. What's really been annoying to a certain extent is that a person practicing evidence-based medicine needs to just justify his actions, way more than the person doing all sorts of other things, which don't go by the book.

For the doctor who is prescribing 10 medications: The patient probably walks in, gets a prescription, walks out within a span of 10 minutes.

But I have to speak for about half an hour -- which I'm happy to do -- but I have to justify, explain to them these statistics, tell them: 'Listen, the vast majority of people are going to get better. And the small fraction, who are not going to get better, unfortunately, there's no drug that we have that can that can alter the trajectory'.

I mean, the (new) antibody cocktail might be one of them, inhaled steroids might be one of them, and we are using them right now. But, but apart from these two drugs, in the early stages, we have nothing that that influences the trajectory, unfortunately.

That's the flip side, right? When I, when I choose to give nothing, I do that with full cognizance of the fact that a small percentage of these individuals are going to deteriorate.

And those individuals, who do deteriorate, at that point are definitely going to wonder if things would have been different had they taken the whole bunch of drugs.

That's sort of what can happen, which you have to worry about?

Right, which gives me nightmares.

I don't sleep at night peacefully, because although I know that I'm doing the right thing, I also know that there's going to be a perception in this small fraction of individuals, who deteriorate, there's going to be this question mark hovering over their head, whether did we did we do the right thing by not taking all the drugs that the entire country is taking right now.

• PART II: Received Both Doses? Be Careful Please

• Coronavirus Interviews You Must Read
• THE WAR AGAINST CORONAVIRUS

*Kindly note the image has been posted only for representational purposes.

Feature Presentation: Ashish Narsale/ Rediff.com