Not many had heard of hydroxychloroquine at the start of the year.
Back in January, some doctors in China began treating COVID-19 patients with the anti-malarial drug, but it was just one of many treatments attempted to stave off the quickly spreading virus.
So how did hydroxychloroquine go from an experimental treatment to being touted by President Donald Trump as a "game changer" in the fight against novel coronavirus?
Medicinal misinformation is not a new problem -- in one example, false rumors abounded during the HIV/AIDS crisis -- but the speed and spread of misinformation related to COVID-19 is on a scale never before seen.
"We've never had a global story like this where people are going through the same experiences in different countries," Claire Wardle of First Draft, a non-profit that researches information disorder, told ABC News. "We're seeing a lot of misinformation jumping from South Africa to London to New York. We haven't recognized the power of misinformation until now. A lot of it has been about political speech, but now this information could actually be harmful to people."
Wardle also said that because the virus is so new and scientists and doctors still don't know much, that information vacuum allows falsities to thrive.
"We've never really had a story where facts felt so slippy," Wardle added. "You hear people say, 'I was told not to wear a mask, and now I'm being told to wear a mask.' When you have a new virus, the data that you have is so young that the doctors haven't had a chance to do the research. So if you hear anybody saying they're certain about anything related to COVID-19, you need to be really skeptical."
Researchers from social media agency Storyful and First Draft News identified a few key moments that they believe amplified messaging around the drug's ties to COVID-19 treatments. There was very little mention of hydroxychloroquine or its chemical cousin chloroquine on English language social media before February, but it appears three key events helped shape the social media conversation around the drug.
French doctor claims to have a cure
On Feb. 25, Didier Raoult, a French doctor, posted a video promoting the use of hydroxychloroquine to treat COVID-19. The following day, an interview he did with La Provence was posted to Facebook and started to gain traction.
Chinese state-run media had touted the drug as a potential cure earlier in February, and a Nigerian doctor made a similar claim, but it was the French doctor who seemed to capture the attention of social media users. An interview with Russian state-owned television, RT News, published Feb. 27, had about 350,000 views as of Thursday.
Raoult's study, published March 20, has been heavily criticized by scientists and academics for not being double-blind and randomized, widely considered the standard for clinical trials. In a double-blind study, neither the patient nor the doctor knows which group each subject is in, reducing the possibility that doctors treat the subjects differently and affect the outcome.
According to a statement issued April 3 by the International Society of Antimicrobial Chemotherapy, Raoult's study "does not meet the Society's expected standard, especially relating to the lack of better explanations of the inclusion criteria and the triage of patients to ensure patient safety." A further statement goes on to say: "Concerns have been raised regarding the content, the ethical approval of the trial and the process that this paper underwent to be published." The study is now under a post-publication review.
Raoult has responded to critics by presenting a larger study carried out on 1,061 patients, but crucially with no control group, of whom he claimed 973 were cured in 10 days. Xavier Lescure, an infection specialist at Bichat hospital in Paris, told France 2: "Any study without a control group does not show anything at all."
Dr. Raoult did not respond to requests for comment from ABC News.
Data released by France's drug safety agency showed 43 cases of "cardiac adverse effects" linked to hydroxychloroquine, underscoring the risk of providing unproven treatments to COVID-19 patients. Last week, a chloroquine trial for COVID-19 treatment in Brazil was cut short after some patients developed heart complications, while one hospital in Sweden has reportedly stopped prescribing the drug for COVID-19 patients.
Elon Musk and Dr. Oz
Despite Raoult's claims the drug could cure COVID-19, it wasn't really until Elon Musk tweeted about the drug March 16 that social media interest spiked.
Although the tweet was not a full endorsement, it linked to a document that's now been removed by Google and marked as potentially harmful by Twitter. The paper originally was identified as being authored by Gregory J. Rigano, a lawyer; Tom Broker, a biochemist who subsequently had his name removed from the publication; and James Todaro, a businessman who graduated from medical school but is now a blockchain investor. Todaro tweeted about the document March 13, and it was referenced -- though by no means endorsed -- by the popular blog Stratechery on March 16, the same day as Musk's tweet.
Broker told ABC News he had nothing whatsoever to do with this document and never authorized the use of his name.
"My name was quickly removed from the article because I did not write it," he said. "I have never worked on RNA viruses, to include SARS-CoV-2. I have no knowledge or professional credentials that would allow me to make or imply any clinical study or medical procedure."
The document cited treatment guidelines from Korea and China and an abstract published China, but did not reference any peer-reviewed research related to COVID-19. The document also said it was produced in consultation with Stanford University School of Medicine and SPARK, a research collaboration group that includes Stanford and industry experts, but that's been disputed.
"Stanford Medicine, including SPARK, wasn't involved in the creation of the Google document, and we've requested that the author remove all references to us. In addition, Gregory Rigano is not an advisor with Stanford School of Medicine and no one at Stanford was involved in the study," a spokesperson for Stanford Medical School said in a statement to Wired magazine.
Twitter now warns users clicking the link that the content may be unsafe, and Google has removed the document, saying that it violates the company's terms of service. A Twitter spokesperson told ABC News the document was marked as potentially unsafe for violating its standards regarding potential COVID-19 misinformation. Google did not respond when asked why the document was removed.
Todaro told ABC News that there was collaboration with a Stanford researcher but could not name the person. He also said that neither Google nor Twitter gave him a reason as to why the document was removed.
"Our paper was not some flash-in-the-pan hoax," he wrote in a message. "Yet Google treated it just like that upon taking it down."
A few days after that, when Raoult's study actually was published, Dr. Mehmet Oz appeared on "Fox and Friends," praising the French doctor's results. He also posted on Instagram that the results of the study were "fantastic news," exacerbating the attention paid to the drug via social media.
When questioned about the criticisms of Raoult's studies, a spokesperson for Dr. Oz told ABC News that "all treatments, including ones showing promise overseas, need randomized clinical trials done in the U.S. in order for doctors to have the information they need to be able to bring new treatments to patients safely."
Trump weighs in
Trump declared hydroxychloroquine a "game changer" in the effort to develop a coronavirus treatment, and on March 19 said the drug had been "approved." Although the drug is approved to treat other ailments, like malaria and rheumatoid arthritis, it has not been specifically approved to treat COVID-19, although doctors are allowed to use it for treating COVID-19.
The following morning, Trump posted on Facebook and Twitter that the drug "had a real chance to be one of the biggest game changers in the history of medicine."
At the White House press briefing later that day, Dr. Anthony Fauci appeared to throw cold water on the theory, calling the evidence anecdotal.
By this point, social media mentions had spiked, and Trump's Facebook and Twitter posts diminished in relevance because discussion over the drug jumped into the mainstream.
In the weeks that followed, the president repeatedly touted hydroxychloroquine in his daily briefings, and there's no doubt that the amplification of scientifically unproven claims on social media has helped raise the profile of the drug, the true effectiveness of which on COVID-19 remains to be seen -- or not seen.
Editor's note:An earlier version of this article incorrectly attributed the below quote to Gregory Rigano when it was in fact from James Todaro.
Todaro told ABC News that there was collaboration with a Stanford researcher but could not name the person. He also said that neither Google nor Twitter gave him a reason as to why the document was removed."Our paper was not some flash-in-the-pan hoax," he wrote in a message. "Yet Google treated it just like that upon taking it down."
What to know about the coronavirus:
- How it started and how to protect yourself: Coronavirus explained
- What to do if you have symptoms: Coronavirus symptoms
- Tracking the spread in the U.S. and worldwide: Coronavirus map
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