Like a police investigation, the epistemologist Vincent Israel-Jost worked for UP' Magazine on the incredible controversy caused by Hydroxychloroquine in the middle of the Covid-19 crisis and was able to dissect, in its most intimate springs, the speech system of the most famous professor in France: Didier Raoult.
With the few months of hindsight we now have and the many twists and turns we have seen on hydroxychloroquine (HCQ), the time seems ripe for an analysis of what has happened. We certainly still do not have an outcome to this public controversy that would allow us to go back over the whole story in light of a clear answer to the question "Is HCQ a Covid-19 treatment or not? "but that's a good thing for analysis. It would indeed be difficult, if we had such a firm answer, to take up each other's contributions other than by attributing good and bad points based on the result now known. In the present case, with uncertainty still looming, a more circumspect analysis is still needed, unaware of the outcome of a controversy still in progress, but more receptive to the arguments of all sides, which must still be considered on an equal footing.
To address the issues raised by this public controversy, that is to say this scientific dispute that has been widely followed, commented on and influenced by the public, the very term controversy cannot be pronounced without mentioning its main character, the one who can be said to have contributed most to making a scientific issue a controversy, Professor Didier Raoult.
A leading figure in the field of infectious diseases in France, a world-renowned specialist and director of the IHU Méditerranée, Professor Raoult combines this recognition and institutional power with a disconcerting ease with which he has been able to take the floor to present his views in a way that has greatly seduced and in any case left few people indifferent.
The tone is generally set, a mixture of seriousness, banter and harshness at times; scientific arguments are mostly understandable and deciphering power and money games, institutional dynamics or work done by other teams brings a touch of novelty compared to scientific communications that are often more austere and focused on a single issue.
But what dominates and really makes the success of his interventions is the freedom of tone, the total absence of concessions in relation to his convictions which seem to be exposed without any filter. He can leave a stage whenever he wants, overwhelm the highest scientific decision-makers, take full advantage of the academic freedom he claims to express himself by always remaining as close as possible to who he is and what he believes in. The results are fairly predictable: not everyone is behind him, especially in his own scientific community, but popular support, in the media and among a good number of personalities, is unfailing, making Professor Raoult the undisputed star of the crisis in France.
From this state of affairs stems a somewhat embarrassing question. Since we are dealing with a man who enjoys an ultra-dominant scientific, institutional and media position, and since this man has taken up the cause of HCQ, how is it that the question has not been decided? How is it that the work carried out by the IHU Méditerranée, which, according to Professor Raoult, demonstrates the clear usefulness of HCQ in the management of patients suffering from Covid-19, does not settle the question?
Yet all the ingredients are there: a leader and opinion leader with a real aura, who leads the French flagship of infectious disease research institutes, driven by a strong conviction and having acted accordingly, treating several thousand people and publishing several articles. And yet, after several months, and without presuming what will happen when new elements still appear on the issue, HCQ is still far from unanimous and the trend is even rather unfavourable in the scientific community.
Hence the uncomfortable situation in which we find ourselves, between Professor Raoult's authoritative and seemingly common-sense word and the broader picture offered by science: how do we situate ourselves and by virtue of what? The public, inevitably affected by a question of treatment at Covid-19 which concerns it, and obliged from the outset to make its way through the midst of discordant sources, has no choice but to weigh up both the arguments of one side and the other, but also their credibility, that of their commentators, etc. The public has no choice but to weigh up the arguments of both sides, but also their credibility, that of their commentators, etc. Everyone is thus led to apprehend this episode as an epistemologist, wondering about the path that leads to knowledge, which we rediscover with this controversy how many pitfalls it is strewn with!
The ambition of this text is therefore to accompany a popular epistemological reflection and to bring to light the elements that explain why, despite Professor Raoult's hyper-favourable situation, he is struggling to convince on the scientific level.
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The Knowing of Marseille
One term gradually came to the fore in Professor Raoult's interventions: "knowing". Preferred to that of a specialist or expert, it obviously refers to a person qualified to give an opinion on a particular field by virtue of knowledge. But in contrast to "scholar", an old-fashioned term with a similar etymology, but which would designate a scientist with a vast culture and great sagacity, "knowing" seems to be much more directly connected with knowledge.
The term thus no longer refers so much to an ability to acquire knowledge, but rather to knowledge that, in the knowing, would already be there. The importance of this term in Professor Raoult's (during his National Assembly hearing for example, at 1:04:25 or 1:07:15) would be anecdotal if the word did not give the impression that a possible, potential acquaintance is, in the knower, present from the start.
This word thus seems to synthesize a whole way of conceiving science, a true philosophy of science peculiar to Didier Raoult, which we can now reconstruct, and which may well shed new light on our way of understanding the HCQ controversy.
Let's rewind to the beginning of the case, the publication that launched the controversy: a study conducted at IHU Méditerranée 1] which claimed to show beneficial effects of HCQ and especially of the combination HCQ + Azithromycin against Covid-19.
A lot of things have been criticized in this study. First of all, scientifically speaking, its methodology left something to be desired according to many specialists, since a cohort of about 20 patients was used as a basis for drawing these conclusions, which is statistically very low, but also because patients who were unable to follow the treatment (including one death) were not taken into account.
Other reservations were also expressed about an overnight publication process, which suggested that there had been no real peer review process, in a journal whose editor-in-chief, Jean-Marc Rolain, is also co-author of the study .
The first question that everyone must ask themselves is: has this first study by the IHU Méditerranée helped to lay the foundations of scientific knowledge in favour of HCQ? In view of the criticisms that have really rained down on this study, the answer is no.
It is not the purpose here to raise the problems of this study, nor to give an opinion on the most serious problems or those that are not. It should simply be observed that the reception of this study has been icy to say the least, and that the scientific world, at whatever level it is considered (science in general, its journalists, commentators, the science of virology and infectious diseases, in France or internationally...) has not declared itself convinced by this study.
However, scientific knowledge differs from personal conviction in that it requires validation by others. What makes scientific knowledge truly scientist of knowledge, it is a number of mechanisms (peer-reviewingThe aim is to provide a means (e.g., presentations at conferences, replication of experiences by other teams, etc.) by which others can take up what you say and convince themselves, using what you provide as evidence and explanations, of what you were convinced of.
What stopped at this first attempt reported by the IHU Mediterranean is the mechanism of adherence to shared beliefs within this institute. Whether the criticisms of this work are justified or not is another matter, which I do not deal with here. It is only a question for all of us who are neither micro-biologists, nor virologists, nor specialists in infectious diseases, to at least acknowledge this thing that seems to me indisputable: the scientists have, for a large majority, not been convinced by this work.
To avoid any possible misunderstanding, let us emphasize the distinction between care and research and make it clear that the controversy we are concerned about is not about how to care for people. No one has found anything wrong with the actions carried out at IHU Mediterranean to test and then treat people, including with the HCQ + Azithromycin protocol and even with the uncertainty about the effects of these drugs.
The actions carried out on the spot have on the whole been rather well received, so the problem that is raised here is not "doing" but "saying". The fact that we had to take risks to provide the best possible care, without being able to ensure that we make the best choice of medication, is an obvious fact experienced by all the caregivers. What is disputed is the idea cultivated by Professor Raoult that we were already sure we were doing the best we could with the famous protocol because we had proof that it worked.
In short, everyone agreed to take risks in the face of uncertainty, but not to say at the same time that they were not taking risks and that they already had all the necessary knowledge. So this is the point on which the controversy focuses: can we talk about real scientific knowledge on which other scientists and carers could rely, or have the efforts made in Marseilles on the research side (the care side being, I repeat one last time, applauded) not come to fruition?
The epistemology of knowing
There was obviously not only a first and short study resulting from the research work of the IHU Mediterranean, but it is important to admit, as a starting point, that this study was null and void in terms of scientific knowledge, judging by the recognition it received from peers. Like an inspector who, after collecting clues and testimony at the scene of a crime, forms his own opinion and submits this set of clues and the account he gives of it to a court of law, the scientist must set himself the task of convincing, with no guarantee that it will work, but with all the chances on his side to ensure that the evidence provided is as striking as possible. In the last instance, it is up to the jury to declare itself convinced by this set and it is only under these conditions that the verdict aligns itself with the inspector's hypothesis, transforming it into judicial truth. A scientist must therefore play the game in the same way and try to provide evidence that makes it as easy as possible for other scientists to be convinced, to rally to the proposed hypothesis (here : "HCQ + Azythromycin works as a drug against Covid-19"), a necessary condition for establishing scientific knowledge. The question here is therefore about the quality of the evidence provided by Professor Raoult.
Here, however, comes the element that goes against all the advantages Didier Raoult possesses (his academic prestige, his charisma and the power he already holds): he behaves "knowingly", calls himself "knowingly" and because of this, speaks and acts like a man who has already proven himself, and who therefore no longer has to take so much care to provide it. This register of proof of data, of argumentation, of justification, is at the basis of classical epistemology. But this is not exactly how Professor Raoult sees the establishment of knowledge.
Let us therefore return to the key role of this initial study, the quality of which has been criticized. This study differs from those that followed, in that Professor Raoult intends to use the positive effects of HCQ to take for granted the benefit associated with the famous protocol. From this first study, it is therefore understood on the side of the IHU Mediterranean that, in terms of knowledge, the lines have moved in the right direction. In this logic, if we know that HCQ is beneficial, there is no longer any question of not treating everyone this way. The following studies will therefore be purely observational, without the element of comparison of the control group.
How do you tell someone that you have a treatment but you're not going to give it to them so that they can be used as a benchmark? The rhetoric is unstoppable, but it will make it difficult to exploit the larger studies (80, then 1061, and finally 3737 patients) since, with beneficial effects of HCQ that are very small at best (other studies would have detected it otherwise, there are dozens of them around the world), the absence of a control group gives little hope of being able to read something conclusive.
This first study on about twenty patients, which served as a tipping point to support the care and research strategy of the IHU Mediterranean, and therefore plays a crucial role in the Raultian conception of knowledge on Covid-19 treatments, can we not say that it is sufficient to initiate knowledge on the subject? How does Professor Raoult defend it?
Questioned at the end of the hearing of the inquiry commission at the National Assembly by the deputy Philippe Berta (3:02:20), who raises precisely the question of a reception of this study by the scientists that could only be bad, Didier Raoult answers: ". This is basal ethics...when you have proof that something works, you stop the trial. So I'm sorry that you don't like my trial, but I like it very much, and I think it has all the basics of a trial, the only way to do trials is to do comparative trials and make a significant difference. "
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The poor overall reception of this test is therefore reported on the only Philippe Berta who would not like this test, and an argumentative movement is set in motion: when we have proof that something works, we are no longer in the test. But precisely, the question is that this first study was not received as demonstrating that something works!
After a few sentences aimed at defending the idea that this first study is methodologically sound (an argument that the weirdness is discussed here ), the argument concludes with a movement often found in Professor Raoult: " I assure you that I am a very great methodologist... " before continuing: " I'm a great scientist, I know what a trial is, and I can tell you, there are about ten of the treatments I've invented that are in all the medical reference books. And this one's going to be in there, too. "and to conclude" I used to be a great scientist and I remained a great scientist after I published this. "
It's a rare thing in science to see someone relying so heavily on past successes to justify the reliability of present work. A person's acquired prestige says of course something about what that person is capable of, and this counts in assessing his or her credibility, but what we see here is the development of an epistemology of prestige, since this is the first thing that is done to support the studies being decried: to reaffirm one's own scientific greatness.
There are countless cases of this same pattern, for example on BFM-TV on April 30  « I'm a real scientist and I'm also an epistemologist. I've been studying the history of science and teaching epistemology for 25 years. » (7:30).
But perhaps the best evidence of the establishment of this conscious or unconscious strategy is provided by another video, dated February 28 4], in which Prof. Raoult answers the question put to him on the debates between scientists and physicians on the usefulness and effectiveness of HCQ as follows. Going to his computer, he points out the difficulty for the uninitiated to find their way among the expert opinions but presents a very simple online search tool that will allow us to better understand what an expert is: expertscape.com. communicable diseases "), you press " expert show "and you see: "I'm the first (world) expert and not only that, but if you look at the places where it happens [...] you find that the only world experts that are readable in France [...] are those from Marseille. ». Here is therefore reaffirmed by an external, international, objective source (the sequence ends with a few seconds of a still shot on the expertscape.com site with the slogan Fast. Easy. Free. Objective) the scientific authority of Pr. Raoult, which will thus be the fundamental mechanism offered to us to adhere to his theses.
We could speak of an "epistemology of the knowing", of the one who knows, from the outset. This knowing, when he thinks something, his quality of knowing acts as a buffer that validates his thought and transmutes it into scientific knowledge. Therefore, no matter how mediocre the form given to the evidence, it is understandable that this register of evidence as usually required in science or in court is not central. The evidence here is incidental, like the vestige of a tradition to which one still consents to participate by sense of protocol, but whose epistemological value is quite symbolic. What proves here is the quality of knowing which is regularly recalled by the principal person concerned.
Hell is other people
The Raultian knowledge establishment scheme, after a few months of implementation, very clearly leads to two types of populations. On the one hand, its supporters, those who bow to its authority and receive the teacher's word in a perfectly vertical relationship.
And then, on the other hand, without necessarily being hostile to the teacher or to the treatment or strategies he advocates, there are those for whom Didier Raoult's words are carefully considered, but as scientific words that can be criticized, answered or doubted, this time in a horizontal relationship. It is in this second category that we find an otherness, that is to say real consciences with which we have to deal: convincing them, debating with them, exchanging ideas and arguments, and so on.
It has to be said, however, that while the first category of people does not pose a problem for Didier Raoult - his collaborators, supporters and all those who listen to him - it is not the same with the second, the others, those who are not huddled under his wing. For those who have not been convinced by the epistemology of the knowing, that is to say by the assured tone, the honorary titles and the reminders of his scientific greatness, and who therefore ask for better scientific arguments, Professor Raoult has a ready-made answer: " I don't care. », « I don't care. ".
One of the things that is quite striking, given the importance that the character has assumed and the opinions he can give on just about every aspect of the crisis, is that he has never been seen to be horizontal and to participate in any advice in which he would be included. in the same vein than others.
The account of his brief stint on the Scientific Council of the Covid-19 crisis speaks for itself. Calling himself a UFO or extraterrestrial in this council during his hearing at the National Assembly (1:11:00), one wonders what made the situation untenable. He answers: " That was not possible. It was a group that knew each other, that had been working together for years, it was the INSERM's REACTing group, and so I got into this - I think it was the President who wanted me to be part of this group - so I came secondarily into a group of people who were used to working together, who had very precise ideas, who had determined what had to be done before I arrived and I did not agree with them. ".
Is that all that this group is guilty of? To be used to working together, to have precise ideas (we can't imagine Didier Raoult getting there with vague ideas) and to have probably waited to move to be convinced by something other than a note of authority from Professor Raoult? Was the idea of sitting with peers and participating in the development of a discussed strategy so unbearable? Earlier, when asked about this scientific council, he replied (49:10): "... the idea of sitting with peers and participating in the development of a strategy discussed was so unbearable? This is not a scientific council! I don't know what it is. The first scientific council I headed was in 1989. I'm sorry, it's been a long time. And I headed one in my university, at the Ministry of Research in 1993, so I know what it is... That's not it. "And it is easier to understand that a scientific council worthy of the name is a council that has the immense merit of being directed by Professor Raoult, i.e. where we find the verticality that is essential to it.
The others, then.
Scientists who are not convinced by the work of the IHU Mediterranean? All in conflict of interest with Gilead.
The reporters? Unable to take the measure of a field that is too complicated for them, always distorting knowledge, Professor Raoult prefers the direct channel, the IHU YouTube channel, whose series is entitled "We have the right to be intelligent" in the face of the cretinism that reigns outside the IHU.
Politics? Badly surrounded when he's not here.
The others are also the madness that has taken hold of a frightened society, the folly that, according to him, leads some to consider that HCQ is "...a disease of the mind...". a deadly poison "(BFM-TV Apolline 12:50 and 13:25) or to turn away from it because Trump or Bolsonaro supported it. The IHU Mediterranean as a haven of peace, rationality, a reasonable place in the face of excessiveness, madness and darkness. All the ingredients are now there to reread the HCQ controversy in the light of this picturesque epistemological landscape.
Knowledge about hydroxychloroquine
As we have seen, scientists as a whole provide opinions that do not allow for a conclusion that HCQ is an effective treatment for Covid-19. So we were and remain uncertain, which is basically not so serious, both for us, the public, who are not obliged to take sides, and for the caregivers who may administer a drug without certainty, based on their experience, knowledge or intuition. However, uncertainty is also mixed with another impression, that uncertainty is itself uncertain. There is a feeling that hovers over us and that gives us the impression that the stage of uncertainty has passed. And yet, on this subject, we have seen:
- that at the purely scientific level, that of the publications, preprints and communications of the IHU Mediterranean, the scientific world was not convinced;
- that the authoritative arguments regularly distilled by Professor Raoult in his epistemology of knowing were well suited to winning the media battle, much less to imposing themselves on the scientific scene.
The figures of the IHU Mediterranean, however, are still to be considered, as they are proof of a certain success. However, this success is based on a much broader strategy than the therapeutic strategy since it includes systematic tests and treatment at a level that may not have been the case in most other centres. So what does the low mortality reflect? An overall success, but one that cannot be excluded from being independent of the beneficial effects of the famous protocol.
As for the massive use that has been made of HCQ, in France and around the world, it is unfortunately not a reliable indicator of its beneficial effects either. People had to be treated well with what was available, but since Professor Raoult is trying to strengthen his argument by talking about this massive use, while this massive use took place because of the buzz generated by Professor Raoult about HCQ, and not because of evidence, we are just going around in circles.
In the end, in a plea that has become more than a systematic indictment of others, of their incompetence, bad faith or outright conflict of interest, Professor Raoult has succeeded in only one thing: making people confused.
Who then benefits from the confusion, the conflict without much will to resolve it, the fragmentation of a knowledge landscape that is no longer understood? To the one who spends all his time saying: " I don't care. I don't have to agree with you. ", i.e. one who can enjoy his position as a leader in both science and the media. In the end, the public will at least have one readable option, and will always know where to turn.
Two models of science
This episode of HCQ prompts us to think about science from a political point of view, and more specifically to ask ourselves the question of the role that others play in the establishment of scientific knowledge. Whereas in the usual conception of science, others play a decisive role as a different receptivity that one must be able to rally, and whose rallying will participate in a validation that gives the knowledge its scientific character, the mechanism implemented by Didier Raoult is quite distinct. He refers others to the role of pure recipient of knowledge whose scientific validity has already been acquired, since the only thing that counts is the origin of the knowledge: the knowing.
What use then are the others, the ones who on expertscape.com ...only point to 10th, 100th or 1000th place? In the classical model of science, their work, their communications and their critical feedback on the work of others contribute to a science which, because it has opened itself up to these otherities, can end up (and often does end up) reaching consensus, that is to say, creating commonality. It is one of the major challenges for science to aspire to the establishment of a common culture, rationality and values, and this does not in any way prevent some scientists from standing out from the crowd with original and fruitful, even revolutionary, contributions. It is in this way that valid scientific content has been handed down from generation to generation and that we can still appropriate it today.
Conversely, when a self-proclaimed astounding contribution is not received as such, but the 2nd, 3rd and Ne orders (according to criteria that another article should be reserved for cutting to pieces) are referred to an illegitimacy to intervene in what is scientific knowledge, one should not give much importance to the durability of this contribution. It is then up to everyone to take hold of this public controversy and its stakes in order to carry out a salutary reflection on these fundamental issues that combine science and democracy.
1] Gautret et al (2020) Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. International Journal of Antimicrobial Agents - In Press 17 March 2020 - DOI: 10.1016/j.ijantimicag.2020.105949
2] See this page for all the necessary resources: https://www.redactionmedicale.fr/2020/04/covid-19-comment-r%C3%A9tracter-larticle-hydroxychloroquine-and-azithromycin-as-a-treatment-of-gautret-p-.html
and in particular these comments by Elisabeth Bik, a Dutch microbiologist and scientific integrity specialist: https://scienceintegritydigest.com/2020/03/24/thoughts-on-the-gautret-et-al-paper-about-hydroxychloroquine-and-azithromycin-treatment-of-covid-19-infections/
3] BFMTV YouTube page, video entitled EXCLUSIVE MAINTENANCE. Didier Raoult confides in Apolline de Malherbe on BFMTV. Broadcast live on April 30, 2020. https://youtu.be/cj4bGVszZP8
4] Video of February 28, 2020 on the YouTube channel IHU Méditerranée-Infection entitled: Chloroquine: why would the Chinese be wrong? https://youtu.be/mJl2nPHAo2g