Updated September 15, 2021 at 9:37 AM ET
MITCHELLS PLAIN, South Africa — On a recent weekday, Dr. E.V. Rapiti's waiting room is full of COVID-19 patients. Rapiti, a family doctor, has made a name for himself recently, posting videos on Facebook touting his treatments for the virus.
In an office behind the waiting room, there are empty boxes labeled "ivermectin" underneath desks. The drug is better known for treating parasites in animals, and the U.S. Food and Drug Administration, the World Health Organization and South African regulators recommend against its use for the prevention or treatment of COVID-19.
But Rapiti is treating dozens of patients a day with it, even some who come into his office near Cape Town moribund, with oxygen levels in the 70s.
Mohammed Noor is in an exam room waiting to see Rapiti. When he first came to the clinic, he said he could hardly breathe. And he told Rapiti that he had already taken some ivermectin, which his cousins use to deworm their horses.
Rapiti gave him more ivermectin. Noor got better.
"It's for animals," he says laughing. "Maybe I'm half animal." Noor believes ivermectin helped him recover, but there is no evidence the anti-parasitic works against COVID-19.
The use of veterinary ivermectin started in South Africa when the second wave of the pandemic hit at the end of last year.
Since then, officials and scientists have repeatedly warned that there is no reliable scientific evidence showing that the drug works against COVID-19. Back in December, the government even banned the importation of ivermectin.
But civil society groups, led in some cases by high-profile doctors, took the government to court and regulators eventually relented, allowing the importation of ivermectin and crafting a "compassionate use program" that allows South African doctors to prescribe the drug in very limited circumstances.
Now the human form of the drug — in tablets and suspension — is being imported and sold out of the back of cars, at pharmacies and at doctors' offices. In some cases, it is being handed out for free.
Desperation leads people to ignore the science
"It's not even like someone is profiteering from it anymore," said Salim Abdool Karim, who used to lead South Africa's COVID-19 response and is one of the world's premiere epidemiologists.
Karim said that South Africa has seen the rise of so-called miracle drugs every time there is a COVID-19 surge. During the first wave, it was the discredited treatment hydroxychloroquine. When cases started surging and people started getting sick during a ravaging second wave, South Africans turned to ivermectin.
"It's within that period of the surge that people are clutching at straws," he said. "They want anything that would be the miracle cure."
At the time, Karim warned that many studies which showed ivermectin worked against COVID-19 were poor-quality research. He asked South Africans to be patient and wait for more definitive scientific proof.
His pleas didn't help. In South Africa, ivermectin has been widely adopted not just as a treatment but as a prophylaxis. And all of this happened as new scientific evidence showed the drug was likely not effective. The Cochrane Review, a British database which doctors rely on to make informed decisions, released a review of dozens of studies that found no clear difference between the drug and a placebo in the treatment of COVID-19.
"They indicate that there is no evidence to support the use of ivermectin," Karim said. "It is unequivocal."
Rapiti finishes seeing patients as the sun starts to dip on the horizon. It has been like this every day during the latest COVID-19 wave. In his office, he has a stack of records indicating he has treated more than 600 patients who came in with COVID-19 pneumonia.
While researchers wait for for the results of clinical trials, Rapiti said he is "in the trenches," in a neighborhood full of people desperate for treatment. Sending them home to get worse or die, he said, is inhumane.
Rapiti works in Mitchells Plain, one of the poorest neighborhoods in South Africa. People here don't have money to pay for treatments like the antiviral drug remdesivir or monoclonal antibodies, which have been found effective against COVID-19.
So, as the second wave of this pandemic crashed into South Africa, poor people turned to ivermectin, which is cheap and widely available.
A research paper, later retracted, sparked use of the drug
Medical science has historically been a cautious field, sometimes waiting years for medical trials to wrap before adopting a new regime. But as this virus spread across the world, doctors needed treatment options fast.
"As a result, we've had to cut corners," said Karim, who also directs the Centre for the AIDS Programme of Research in South Africa. "And in the medical world, cutting corners carries a high price."
During the pandemic, the medical world has relied heavily on so-called pre-print articles, or scientific papers that haven't been through the rigors of peer review. The ivermectin craze in South Africa was fueled by a paper that was never peer-reviewed and that was eventually found to contain major problems with its data.
"It got 150,000 views," said Karim. "It influenced so many people to use ivermectin."
The paper was eventually retracted. But by then, doctors in Karim's own medical school had publicly advocated for the use of ivermectin to treat COVID-19. As Karim sees it, the medical fraternity itself had become "complicit" in pushing ivermectin.
He says this pandemic has tested science in many ways. Doctors, overwhelmed by sick patients, are confusing clinical observation for scientific rigor. Studies have shown patients sometimes recover and thank their doctors following treatment with a placebo.
"The truth is that clinicians who are treating individual patients create impressions that become self-fulling prophecies. The really sick ones they've harmed don't ever come back to them. And the patients they see the next time who have recovered and got ivermectin, they make a link that doesn't exist," Karim said.
When Karim was head of South Africa's COVID-19 response, he tried to make that point. He told South Africans to wait for the data. He explained that if the medical profession still relied on subjective, clinical observation, we might still be treating diabetes with arsenic.
He shakes his head. Scientists in South Africa have lost the battle with ivermectin. There is no taking it back, he says.
And he worries — about accidental overdoses, about South Africans falsely believing the drug is protecting them. The best we can hope for, Karim says, is that the people dispensing ivermectin won't cause too much damage.
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