SALT LAKE CITY — Just days before a separate state office would finalize a controversial purchase of 20,000 medication packs of anti-malarial drugs for COVID-19 treatment, Utah Department of Health leaders and the Utah Medical Association were in hot water for a different issue.

They were facing an onslaught of incredulous — and some angry — emails from other medical professionals, including some from inside the state health department itself.

The emails questioned why the state’s own health department was quoted in a Utah Medical Association message to physicians as “suggesting” five days of hydroxychloroquine — with or without zinc — or seven days of chloroquine compounded with zinc to treat patients who test positive for COVID-19.

“We are sending out this information as a suggestion from the Utah Department of Health,” the Utah Medical Association stated in a March 27 email, with the association’s president, Matthew S. Wilson, and a slew of other association leaders names listed at the bottom.

“They are recommending that providers use a long-standing medication to treat COVID-19. This medication ... is showing some promising data for affecting the course of COVID-19. While the data are limited and no double-blinded studies have been finished, we have attached some articles of studies that have been done and the findings.”

Confused and concerned physicians flooded the inbox of Dr. Angela Dunn, Utah’s state epidemiologist who has become a high-profile public face in the state’s fight against the coronavirus pandemic, asking if the state’s health department was endorsing use of the anti-malarial drugs for COVID-19.

“Wanted to double check if this is actually the recommendation of UDOH, especially with specific dosing regimens,” wrote Michael Rubin, professor of internal medicine at the University of Utah’s School of Medicine in the division of epidemiology, in an email to Dunn. “Who would be the contact person at UDOH for this? I know there are a lot of providers, particularly infectious disease providers, that are extremely concerned about this message going out to everyone.”

Inside the state’s own health department, epidemiologist Dallin Peterson questioned whether the letter was even real.

“It looks like this bogus letter went out to all providers,” wrote Peterson, forwarding the letter to Dunn. “Do you know anything about this?”

“It isn’t bogus,” Dunn replied. “Dr. Babitz wrote it.”

She was referring to Dr. Marc Babitz, the deputy director of the Utah Department of Health.

In response to another state epidemiologist, Bree Barbeau, who wrote she hadn’t “heard anything about UDOH recommending any of those treatments,” Dunn wrote that Babitz was responsible.

“Dr. Babitz put that letter out without anyone’s knowledge,” Dunn wrote. “I have spoken with infectious disease clinicians and toxicologists who disagree with this approach (as do I). I have asked Dr. Babitz where we should direct these calls.”

Dunn, in an email to Babitz and copied to the health department’s director, Dr. Joseph Miner, challenged recommendations to use these treatments for COVID-19 patients.

“As you know, I disagree with this approach,” Dunn wrote. “We are getting calls to our hotlines now as well. Where should we direct these inquiries and questions from concerned clinicians and the public?”

Later, Babitz and Utah Medical Association officials worked together to draft a “clarification” for the letter to physicians, saying the health department only wanted to offer suggested doses should physicians chose to prescribe the medication for COVID-19 treatment.

Those emails depict a divide that had formed between Dunn and Babitz over the anti-malarial drugs and whether they had a place in Utah’s response to the coronavirus pandemic.

Trump touting ‘should help’

Behind the scenes — weeks before Utah’s $800,000 purchase of 20,000 medication packs of those same drugs came to light and was later refunded — Dunn and Babitz had been at odds over whether anti-malarial drugs should be used to treat Utahns who have tested positive for COVID-19, according to a cache of emails from Utah Department of Health leaders obtained by the Deseret News on Tuesday through a public records request.

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Even still, emails show decision-makers in the state’s department of health, including its top two leaders Babitz and Miner — energized by President Donald Trump’s touting of the drugs in mid-March — plowed ahead, driven by what Babitz described as a “team of state senators” wanting to prepare a plan for Utah COVID-19 patients that included a treatment “option.”

Miner told the Deseret News Tuesday that he was not involved with the state’s $800,000 purchase of the drugs, but rather what he, Babitz and other health department officials were working on was a separate standing order meant to facilitate the distribution of the drugs. It was an order that could be used by any pharmacy capable of providing compounded hydroxychloroquine or chloroquine.

Dr. Joseph Miner, executive director of the Utah Department of Health, left, and Gov. Gary Herbert conduct a press conference in the Emergency Operations Center at the Capitol in Salt Lake City on Friday, March 6, 2020. Officials announced the first known case of COVID-19 diagnosed in Utah. | Spenser Heaps, Deseret News

But Miner confirmed there were certainly “differences of opinion” among his own health department about whether those anti-malarial drugs should or could be used to treat COVID-19.

“Yes, early on there was a difference of opinion,” Miner said. “Dr. Babitz had heard from several physicians that this was something that we ought to look at.”

But just like on the national level — especially after the U.S. president began touting the drugs — there was conflict in the health department over the usefulness of the drugs for COVID-19, Miner said.

But now, after the Food and Drug Administration cautioned against using them outside of hospitals or clinical trials, Miner said, “I think we’re on the same page.”

“I don’t think there’s a disagreement now,” he said. “We’ve discussed it. ... There are no questions about it, it’s not worth promoting it, certainly not worth stockpiling it or buying it, which we never thought of.”

The concept began, Miner said, with only a handful of people.

“The entire origins of the whole thing never originated with the health department,” he said. “It was organized with Silicon Slopes, a couple of University of Utah professors, and a pharmacist.”

From the beginning, Babitz and Miner worked with Dr. Kurt Hegmann, a University of Utah physician specializing in preventive, occupational and environmental medicine, and Dan Richards, owner of Meds in Motion, the Utah pharmacy that ended up charging — and later refunding — Utah for $800,000 for those medication packs.

Richards, emails show, was directly collaborating with Babitz to help draft the language of a standing order that Miner at one point was poised to sign. But the standing order was later halted by the governor’s office when it was determined it wasn’t needed.

On March 19, as Babitz and Richards were emailing back and forth on the final version of the standing order, Miner emailed that Trump was “touting chloroquine and hydroxychloroquine at a news conference right now.”

“That should help with community acceptance of this option,” Babitz wrote back. “I will say privately that I wish we had ‘trumped’ his announcement with this great plan from Kurt, Dan and Mark.”

Also included in that email thread was Mark Newman, CEO of Nomi Health, who had early on pitched crowdsourcing Utah tech companies to help tackle the pandemic, including providing testing and medication. Since then, those ideas have turned into multimillion-dollar, no-bid contracts that have raised questions.

‘Irresponsible’ and ‘reckless’

Jarred by the Utah Medical Association’s letter showing the Utah Department of Health suggested dosage for anti-malarial drugs used to treat COVID-19, Dr. Scott K. Aberegg, a U. associate professor of medicine, emailed Babitz.

“To my knowledge, there are no credible data that support a recommendation for this drug for this indication,” Aberegg wrote. “I will be frank: This smacks as irresponsible and even reckless.”

Aberegg asked for clarification, calling it “very concerning.”

In response to Aberegg and other medical professionals concerned about the email, Babitz replied with a “timeline of events” to explain the letter.

Babitz, in his email, starts with Trump’s announcement “to the world that chloroquine and hydroxychloroquine can combat COVID-19.” Next, he wrote “UDOH is asked by a team of state senators to work with a private group preparing a plan to allow Utah residents to do a computer-based screening program that uses CDC criteria to give the individual a risk rating for COVID-19 and to recommend testing and if positive, an option of treatment.”

Then, Babitz wrote “this private group asks UDOH to prepare a standing order that UDOH could issue to allow pharmacists to dispense limited quantities” of the drugs.

Next, Babitz said a survey of Utah pharmacies revealed that a number of Utah physicians had already began writing prescriptions “of varying doses and duration for these medications, and not for patients on chronic treatment for rheumatoid arthritis or lupus.”

“This raised our concern that Utah physicians had no information regarding medication, strength, dosing frequency or duration of treatment, and problems could result from overdose,” Babitiz wrote, adding the health department then asked state licensing officials and the Utah Pharmacy Association to send a notice to all pharmacies to stop filling the prescriptions except for “regular, chronic users.”

Then, Babitz said the health department completed a draft of the standing order, which was reviewed by legal staff and drafted in consultation with Richards and Hegmann.

Next, on March 25, Babitz said the “governor’s office reviewed the work of this private group with Senate leadership and determines that this is not needed at this time.”

“UDOH is asked to put a hold on the standing order and emergency rule,” Babitz wrote. “Governor’s office believes that at the present time there is enough capacity for patients to be evaluated by a health care provider who can determine next steps.”

It was after that that the Utah Medical Association asked for information in the standing order, including names and dosing of the medications, Babitz wrote.

“No one in UDOH has suggested that these medications can cure COVID-19,” Babitz wrote. “No one in UDOH has recommended that all patients who test positive be treated with these medications. However, if a health care provider, for whatever reason, decides he wishes to treat a COVID19 positive patient, our desire was to recommend the safest dosing of these medications.”

Miner, on March 27, directed Babitz and Michelle McOmber, CEO of the Utah Medical Association, to revise the letter to clarify the state health department’s position on the drugs.

“I admit there was much enthusiasm among clinicians, pharmacists and political leaders locally and nationally about the prospects of using these medications to see if they would help blunt the severity of the pandemic,” Miner said, explaining why the department was considering the standing order.

“But after further consideration,” Miner continued, “we know we must have better scientific research before recommending them.”