Ladapo Rides Again
Treatment tidbits, health inequities, long COVID, guidelines, measles, pandemic recovery, medical greed, American exceptionalism, and weirdities.
Treatment
Experiences with the Paxlovid-access system, Paxcess, have been mixed, as Leana Wen reports in a useful column. Pharmacists can theoretically prescribe it themselves but rarely do, being unequipped to evaluate blood tests or instruct patients on handling medication incompatibilities.
Low-income patients can also access molnupiravir for free, though I don’t know why anybody would prescribe it. Molnupiravir doesn’t prevent severe disease or hasten viral clearance, and may prolong infection duration, induce mutations that could be transmissible, and breed new variants. The FDA should, like the European Union, withdraw authorization.
Among 731,349 American patients eligible for Paxlovid between April and September 2022, unvaccinated patients were less likely to receive it (20.2%) than those with two or three vaccine doses (27.0% and 33.0%). That’s the wrong way round. Three-dose vaccination and Paxlovid each halved the risk of hospitalization; in combination they reduced risk by 78%.
In a June 2023 preprint, NIH researchers estimated that if half the eligible patients instead of 10% had received Paxlovid between December 2021 and February 2023, 48,000 lives would have been saved. Now another modeling study, that may not have excluded people with Paxlovid contraindications, estimates that with 50% coverage over 300 days beginning in January 2022, 79,000 lives would have been saved.
Science writer Jonathan Lambert has nicely debunked nonsense about boosting the immune system to prevent COVID-19, adding practical advice to the immunocompromised about handling their risk. Unfortunately Lambert bought the metformin/long COVID story: “Bramante and colleagues published a randomized clinical trial study last year that showed that non-hospitalized patients who took metformin within a week of infection were 40% less likely to develop long COVID than those who got a placebo.” But as I’ve told you, metformin only helped the obese and the unvaccinated. In unvaccinated patients metformin lowered the risk of long COVID from 14.1% to 6.3%, in vaccinated patients from 7.2% to 6.1%, so vaccination itself cuts the risk of long COVID in half. A better metformin study is now recruiting. I emailed him with these data.
I also commented on a MedPageToday article that cited Bramante uncritically. The authors must have taken my comment seriously, because the following day all mention of metformin had been removed.
Health inequities
One might think that having a world-class medical facility in the neighborhood would benefit your health. Nope! In The City and the Hospital: The Paradox of Medically Overserved Communities, social scientists examine the relationship between three high-end American hospitals and their surrounding communities. Conditions including diabetes, heart disease, and mental illness were more common among people who lived nearby, partly because locals avoided those hospitals for fear of high costs, excepting Emergency Rooms; advanced care went to solvent customers.
American specials:
- Native Americans die of liver disease four times more than Whites, but are one-third as likely to receive a liver transplant.
- Black and Asian patients are vastly underrepresented in antibiotic trials, according to a study from Duke and Yale.
- Analyses of conversations of physicians (90% White) with caregivers of White and Black ICU patients found that Black caregivers received less medical information, less emotional support, and less respect for their preferences.
- Black, Indigenous, and People of Color Americans had greater post-COVID-19 burdens than non-Hispanic Whites, including health status, activity level, and missed work, despite similar initial severity.
Researchers detected systemic racism in a commercially available AI algorithm. It recommended giving less healthcare to Black than White patients, having been constructed on the basis of unfairly allocated past care. An editorialist comments, “Whereas in a previous era, the intention to deepen racial inequities was more explicit, today coded inequity is perpetuated precisely because those who design and adopt such tools are not thinking carefully about systemic racism.”
The rich notoriously outlive the poor. Can you guess by how much? A baby born in Washington D.C., which is 45% black and 13% poor, has a 75.3-year life expectancy. In Bethesda, less than ten miles away (5% black, 4% poor), it’s 88.3. Even within D.C., life expectancy ranges in different neighborhoods from 63.2 years to 96.1. Since longevity depends largely on factors such as where and how you live, Medicare for All won’t fix those gaps.
Thirteen percent of US households – including 22% of Black households and 33% of households headed by single mothers – struggled to meet their nutritional needs at some point during 2022. People in the most food insecure group are 80% more likely to die prematurely.
Measles
Faced with an outbreak of measles in a Fort Lauderdale school, potentially deadly, Joseph Ladapo knew exactly what he was supposed to do: declare a public health emergency, and urge parents of unvaccinated children both to vaccinate them and to keep them home for the 21-day incubation period. Instead, he told parents to do whatever they pleased, just watching for measles symptoms. Florida Congresswoman Debbie Wasserman Schultz is rightly calling for his ouster. Unlikely, since Ladapo is a favorite of Governor Ron DeSantis.
Only 91% of Florida kindergarteners are fully vaccinated against measles, short of the 95% needed for herd immunity. Italy reported 43 cases of measles in 2023, versus 15 in 2022 and nine in 2021. I worry, because in 2020 barely more kids were measles-vaccinated in Italy (92%), where it’s mandatory across the board, than in Florida, where up to 8% of children have religious or medical exemptions. One reason might be that though vaccines against diseases such as tetanus have been obligatory in Italy for decades, measles only joined the list in 2017.
The UK saw 650 confirmed cases just between October 1st and February 28th, the tragically inevitable result of an 85% vaccination rate. Leana Wen nicely contrasts the public health measures needed for measles with those for COVID-19. Given the rarity of severe COVID-19 in kids, I think controlling measles is far more important.
Long COVID
An interesting article in the Washington Post discusses the devastating toll long COVID can take not just on individuals but on relationships. Unfortunately the first photograph shows a patient cuddling with her husband, although it’s crucial to protect long COVID sufferers from repeat infections, which worsen symptoms in 85% of cases.
COVID-19 during pregnancy can of course risk long COVID. A conference presentation found it less common among pregnant women (9.3%) than among unselected adults (15-30%), but that’s the opposite of what Spanish researchers found.
A CDC study followed first-wave COVID-19 patients over 11 months to see how many developed fatigue. Seventeen percent did, versus 5% of matched swab-negative controls. In 8% of patients, 0.4% of controls, the fatigue became chronic. Women were more at risk than men, as were people with preexisting conditions from hypothyroidism to anxiety, depression, chronic pain, cancer, and hayfever.
Following a bout of COVID-19, military veterans had excess outpatient visits for all kinds of illnesses for over a year.
In the 2022 National Health Interview Survey, 6.9% of American adults said they had had long COVID at some point, and 3.4% still did. The 2022 Behavioral Risk Factor Surveillance System (BRFSS) found a similar 6.4%, with West Virginia worst off (10.6%). West Virginia also ranks first in overdose deaths per capita, though Tennessee, Kentucky, and Louisiana are close behind. In October 2023 the Census Bureau estimated that long COVID had affected a quarter of all American COVID-19 survivors, down from 35% a year earlier. 5.3% of adults had ongoing long COVID, and Tennesseeans led the pack at 8.0%.
A Japanese study reports higher rates of long COVID in adults than I’ve ever seen, and far higher rates in children (47.6% and 10.8% respectively at three months, 31.0% and 6.8% at one year), vs. the usual 15-30% in adults (here and here and here and here) and under 2% in children. Contrary to most other researchers, they found no higher risk with the wild-type virus and no protection from vaccination. These sky-high rates may reflect participation by only 37% of patients, likely skewing the subjects toward persistent symptoms, and the fact that many were hospitalized.
Speaking of pediatric COVID-19 complications, one I’ve never discussed is multisystem inflammatory syndrome in children (MIS-C). It’s still happening, though only at 2% of the rate early in the pandemic. Vaccination may be protective, since 82% of patients had never been vaccinated.
COVID-19 maven Zeynep Tufekci has made an impassioned plea for more and better research funding, pointing out that the NIH’s low long COVID budget has gone largely toward a merely observational study, with treatment trials limited to an “online brain training program” and a trial of Paxlovid that joins a similar one in Sweden and a British study of remdesivir; another trial now tests human immunoglobulin. Tufekci mentions one candidate treatment new to me, tiny-dose naltrexone, describing one patient who seemed to benefit; small studies in Ireland and California give some support. She aptly compares long COVID activism with the AIDS activism that pushed George W. Bush into the greatest (only?) triumph of his stint in the White House, the PEPFAR initiative that brought low-cost HIV drugs to Africa.
An Irish study performed dynamic contrast-enhanced MRI brain imaging 7-12 months after infection in patients with long COVID brain fog. They found disruption of the blood-brain barrier, systemic inflammation, and abnormal clotting, supporting reports of poor cerebral circulation.
A British study described 381 COVID-19 patients who had high-titer SARS-CoV-2 for 30 days, and 54 for 60 days. It’s not clear whether the appropriate denominator is 77,561, for viral persistence rates at one and two months of 0.49% and 0.07% respectively, or the 3,603 who the press release said had multiple swabs, a number found nowhere in the article itself (for 10.6% and 1.5% 30- and 60-day persistence). People with prolonged infections were 50% more likely to develop long COVID.
There may be clues to long COVID in an ambitious study of Post-infectious Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. It enlisted more than 75 scientists and cost millions, but enrolled only 17 patients. Results included low parasympathetic activity, chronic stimulation of the immune system by microbial antigens (perhaps bolstering previous evidence of T-cell exhaustion), gut microbiome abnormalities, and low cerebrospinal fluid levels of certain neurotransmitters.
A recent autopsy study of 29 COVID-19 patients says SARS-CoV-2 infects the central nervous system (brainstem and cerebellum) only minimally, speculating that neurological symptoms like fatigue and brain fog are due to whole-body inflammation. An earlier autopsy study found SARS-CoV-2 RNA throughout the brains of 10 out of 11 patients, months after their death, a finding the new article calls “not intuitive,” perhaps because of the low quantity of viral material.
A huge British study documents deficits in memory, reasoning, and executive function in survivors of confirmed or suspected COVID-19 with persistent symptoms after 12 weeks. Patients who were hospitalized, infected early in the pandemic, or had brain fog were the worst off, though even “fully recovered” patients had small cognitive deficits. And a Norwegian study found low scores on a memory questionnaire for up to three years after a positive COVID-19 test.
Guidelines
Copying California and Oregon, the CDC has liberalized guidelines for people who test positive for COVID-19, except for healthcare workers. Patients can now return to work or school as soon as they’re feeling better, making no distinction among respiratory viruses, even though COVID-19 bears much higher risk than influenza for hospitalization and death, with much worse long-term consequences. This policy replaces five-day self-isolation, already overly lenient since two-thirds of patients are still infectious on day five. Immunosuppressed people are particularly worried. Jeremy Faust asks, “Where’s the science?” adding: “Will this increase economic productivity (earlier return to work) or actually decrease it (more sick days due to the virus spreading more freely)?” Eric Topol calls it “a reckless policy change.” Mike Hoerger, Director of the U.S. #COVID forecasting dashboard (PMC), is scathing: “Any suggestion of a national Covid 1-day isolation policy is a catastrophic misinterpretation of medical evidence that will severely harm tens of millions… throwing lighter fluid on the raging fire of transmission.” He calls the current US wave a “prolonged high-transmission surge,” already the second longest ever, likely continuing for weeks.
The “People’s CDC” points out that these guidelines impact the accommodations we can ask for at work, at school, and in hospitals, and our rights in interactions with the legal system. One positive note: the CDC’s awful proposed infection control guidelines have been put on hold.
Italy dropped mandatory self-isolation last August, but tells infected people to wear KN95 masks in company for ten days and avoid crowds, healthcare facilities, and contact with high-risk individuals. Masks are still obligatory in nursing homes and other medical settings with fragile or elderly patients, but unfortunately not in Emergency Rooms.
The White House has abruptly stopped requiring COVID-19 tests for people meeting with President Biden. Weirdly, this is just days after two co-hosts of a Biden fundraiser tested positive for COVID-19. Last July multiple members of an Israeli White House delegation also tested positive.
Damage and recovery
I wrote last time that American schoolkids are starting to regain learning lost during school shutdowns. The states that have done the best are Alabama for math, Illinois and Mississippi for reading. I was surprised to see Connecticut, Massachusetts, and California doing particularly poorly, but then I saw that California students scored pretty low prepandemic too.
A death certificate study found 1,194,610 excess US deaths from natural causes during the first 30 months of the pandemic, versus an official COVID-19 death count in August 2022 of 1.03 million – no, it wasn’t just from people avoiding healthcare facilities during lockdowns. The authors calculate the true COVID-19 death count at 15.8% higher than the official one. With another 140,000 Americans dying of COVID-19 since August 2022, the true total is probably not 1,170,000 but 1,355,000.
A report from the US Centers for Medicare and Medicaid Services says healthcare deteriorated during the pandemic. In 2021, 47% of quality measures worsened, especially regarding patient safety, whereas only 13% improved.
Americans are catching up on health care they skipped during the pandemic, when 134,000 cancer cases were missed; rates of breast cancer detection but not lung, colon, or cervix returned quickly toward normal. Some of the catchup is welcome (treating cancer and hypertension), but unfortunately much of it reflects bouncebacks of procedures that are invalid (many back surgeries) or overused (cardiac stenting).
Medicaid unwinding: states have now reviewed about half the 94 million people who were on Medicaid last March. Over 17 million (18%) have been “unwound,” while 35 million had their coverage renewed. Texas kicked off 55%, California 24%, Maine 13%. In 70% of cases the reason for losing Medicaid was not ineligibility but procedural, ranging from 23% in Maine to over 90% in Nevada, Utah, and New Mexico. At least 24 million, one in four enrollees, could eventually lose coverage; returning to 2019’s 79.2 million. A corollary may be the shuttering of safety net clinics whose patients, and funding, depend on Medicaid.
Nursing homes, where more than 15% of US COVID-19 deaths occurred, are also suffering. They remain “monumentally” understaffed, and haven’t fixed the combination of inadequate infection control measures and underused Paxlovid that caused the bloodbath.
Another institution collapsing without pandemic-era support is child care. Since federal benefits expired last September over half the programs are cutting enrollment, largely due to staffing shortages, and one in three may shut down altogether. Some parents spend 24% of their income on child care, with many even dipping into their savings.
Exceptional America
“Children are more likely to go hungry or live in poverty in America than our peer countries, and more likely to die: think drugs, guns, accidents, and inequitable health care. Steven Woolf of Virginia Commonwealth University calculates that if the US had the same pediatric mortality rates as the rest of the rich world, we’d save 40,000 young lives annually.
The Alabama Supreme Court has ruled that frozen embryos resulting from In Vitro Fertilization are “extrauterine children,” based on a 2013 state law and a 2018 constitutional amendment declaring that life begins at conception. Most Alabama IVF programs promptly closed down. This is proving a bridge too far even for Donald Trump, Alabama’s reactionary governor, and its 75% Republican state legislature, though maybe not for the 125 House Republicans who recently sponsored a Life At Conception Act with no carveout for IVF, and the 195 who voted against a Right to Contraception Act in 2022. Florida Republicans quickly backed off a “fetal personhood” bill, and Mike Pence, a radical evangelical, has used IVF himself. Nikki Haley said, “Embryos, to me, are babies,” before partially walking it back.
Several physicians, flanked by organizations including “Christian Medical and Dental Associations,” have sued to reverse the FDA’s 2000 approval of the abortion pill mifepristone. Judge Matthew Kacsmaryk agreed in full, the Fifth Circuit Court of Appeals in part, and the case is now before the Supreme Court. Even The New England Journal of Medicine has discussed the case. But three articles cited by abortion opponents, including two mentioned by Kacsmaryk, have been retracted for lack of scientific validity and undisclosed conflicts of interest. Abortion-ban states are losing ob-gyns, with 22% of Idaho’s obstetricians quitting or leaving the state over 15 months; similar exoduses in other red states could create “maternity care deserts.”
Hearing loss: a remarkable investigation by the Washington Post has found that people in counties that went for Trump in 2020 are more likely to have poor hearing than in those that went for Biden. Trump voters are often rural or blue-collar, with machinery noise exposure. They’re predominately Whites, who have twice the rate of hearing loss as other ethnicities. And they’re more likely to own guns (52% of Republicans, 28% of Democrats), boom BOOM.
For-profit medicine
Providence health care system is refunding nearly $21 million in medical bills paid by low-income residents of Washington – and it’s erasing $137 million more in outstanding debt for tens of thousands of others – to settle allegations that it overcharged those patients and then used aggressive collection tactics when they failed to pay.” One Providence pathologist also missed multiple cases of breast, cervical, and thyroid cancer. Great hospitals!!! Greed plus incompetence.
The latest Medicare scam is a ninefold increase in billing for unnecessary urinary catheters during 2023, totalling $2 billion. A similar scheme involving $1 billion in unnecessary back and knee braces led to 24 people being charged with fraud in 2019.
KFF’s surprise bills of the month.
- December 2023: A five-minute telemedicine visit for sinusitis, meant to cost $60, was billed for $660, which the insurer refused to pay.
- January 2024: Two preventive colonoscopies, supposedly free under the Affordable Care Act, were billed for $2,023 each, and insurers paid only 20%.
- February 2024: A mourning family was billed $81,739 for an air ambulance ride, without insurance coverage.
At a Senate hearing of Bernie Sanders’ HELP Committee, three Big Pharma CEOs were grilled on their outrageous prices. Merck charges American diabetics $6,900 for Januvia, when the identical product goes for $900 in Canada and $200 in France. In Italy a month’s supply costs $27 ($4 on the National Health Service), still obviously enough to make a profit. Sanders pressed the CEOs to agree to lower their prices to match those in Japan and France, but of course they refused. When Bristol Myers CEO Christopher Boerner emphasized the importance of patient choice in the U.S. health-care system, Sen. Chris Murphy mentioned a constituent who uses Bristol Myers’s blood thinner, Eliquis.“Here’s her choice,” Murphy said. “Her choice is to pay the $350 and go without food or pay her rent late, or not take the drug and risk heart attack or stroke. Is that the choice you’re talking about?”
Only in America could the official White House physician be a drunkard nicknamed “Candyman” and “Doctor Feelgood” for freely distributing sedatives, stimulants, and opioids. Dr. Ronny Jackson, now a Republican Congressman, said in 2018 that Donald Trump was not just in “excellent health” but had “incredible genes,” was “mentally very, very sharp,” and with a better diet could “live to be 200”!!! A new report on his troubled clinic emerged in February, two years after a previous one got him demoted from admiral to captain. The same quack treated Barack Obama, and could be recalled to the White House if Trump wins in November.
Dubious
- An article in the Cornell Chronicle titled “Surveillance surveys give clearer picture of COVID’s spread” looked interesting, citing “a high level of asymptomatic infections.” But the linked article gives no results at all, only a description of the challenges in performing surveillance surveys, and the researchers’ plans to overcome them.
- Fox “News” has featured data from the Global Vaccine Data Network. A mountain of a study, examining 99 million vaccinated individuals, gave birth to a mouse of a result: a small, well-known risk of myocarditis related to mRNA vaccines, and the equally well-known, greater risk of serious clotting problems and Guillain-Barré Syndrome related to viral vector vaccines from AstraZeneca and Johnson & Johnson, neither of them used nowadays. COVID-19 itself can lead to GBS, and mRNA vaccines actually decrease the risk.
- Four pandemic misinformation-mongering organizations netted $118 million between 2020 and 2022, according to a Washington Post analysis of tax records.
- The latest vaccine BS claims the Red Cross won’t let people who are vaccinated against COVID-19 donate blood. Nope. People who have had “live attenuated COVID-19 vaccine” must wait two weeks before donating blood because of the risk of transmitting infection. But no live attenuated COVID-19 vaccine has ever actually been used, though products from Codagenix and Meissa reached Phase I. The only ones currently under development are intranasal products whose efficacy is low, pending, or unknown.
Extra: From the Audiobook of Dottoressa: An American Doctor in Rome
Thanks! Been waiting for your latest medical news, getting the best of medicine out to us -
Thanks Susan, comprehensive and well written. Good to have you back. The abortion issue is terrible and 'maternity deserts' will be incredibly dangerous. As usual the poor with bear the brunt. Killer Conservatives!!