Disaster Looms
Luís Filipe Gomes
If you arrive at wording that says [Message clipped], make sure you click on “View entire message.” Disaster LoomsTesting, prevention, COVID-19 miscellany, followups, looming disaster, long COVID, and the state of the pandemic, plus an Extra from the audiobook of Dottoressa: An American Doctor in Rome.
RFK Jr.’s increasing rejection of modern medicine
Testing and prevention
syphilis patients left untreated in the Tuskegee study
A reader told me the tests she obtained through Covidtests.gov expire very soon, and that one expiring in 2026 costs triple; she suspects the government of being miserly. It should be said, though, that between the winter COVID-19 surge and the early flu season, those tests might get used after all. The work requirements that Georgia has placed on eligibility for Medicaid, absurd, immoral, and spending far more on administration than on medical care, also slowed the approval process to a crawl. Only 5,542 people had enrolled by November 1, whereas under full Medicaid expansion nearly 300,000 Georgians would gain coverage. During Medicaid “unwinding,” still only half completed, about 600,000 Georgians lost coverage – including 150,000 kids. Uptake of updated COVID-19 vaccines is poor; on December 2 17.9% of all American adults, 32% of nursing home residents, and 41.6% of adults over 65 had been vaccinated. In Italy, where it arrived 2 months later, only 30% of people over 70 were vaccinated by January 9. Early data: it prevents 68% of hospitalizations and 56% of outpatient visits. Texas researchers found that COVID-19-vaccine-hesitant Black women added historical medical racism (see “Tuskegee study”) to the “usual reasons” for hesitancy. Israeli and Portuguese researchers have produced an intranasal, room-temperature COVID-19 vaccine “at least as effective as Pfizer’s.” In mice, it elicited antibodies against alpha, beta, delta, gamma, and omicron variants. Omicron and its subvariants now cause all COVID-19 cases, so the others are irrelevant. And the one they examined, BA.1.1, hasn’t been seen for years. The grand jury Ron De Santis convened to investigate wrongdoing related to COVID-19 vaccines found no evidence of criminal activity, but claimed unspecified “profound and serious issues” related to vaccine development and safety surveillance. Yale researchers think northern hemisphere adults should get vaccinated against COVID-19 in early autumn, 3+ months after their latest infection. HHS has received 10,473 claims of damage related to COVID-19 vaccines, finished reviewing 25% of them, and found 52 eligible for compensation. COVID-19 miscellany
psilocybin mushrooms
Studies from Johns Hopkins and Denmark suggest that “cytokine storm” related to mitochondria underlies severe COVID-19. In October 2023 I wrote presciently, regarding long COVID: “Another recurrent hypothesis is dysfunctional mitochondria. The brilliant Eric Topol is impressed by the latest study, but its findings seem to me more relevant to the severity of COVID-19 than to the persistence of symptoms.” An unusual study examined not COVID-19 patients but the physicians and nurses who cared for them. Treatment with low doses of psilocybin brought sustained improvement in depressive symptoms and burnout. In a small American study, about 10% of subjects lost private health insurance during the pandemic, negatively impacting their mental health. South Korean researchers found COVID-19, especially in unvaccinated or hospitalized patients, to slightly (9-45%) increase the risk of future autoimmune and connective tissue disorders such as rheumatoid arthritis, lupus, ankylosing spondylitis, and Crohn's disease, whereas an earlier Chinese study found risks to double or triple. COVID-19 can trigger flares of rheumatoid arthritis and perhaps lupus. Swedish researchers report that even mild COVID-19 causes greater deterioration in kidney function than non-COVID-19 pneumonia. The FDA has revoked the Emergency Use Authorizations of four COVID-19 monoclonal antibody products ineffective against current variants: bebtelovimab, sotrovimab, casirivimab/imdevimab (REGN-COV2), and tixagevimab/cilgavimab (Evusheld), leaving pemivibart (Pemgarda), intended only for prevention, the sole authorized product. Follow-ups
Luigi Mangione, accused murderer of UnitedHealthcare CEO Brian Thompson
Fatal opioid overdoses continue falling in the US, but addiction treatment remains inadequate. The largest chain of methadone maintenance clinics, Acadia Healthcare, enrolls people not using opioids, provides little (often mediocre) counseling, falsifies records, and bills for nonexistent services. Other programs may be even worse. Prior authorization (insurers refusing to cover procedures, treatment, or operations, leading 78% of physicians to stop trying, with mental health services often denied if the patient improves): The Biden Administration has acted to prevent the worst abuses. Following steps pioneered by many states, starting in 2026 urgent requests must be responded to within 72 hours and routine ones within seven days, use of AI to deny requests is limited, and insurers must justify denials. Some think these reforms don’t go far enough. In related news, a “Medicare Advantage” insurer settled a fraud case (payouts for nonexistent diagnoses) for $100 million. UnitedHealthcare: A Senate report says UnitedHealthcare, whose CEO was gunned down recently on a New York City sidewalk, bringing a tsunami of protests and the lionization of his murderer, recently doubled denials for post-acute care for the elderly and limited treatment of autistic kids, pressuring its human reviewers to hew strictly to an algorithmic recommendation system. See a scathing critique by Lynn Parramore. I’ve mentioned that the Biden Administration expanded Obamacare access to “Dreamers” brought to the US as children, but that Republicans threatened to sue. About 100,000 of the half-million DACA recipients were expected to sign up for 2025 coverage. Now a Trump-appointed judge has ruled the expansion illegal in 19 Republican-run states. I’ve mentioned that if Obamacare subsidies are allowed to expire in 2025 insurance plans could become more expensive. It’s even worse than I thought. The Congressional Budget Office estimates that without a permanent extension 3.8 million people/year would lose coverage between 2026 and 2034, with premiums rising by an average of 7.9% yearly. Kentucky has sued pharmacy benefit manager chain Express Scripts for fueling the state’s opioid epidemic. It turns out that Purdue Pharma, of OxyContin infamy, was giving Express Scripts billions of dollars in bribes. The Republican-dominated Ohio Supreme Court has blocked similar lawsuits against pharmacy chains from proceeding. A recent deal to avoid a government shutdown stripped out reforms limiting the power of PBMs. “Pharmacy deserts” following widespread store closures disproportionately affect seniors. I wrote in July that Amazon’s One Medical “hires incompetent providers, putting patient lives at risk.” Incompetence has led to at least one death following a telemedicine visit. I’ve mentioned that Italian doctors emigrate in part for better pay. Italian physicians are in fact paid 22% less than the OECD average, lower than most Western European countries and strikingly less than in North America. Elective surgeries and other patient care have worse outcomes in American hospitals owned by private equity, with nurses testifying under oath to “unsafe” and “untenable” conditions. Disaster looms
If you want to work in RFK Jr.’s HHS, here are some of the actual items on the screening questionnaire: “I make people feel at ease more than I spend time reflecting on things.” “I don’t have that much interest in having sexual experiences with another person.” “I don’t feel much empathy for others.” “I require excessive admiration.” “I believe in things many others don’t – like having a ‘sixth sense,’ clairvoyance, and telepathy – and as an adolescent, I had bizarre fantasies or preoccupations.” “I consistently use my physical appearance to draw attention to myself.” “I can usually talk my way out of anything.” Well before the election Danielle Ofri was already warning about the healthcare implications of Chevron’s overturning, and how Donald Trump could sabotage the Affordable Care Act without overturning it. Trump spells public health disaster both at home and worldwide. See expert reactions to Trump’s health appointees here, here, here, here, here, here, and here. The American Public Health Association and “Protect Our Care” particularly blast RFK Jr., with even the Washington Post weighing in. while others focus on Jay Bhattacharya, Marty Makary, Mehmet Oz, or David Weldon. A physician-only surveyasking “Who is Trump’s Best Healthcare Pick?” got 16 comments, of which 8 including my own said, “None of the above.” Seven federal lawmakers wrote to Mehmet Oz, Trump’s MMS pick, criticizing both his personal conflicts of interest and his vow to eliminate traditional Medicare in favor of Medicare (Dis)Advantage. A Buffalo physician wrote a cogent critique of RFK Jr. and Oz, called “Fighting Misinformation Like a Doctor.” MedPageToday calls the health picks “Not just team of rivals but ‘team of opponents,’” pointing out discrepant views on abortion, vaccines, weight-loss drugs, pandemic response, etc. RFK Jr. has many gripes with the FDA, some legitimate, some not. Disaster may already be here: RFK Jr.’s lawyer Aaron Siri has asked the FDA to revoke approval of both the polio vaccine that’s 90% effective against paralytic disease and the cancer-preventing hepatitis B vaccine – and to pause vaccination against tetanus, diphtheria, and hepatitis A. The polio vaccine has saved 20 million people from paralysis and spared 1.5 million lives. Hundreds of thousands of Americans had polio, among them Tanaquil Le Clercq, Mia Farrow, Alan Alda, Donald Sutherland, Francis Ford Coppola, Joni Mitchell, Franklin Delano Roosevelt, and Mitch McConnell. The only countries where polio is still endemic are Pakistan and Afghanistan, though it recently reappeared in the Gaza strip after 25 or 36 years. Skin in the game: I was supposed to participate in the Salk vaccine trial when I was in first grade, but for some long-forgotten reason I didn’t. The Louisiana Department of Health has forbidden public health workers to promote vaccines against COVID-19, influenza, or mpox, drawing comments like “If this was a practicing clinician in the community doing this, they would be going in front of the board about their license.” RFK Jr. seems to wield power even before his nomination. Since Idaho has the lowest vaccination rate in the country, we shouldn’t be surprised at their more than 1000whooping cough cases last year, vs. fewer than 50 in 2023. 32,000 US cases were reported, more than five times as many as in 2023 – vaccines missed during the pandemic. If RFK Jr. becomes HHS secretary things will only worsen. By May 10, 2024 Italy already had 110 pertussis hospitalizations, vs. 12 in all of 2023. Trump is skeptical of mandatory vaccines for schools, though he’d make an exception for polio shots, as might even RFK Jr. Blake Masters said Ted Kascinski, the “Unabomber,” had “good insights.” Trump’s nominating him to head the Bureau of Alcohol, Tobacco, Firearms, and Explosives is a sick joke. House bills propose abolishing that department altogether – also OSHA and the IRS, and repealing the National Voting Rights Act, the Affordable Care Act, and the Inflation Reduction Act. And Trump is again threatening to withdraw from the WHO, “on day one.” Long COVID
Hypermobile joints (“double-jointedness”), associated with fibromyalgia and chronic fatigue syndrome, increase long COVID risk by 30%; autoimmune diseases such as rheumatoid arthritis quadruple the risk. Other novel risk factors: socioeconomic deprivation, unemployment, and obesity. Does Paxlovid prevent long COVID? An NIH study said it lowered risk by 13%, a VA/Washington University studyby 26%, and a metaanalysis by 23%, while another VA study found no protection. A Saudi study of university students found that in 24% COVID-19 symptoms lasted more than two weeks and in 7% more than a month, especially loss of smell, fatigue, shortness of breath, and headache. Persistent symptoms were associated with higher depression scores. Unfortunately the study doesn’t report longer persistence, say 3-6 months. NASEM's lucid definition, “an infection-related chronic condition that occurs after COVID-19 and remains present for at least 3 months as a continuous, relapsing and remitting, or progressive disease state that affects one or more organ systems,” could improve diagnosis, surveillance, disability benefits, and more. There may be a tsunami of disability from long COVID, which affects 6.9% to 22.8% of Americans, It’s harder to certify under the Social Security Administration than under the Americans With Disabilities Act. Four hundred million people worldwide have experienced long COVID, according to a review article that unfortunately cited uncritically a Bramante article claiming prevention by metformin (it worked only in the unvaccinated). Since Black Americans suffered disproportionately from COVID-19 and have increased risk of long COVID, one might have expected high interest in their long COVID experiences. On the contrary, their symptoms get neglected, and they are underrepresented in the NIH RECOVER initiative. In one study among African-Americans, psychological issues from depression to psychosis and attempted suicide, were particularly salient. Another found Black and Hispanic long COVID patients less likely than non-Hispanic Whites to report sleep disorders, brain fog, or fatigue. A Belgian study detecting persistent SARS-CoV-2 in most long COVID patients is now published in The Lancet and supported by a UCSF study and in one case series seven of 13 cases improved on Paxlovid. Unfortunately for the viral persistence hypothesis, Stanford University had to halt its Stop-PASC trial after enrolling 155 patients, when 15 days of Paxlovid didn’t beat placebo. Brain imaging is generally normal in long COVID patients, except for impaired circulation on ASL-MRI, PET/CT, and SPECT. One Spanish MRI study did report thinning of the left posterior superior temporal gyrus, key to language understanding, and a Chinese fMRI study found changes in the putamen, temporal lobe, and superior parietal gyrus. American researchers detected SARS-CoV-2 antigens, mainly spike protein, in the blood of 25% of COVID-19 patients a year after infection. They didn’t ask about symptoms, so any associations with long COVID remain unknown. American researchers found adolescents with long COVID more often fatigued than younger children. Their rates of 39% and 45% were extraordinarily high. A University College London study found that only 70% of 11-17-year-olds with long COVID had recovered two years later, though most patients improve by six to twelve months. A US study confirms that routine lab tests are normal in long COVID. Australian researchers found COVID-19 more severe than other respiratory illnesses and more likely to bring prolonged symptoms, though COVID-19 and influenza have similar in-hospital mortality. A Veterans Administration study describes long COVID lasting three years; a patient of mine has exceeded four. Another one, confirming earlier results, found just 15% prevention by vaccines, in contrast with the 46%, 59%, 58%, or even more reported by others; patients vaccinated even 6+ months earlier have less long COVID. In still another VA study one-year long COVID rates in unvaccinated patients were 10.4% pre-Delta, 9.5% Delta, and 7.8% Omicron; in vaccinated patients Delta 5.3%, Omicron 3.5% – striking vaccine protection. An editorialist warns that long COVID risk persists. A National Academies report emphasizes the persistence, heterogeneity, and severity of long COVID. Treatment options recently added to the RECOVER initiative: modafinil and solriamfetol for daytime sleepiness, melatonin and high-intensity light therapy for insomnia, cardiopulmonary rehabilitation and structured pacing for exercise intolerance, Transcranial Direct Current Stimulation for cognitive dysfunction. Still no sign of “immunosuppressants, immune enhancing drugs, or corticosteroids.” In 2022 Israeli researchers published a randomized trial of hyperbaric oxygen therapy, which improved energy, cognition, mood, sleep, and pain. Now they’ve shown those effects to persist a year later. I consider HBOT, which some Americans can try for themselves, the most promising long COVID treatment. American researchers found low-dose lithium carbonate useless for long COVID; they thought higher doses might work, though many lithium side effects resemble long COVID: confusion, poor memory, tiredness, headache. Norwegian researchers found a brief outpatient Cognitive Behavioral rehabilitation program to improve both physical and psychological long COVID symptoms, building on a similar Dutch study targetting fatigue. A New England Journal of Medicine piece uncharacteristically features patients who describe long COVID experiences in their own words. UK but not Norwegian researchers found objective cognitive deficits in patients reporting poor memory or brain fog. Those same Norwegians say post-COVID patients have twice the rate of executive function deficits (emotional control, organization, mental flexibility) as uninfected controls. Other UK researchers describe cognitive complaints, objective findings, and cerebral grey matter shrinkage a year after COVID-19 hospitalization. An Oxford University study found that 2-3 years after hospitalization 62.3% had fatigue and 52.1% cognitive difficulties; a third lost 10+ IQ points, and 11% lost 30+. A peculiar international survey of 3762 “long COVID” patients, of whom only 1020 had documented COVID-19, gives an interesting overview, following Zeynep Tufekci's suggestion that patients fund their own research. Pregnancy risks severe COVID-19, and 9.3% of women infected during pregnancy reported long COVID at 10 months, similar to unselected patients. The state of the pandemic
In late August US wastewater SARS-CoV-2 levels were high or very high in 47 American states, on September 21 only 34, and data kept improving until just seven states were high or very high on November 21st. But by December 28, 24 states and D.C. were again high or very high, jump-starting the winter surge. Hospitalizations have been rising since mid-November, without clear patterns, but deaths keep dropping. Italian and European data are basically stable. Since November American hospitals must again report COVID-19 cases. A year-end WHO report says total reported cases worldwide fell by 39% during the month ending in mid-November, reported deaths by 36%, and reported hospitalizations by 15% (though rising in Europe). Cases rose substantially in 20 countries, however, hospitalizations in 10, and deaths in 8. All these figures are underestimates, between decreased testing, decreased reporting, and reporting delays. In the same report: 67% of the global population had a primary vaccine series by 2023, the proportion of COVID-19 deaths among the elderly has increased steadily since mid-2021, test-positivity rates are falling, especially in Europe, 2024-25 vaccine uptake is low even among the elderly, long COVID remains treatment-resistant, routine vaccinations are lagging worldwide, Russia has the highest COVID-19 death rate in Europe. Dr. Ghebreyesus, Director-General of the WHO, believes the real death toll from COVID-19 is at least triple the official 7 million. In the same remarks he named December 12 “Universal Health Coverage Day,” calling UHC (all people having equitable access to the essential health services they need without being exposed to financial hardship) one of WHO’s top priorities. The WHO Constitution was the first document in international law to call health a fundamental right for all people. He didn’t mention that the world’s richest, most powerful nation, the US, is the only developed nation without UHC, and the G7 member with the shortest life expectancy.
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