Category Archives: health and healing

It’s Still Mainly Medical, Not Moral

“If we are going to debate abortion in every state, given how fractured and angry America is today, we need caution and epistemic humility to guide our approach.” — Peter Wehner in The Atlantic

I showed up for one of the many Bans Off Our Bodies rallies across the country on May 14. It was the least I could do. It wasn’t enough. I’m not sure what will be.

Some Black folks on Twitter were shaking their heads at the stupidity of people who officially signed up to go to these things, wore recognizable T-shirts, shared photos, and in general made themselves obvious. They knew from bitter experience that being identifiable at a protest can lead to unpleasant consequences. In Albuquerque, going to an event like this is a pretty mainstream thing to do, and my old white lady self had little to worry about, but that was a wake-up call. I know it’s not so easy everywhere or for everyone.

Why is it always framed only as a women’s issue?

The closest thing to a threat I noticed was a tall, heavyset guy, a rather imposing figure, wearing a shirt that bore a childishly offensive message intended to incense Democrats, yelling anti-abortion insults nonstop through a megaphone. He was the only visible representative of his side, and he certainly did nothing to help their cause.  He was also failing to get the attention he apparently wanted.  Everyone was ignoring him.

“It’s not what people want.”

The other day one of my patients, a lady in her late 60s, told me that her husband is extremely angry about Justice Samuel Alito’s draft that shows the court plans to overturn Roe v Wade and throw the country further into red/blue chaos. She is not angry herself, she said, because, as she stated with total confidence, “It’s not going to happen.” I asked her why she would say that. “It’s not what people want,” she replied.
 Her pronouncement was like an incantation. It felt incontrovertibly true and immediately real. Perhaps, since about ¾ of Americans do think Roe should remain, she will be proven correct. After a lot of pain, death, and waste, I fear.

This morning I read a local news story that referred to a university student group as pro-abortion. What lazy reporting, and terrible messaging. It feeds into the false narrative that Democrats want to allow abortion up till the moment of birth. It intensifies polarization and makes rational communication all the harder.

It must be stated firmly that no one is “pro-abortion.” That is not at all what people mean when they express the importance of keeping abortion available. This morning I read a local news story that referred to a pro-abortion student group. What terrible reporting, and worse messaging. It feeds into the false narrative that Democrats want to allow abortion up till the moment of birth. It intensifies polarization and makes rational communication all the harder.

Most Americans express middle-of-the-road, nuanced, pragmatic, compassionate views on abortion. They know it’s complicated and that every situation is unique. They want it to remain legal, but they are comfortable with a certain degree of restriction. That’s what poll after poll tells us. The ‘90s mantra of “safe, legal, and rare” seems to describe the mainstream attitude well.

No one wants to find themselves in the position of needing an abortion. No one hopes or plans that someday they will terminate a pregnancy. The very fact that someone is looking to do that means that something, somehow has gone wrong. Maybe horrifyingly wrong.

Even in a perfect world in which every pregnancy was wanted and celebrated, in which rape and incest did not exist, in which every family was confident that they could support every child who came along, there would still be cases in which abortion was needed for medical reasons. More of them than you might expect. That could happen, has happened, to people who desperately wanted that child to grow and be born. It could happen, has happened, to people who believed abortion was wrong and never in a million years expected to need one. Nature doesn’t care about our religious beliefs or political attitudes, or our desires or our convenience. Nature follows her own laws.

This is the point I want to drive home today, that abortion is medical care and that it must remain available to save lives and prevent great harm. It was over 10 years ago that I wrote the post I’ve copied below, “It’s Mainly Medical, Not Moral.” At the time, the big war was over coverage for contraception under the Affordable Care Act. Note this well: despite Justice Alito’s assurances that the Supremes are only talking about abortion, not contraception, LGBTQ rights, or anything else, the right wing has been fighting against access to contraception all this time. It absolutely is a target and they will come after it.

As an LGBTQ person, I’m very nervous about where this is going. As a woman, I’m anxious, even though I’ve been out of the reproductive game for decades. As a health care professional, I’m afraid for all the doctors and other providers who have to care for their patients while trying not to run afoul of laws that make no sense. And as a person who wants democracy to be a reality in the United States, I’m terrified.

A couple of days ago I was spinning down into a maelstrom of fear and depression. Then I realized what should have been obvious: They want me to be afraid. They want us all to be paralyzed by fear and unable to get ourselves together to oppose them. Let’s not give them that.

Catch-22s all over

One would think that since effective contraception leads to far fewer abortions, anti-abortion folk would be much in favor of it. And one would be wrong, at least in the case of the more extreme elements of their movement. This is what I find most incomprehensible of all. There is a clear path to reducing the number of abortions: reduce unwanted pregnancies. Yet the same states that want to outlaw abortion also refuse to expand Medicaid, and work in every other way they can to limit access to birth control. Under this regimen, people can’t prevent pregnancy, can’t terminate it, can’t afford to get prenatal care or give birth, can’t afford care for the baby while they go to work, and can’t afford to stay home to do child care themselves. Especially for the poor, it’s hard to see what the option is supposed to be. (Breed babies for the rich to adopt, perhaps? That’s what Justice Coney Barrett’s flippant and heartless rhetoric suggests.)

It’s been pointed out that if we as a country really cared about babies, we’d do more to provide health care, child care, decent wages, and so forth, and obviously we don’t do that. There are some fervently anti-choice organizations that do try to support pregnant women in distress and those with newborns. I personally know two families that have taken young, financially stressed pregnant women into their homes and literally supported them. However, these efforts are far from state policy and are not remotely adequate to handle the thousands of individuals and families in difficult situations as a result of pregnancies.

A world in which abortion is criminalized means that some women will be arrested and jailed after having miscarriages or stillbirths. That’s been going on in El Salvador for many years, and despite a push to free women who have been imprisoned under such circumstances, it has just happened again. A woman who had an obstetric emergency and sought care at a hospital, as any of us would have done, was convicted of homicide after losing the baby. She has already been in pretrial detention for two years.
https://www.vice.com/en/article/k7wd9n/a-woman-just-got-30-years-for-homicide-after-losing-her-baby
https://abcnews.go.com/International/wireStory/el-salvador-woman-accused-abortion-30-years-prison-84630286

But this is not just something that happens in faraway lands— it has already been happening here, for quite a while, even with Roe still in place. And not only do women risk arrest if their pregnancy goes awry, they may be unable to get medications that are commonly used to treat miscarriages, because those can be associated with abortion. https://www.npr.org/sections/health-shots/2022/05/10/1097734167/in-texas-abortion-laws-inhibit-care-for-miscarriages

A miscarriage is medically indistinguishable from a medication abortion, so anyone who has had one is potentially vulnerable to prosecution under such draconian laws. This means that the totally normal, sensible act of going to a hospital can put a person in grave danger. And of course when one is bleeding heavily, avoiding going to a hospital is not a very safe choice either.

This is not what most people want our country to be like. We know that a strong majority of Americans, including a majority of Republicans, want Roe v Wade to stand. We know that most Americans want to see, at the very least, exceptions for rape and incest, exceptions that the farthest-right state legislatures no longer wish to allow. It’s astonishing that a policy so widely opposed by people all across the political and social spectrum can even be considered as law.

Welcome to the age of minority rule.

Should we rage?

The forces arrayed against reproductive rights have had passion and long-term commitment on their side. Those wanting to keep abortion and contraception available have been more complacent— for so long, there seemed to be little reason to scream about rights that everyone, even certain Supreme Court nominees, recognized as “settled law.” (What patsies we were.)

So now we are beginning a “Summer of Rage,” in which protests will be loud and persistent. I don’t know whether this is the best course. We can’t be complacent anymore, and this is a genuine emergency that deserves every effort to hammer it into the public consciousness. Would we be better off with a more rational, conversational approach? That would be my way of doing things, but I can’t say that it’s worked particularly well so far, so maybe hot pink rage really is the ticket right now.

Medical hazards and crises

At any rate, in this post I would like to speak to the typical person and bypass extreme rhetoric. I want to again point out some of the dire medical reasons a pregnancy may need to be terminated, no matter what the ideology of the mother, the health care personnel, the state, or anyone else. There are many more that I won’t get around to here.

First, the likelihood, or should I say certainty, of young girls being impregnated by relatives or others. Incest is far more common than we like to think. All too often this happens to a child who is too young and small to safely carry a baby to term and give birth. Beyond the sheer cruelty of putting a child through this— how can anyone justify sacrificing one child to save another, especially another who was unlikely to survive to begin with? There have been famous cases like this in countries where abortion was totally banned. There are guaranteed to be more.

Even before the current era of extreme state laws, some states commanded that minors would have to have permission from their parents to get abortions. Right-wing forces tend to hold a rosy picture of caring parents in nurturing families in which a confused teenager might be lovingly guided to make good choices, but obviously that is not always the reality. What if, in fact, the parent is the perpetrator? Are we really going to require girls to give birth to their siblings? Does that make either medical or legal sense?

Pregnancy and birth are not only dangerous for the youngest girls, though; they’re hazardous for everyone with a uterus. You probably already know that the US has an embarrassing level of postpartum deaths, and that the rate is worst for Black women. (Poorer women get worse care in general, but even wealthy Black women face increased risks.) The people most impacted by draconian laws against abortion are also the ones who are less likely to get through pregnancy and birth safely.

In addition to the fundamental, “normal” risks of pregnancy and childbirth, there are the many unforeseen tragedies that can befall a fetus during gestation and that can threaten the mother’s health and/or life. Laws that purport to make exception for saving the life of the mother but are written without medical understanding, and without details about what is actually allowed, tie the hands of doctors in emergencies and lead to unnecessary deaths. When this happened to Savita Halappanavar in Ireland, the country responded to the outrageous situation by changing its laws. The same kind of deaths will no doubt occur here. It’s just a matter of time.
https://www.irishcentral.com/opinion/niallodowd/savita-halappanavar-abortion

In fact, last week I read about a woman who had a similar problem to Ms. Halappanavar’s— her water broke, it was too early for the fetus to survive outside the womb, sepsis was likely. And she lived in Texas. Because the mother’s life wasn’t in danger at that very moment, even though it probably would have been in the very near future, the doctors felt unable to terminate the doomed pregnancy— as they would have before the new law kicked in. The mother ended up being driven about 8 hours by ambulance to a neighboring state, a stressful, dangerous, expensive, and totally unnecessary trip. This is craziness.
Don’t understand why doctors would be prevented by law from saving a woman in such circumstances? Let a real OB-GYN explain how incredibly fraught and confusing an emergency can become:
https://www.youtube.com/watch?v=zjB5Jakytyc

We have to remember that suicide is also a major risk to the life of a distressed pregnant person. Here is an anecdote from another OB-GYN:
“During medical school in Florida, my first experience with abortion was with a 19-year-old woman who had been gang raped and was now pregnant; she was suicidal and placed in the behavioral unit. Our team saw she was devastated; she did not want to continue the pregnancy. It was simple; this traumatic, unforgivable experience would ruin her life. I was disappointed to see the reluctance to offer the care she needed. Only one physician, a newly graduated physician who trained in LA, immediately offered her care. His care could change her future and offer her some peace of mind for her mental and physical turmoil. I wanted to become the physician that would not back down, would show up and would be present for a patient in her time of need. When I applied to residency, I knew I wanted a program that offers training in abortion care.”
https://abq.news/2021/09/op-ed-we-stand-with-texas-patients-against-the-sb8-abortion-ban/

It’s not my purpose here to try to list every kind of medical crisis that could occur during a pregnancy and make termination the best or only choice. There are so many heartbreaking things that can happen to either the mother or the fetus, and each one requires its own unique response. Things that go horribly wrong often do so late in pregnancy, well after the 6 weeks Texas allows and even after the or 15 or 20 some other states have wrangled over. (Savita Halappanavar developed sepsis at 17 weeks.) Pregnant people, their families, and their doctors need the flexibility to make the right decisions in the moment, often with very little time available. Legislators making rigid, blanket pronouncements cannot possibly cover all the contingencies that have to be dealt with in the complex reality of reproductive health care.

Ten Years Ago— Plus Ça Change

When I wrote “It’s Mainly Medical, Not Moral” on 2/20/12, the big battle was over the Affordable Care Act’s provision to cover birth control. We have only gone backwards since. Here is the text of that post.
https://elenedom.wordpress.com/2012/02/20/its-mainly-medical-not-moral/

It’s Mainly Medical, Not Moral

You’re probably sick of hearing about the war over insurance coverage for contraception under the Affordable Care Act, but I think I have a few useful points to make that haven’t been brought up elsewhere.

For those of you who live elsewhere, let me catch you up on this only-in-America craziness.  The Affordable Care Act, otherwise known as the health care reform law, mandates that contraception must be covered by insurers without co-pays (direct costs at the time of service) to the patient, and that employee health plans must provide this coverage.  While there is an exception for employees of churches and other places of worship, hospitals, universities, and other institutions owned by religious sects are included in this mandate.  A number of right-wing forces have complained that this tramples upon religious freedom.  After being thoroughly raked over the coals, the President and his advisors worked out a compromise: the religious groups would not have to pay for the coverage, and it would be provided directly by the insurance companies, so that those who object could keep their sense of purity.  Insurers have agreed to this because providing contraception saves them money (and is expected to save money for the entire health-care system as well as for individual families).  The war is still raging as I write this, with the self-styled guardians of freedom insisting that the government is still overstepping its bounds.

On the front lines of this trumped-up battle, we find none other than the Conference of Catholic Bishops, the same fine folks who protected us from the evil, dangerous practice of Reiki by banning it in all Catholic hospitals and other institutions.  (See my post “Attack of the Bishops.”)  Need I state the obvious?  These ideas are being promulgated largely by partnerless elderly men.  These are not people who have any need to prevent pregnancy or any understanding of what that issue is like for those who do, including the 98% of Catholic women who use birth control at some point in their lives.  This outrage is compounded by the fact that Viagra is covered and the bishops have no problem with that.

A letter I wrote about this recently was published in the Albuquerque Journal on Sunday 2/12/12, before the President backpedaled, and before Rep. Darrell Issa convened a panel of ALL MALE religious leaders, Catholic and otherwise, to testify before Congress.  Issa and his Religious Right cohorts have managed to make it crystal clear that their agenda has little or nothing to do with religious freedom, and is really about a) attacking the president and killing the Affordable Care Act any way they can, and b) controlling women.  They’ve abundantly shown that they want to get rid of not only abortion but all forms of contraception.  And while wailing about the government infringing upon their freedom, they’ve shown that they have no problem with curtailing the freedom of others– especially if those others happen to have pairs of X chromosomes.

Here’s my letter:

“In all the indignation-filled rants I’ve heard about the Obama administration requiring religious institutions to include contraception in employees’ health insurance coverage, there has been one glaring omission:  No one has mentioned the fact that quite often, hormonal contraceptives (the Pill, patches, or implants) are used for medical reasons that have nothing to do with birth control.    Many women take the Pill, etc. for conditions like polycystic ovary syndrome or severely painful periods.  Many of those women are not even sexually active, or not sexually active with men.  I’ve seen this quite a bit with my own patients.  Whatever one thinks about contraception, it’s hard to imagine even the staunchest Catholic objecting to legitimate medical treatment for such conditions.

“I’d just as soon see women use natural alternatives, but in many cases hormonal birth control really changes their lives for the better.  The costs of these medications can be quite substantial, however, and that can put them out of reach for students and low-paid workers.  The costs of the conditions they treat can be substantial, too, as when a woman must miss work because of debilitating pain.  We would not ask an employee to forgo painkillers for arthritis or inhalers for asthma.  How is this different?

“The President may have lost some votes with this decision, but there are quite a few of us who are relieved to see him standing up for women and for what makes medical sense.  Try as I might, I can’t see this as primarily an issue of religious freedom or of morality.  Women who object to contraceptives are still free not to use them.  Morality means doing the best we can for everyone in our society, and that includes medical care, which includes birth control.”

I didn’t want to get all confessional in the newspaper, and I wanted to focus on a single point for impact, without bringing in other aspects of the situation, but I have a personal story that I think sheds particular light on the complexity of this issue and the reasons a total ban by religious “authorities” is not only ludicrous but cruel.

When I was about 25, I developed severe cervical dysplasia, well on the way toward cancer.  This was treated with cryosurgery to remove the diseased cells, which was a standard treatment back then; no one realized at the time that cryosurgery would only mask the problem, which would resurface later on.  My primary care doctor told me I should have a hysterectomy, which showed a remarkable ignorance on his part, it seemed to me, as the precancerous cells were not invasive and might never be.  I had not yet had a child, and was determined to be able to do so.  After I healed from the cryosurgery, I did get pregnant, and my daughter was born when I was 27.  Over the next couple of years I became allergic to or unable to tolerate most forms of birth control, and so, with my husband and my very small daughter in agreement (Lenore’s opinion was “We have enough babies around”), I had a tubal ligation.  Which was covered by insurance, by the way, because my husband is one of those awful, greedy public employees, a teacher that is, and he gets all those totally undeserved benefits.

That was not the end of the medical story.  I had a number of years of clear Pap smears, then skipped a year, because it didn’t seem critical to have one at that point.  The next Pap showed carcinoma in situ.  The tissue underneath the layer affected by the cryosurgery had been stealthily developing toward cancer the whole time, and it had simply taken that long to show up on the surface.  By that time, most of my cervix consisted of abnormal cells, and I was noticeably ill.  To deal with this, my OB-GYN did a cone biopsy to remove all that– they use the word “biopsy,” since it does have a diagnostic aspect, but it’s a far larger matter than the word suggests.

The hospital personnel wanted to do a pregnancy test.  I explained that I’d had my tubes tied.  They impressed on me repeatedly that after this procedure my cervix could not support a pregnancy, and that I needed to be OK with that.  I reassured them again, and the surgery was done.  The pathologist found that there were still diseased cells around the edges of the cone, so a few months later I went through the whole thing again, nearly bleeding to death afterward, and ending up with even less of a cervix.  I emerged from the process weakened but cancer-free.

I often thought about what would happen if a woman in this condition did get pregnant.  Surely it has happened many times.  An embryo would start to grow, everything going fine, and at some point it would lose its moorings in its mother’s womb and essentially fall to its death.  I wondered how far developed the poor creature would be when that happened.  It seems horribly sad, doesn’t it?  The child would be doomed from the start.  The mother would suffer both mentally and physically for nothing.  And all of that could be prevented with the use of reliable contraception, or with my chosen option, sterilization.  If it could not be prevented for some reason, it seems very clear to me that abortion would be a far kinder choice than allowing the baby to keep growing until its inevitable demise, possibly till it could begin to feel something, and certainly exposing the mother to greater risks and discomforts.

I have always wondered how very observant Catholics would find their way through this dilemma, since there would be no way to avoid pain and tragedy, only to minimize it.*  The Church’s official stance, I suppose, would be simply “Don’t have sex.”  Ever again, or at least not until menopause, so that such a tragic pregnancy could never get started.

And of course there are also medical situations where pregnancy would be life-threatening or seriously health-threatening for the mother.  These women need their contraception to be as effective as possible, and depriving them of it verges on criminality, I would say.  Birth control advocates tend to mean hormonal drugs when they speak of “effective” contraception, and that has been the focus of much of the fighting.  I certainly think women should have access to these medications, but I don’t want to come across as a wholehearted fan of the Pill and its cousins.  The Pill, patch, and implant can be problematic for many women, and they can have dangerous side effects, especially as women age.

A friend of mine who cannot use these drugs was put in a ludicrous position by our local Presbyterian Health Plan, on purely ideological rather than medical grounds.  Having been unable to tolerate the type of IUD that releases hormones into the body, she and her doctor decided that she should try the old-fashioned, non-hormonal IUD.  Presbyterian refused to cover that, saying that it’s an abortifacient rather than a contraceptive, and therefore not morally acceptable.**  They were happy to cover the hormonal IUD, which they insisted my friend should use despite the fact that it was already proven to be unsuitable and harmful for her.  The patient’s medical needs meant absolutely nothing.  Let me repeat that, because this is how our system works, and we need to be clear about it:  The patient’s medical needs meant absolutely nothing.  Her own beliefs and moral convictions also meant absolutely nothing.  Fortunately, although she was a college student doing low-paid restaurant work, this young woman was able to get the money together to pay for the IUD herself.

And that is what we face when religion, and only some people’s religion at that, is allowed to determine our medical care.  If the bills currently being proposed by certain members of Congress were to become law, any employer could refuse to cover any type of treatment for any reason.  I don’t think that will come to pass, but stranger things have happened, and we need to stay on top of this situation.  I can only hope that American women will continue to get more and more engaged and will work to hold the ground we’ve gained– and that men have gained along with us– over the past few decades.

I promise to get back to more spiritual matters in my next post.

*Despite 12 years of Catholic school and being good friends with a nun, I still can’t answer this.  Odd situations like this never came up in the typical anti-abortion rhetoric.  And by the way, I don’t remember Catholics railing against birth control back in the ’70s the way it’s happening now.  Maybe I just didn’t notice.
**The common scientific view is that pregnancy begins with implantation, not with conception.  The IUD prevents implantation.

For some other current perspectives:
http://msmagazine.com/blog/blog/2012/02/13/hervotes-americas-supposed-war-on-religion-and-the-actual-war-on-birth-control/

http://msmagazine.com/blog/blog/2012/02/14/conservative-war-on-contraception-is-nothing-new/

A Few More Things to Consider

“I am not pro-abortion.

“Like nearly all pro-choice human beings, I never rejoice over or celebrate these decisions, because I know that they are ones reached after arduous deliberation and great pain; that they are often born out of emotional trauma, physical assault, or dire medical news.
“I know that abortions are not chosen impulsively or without careful or prayer wrestling.
I believe in education and in birth control and in doing everything possible not to create an unwanted pregnancy. All pro-choice people I know believe these things.

“…There is a sad irony at play when I realize that a pro-life woman arguing with a pro-choice man like myself,  is essentially relinquishing control over her destiny to other men and I am saying she deserves better.” — Pastor John Pavlovitz
https://johnpavlovitz.com/2022/05/11/a-pro-choice-man-grieving-pro-life-women/

“[George H.W.] Bush would remain a staunch advocate of reproductive freedom for women until political considerations during the 1980 presidential elections, when he was on the ticket with Ronald Reagan, accounted for one of the most dramatic and cynical public policy reversals in modern American politics.”

“Reagan had supported California’s liberal policies on contraception and abortion as governor, and Bush as Richard Nixon’s Ambassador to the United Nations had helped shape the UN’s population programs. But Republican operatives in 1980 saw a potential fissure in the traditional New Deal coalition among Catholics uncomfortable with the new legitimacy given to abortion after Roe v. Wade and white southern Christians being lured away from the Democrats around the issue of affirmative action and other racial preferences. Opposition to abortion instantly became a GOP litmus test, and both presidential hopefuls officially changed stripes.”
https://msmagazine.com/2012/02/14/conservative-war-on-contraception-is-nothing-new/

Faced with the lowest and slimiest of Twitter trolls, one woman retorted, “I’ll ask my rapist nicely to wear a condom.”

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Filed under health and healing, history, human rights, politics, sexuality

Three Conversations

The war against misinformation continues. I’ve been trying to frame it as something other than a war. But I don’t feel able to leave the field. How do I do my job of health education effectively and without being a jerk? How do any of us talk with folks who have become untethered from reality? Should we even try, since we aren’t likely to get through to them?

I’m trying to cut down on reacting, but at times it feels necessary. A couple of weeks ago I wrote comments to a blog belonging to a person I used to respect greatly, an MD who has really gone off the deep end. I hated to jeopardize the connection I have with him, but what he had written was so egregious and harmful that I felt I had to say “no farther.” I cringed a bit while awaiting the result. He replied that he was interested in hearing from people with completely different worldviews, and while he didn’t think I was right in the least, he listened amicably. It was not horrible.

Later, I received a message from someone I didn’t know, thanking me for standing up that way. Was it worth jumping in? She thought so.

Sometimes skirmishes show up unexpectedly. Sometimes they lead to some fascinating meetings of minds. Other times there seems to be no possible good outcome. Maybe writing this won’t bring any better outcomes, either, but I guess I need to think on the page for a bit. I would be very interested in hearing about your own experiences along these lines.

Conversation One

I volunteered with Albuquerque Mayor Tim Keller’s reelection campaign. On Election Day, I arrived at the polling place, a middle school, to wave a sign around and present a friendly face to voters. I got there late in the day and found the earlier volunteer still walking up and down the sidewalk with her own sign. We got to talking, and it turned out that she was a nurse doing some interesting community work.

A forty-something man approached us. I expected that he would have some normal sort of voter question. Instead, he started one of the most abnormal conversations I have ever been a part of. He wanted to tell us why he was not voting for Mayor Keller, even though he liked him and was generally in favor of his policies, except for one crucial issue. For some reason I never came to understand, he felt it was important to explain and justify his decision to us.

He told us that he had been away from Albuquerque for quite a while and hadn’t heard much of anything about the candidates. There was just one thing he had heard from GOP candidate Eddy Aragon, and that was that if a vaccine mandate were imposed, he wouldn’t enforce it. So our voter planned to give his vote to Aragon.

Aragon had shown himself to be way out there in debates, one of those far-right defenders of “freedom” who refused not only vaccines but masks and public health restrictions of all kinds— even supporting a restaurant that was refusing regular health inspections as well as the mask requirement. He was in every way the antithesis of Tim Keller (except that they had both played football at St. Pius High!). I told our voter that if he liked Keller’s policies overall, he really wouldn’t like Aragon’s, and he might want to find out more and give some more thought to his decision. He insisted that the vaccine issue outweighed everything else. I reminded him that the city didn’t even have a vaccine mandate. He was unmoved.

That was when things started to get very unusual. This was already getting to be a fairly long conversation, but the voter showed no signs of moving on into the building. He continued to explain his point of view, seeming to be looking for validation. I warned him, just so that he wouldn’t waste his time, that we were both health care professionals and were disposed toward wanting people to be vaccinated. He was undeterred.

He told us that he follows the Shinto religion and that this includes intensive purification practices. Now, he isn’t Japanese, and I’ve never heard of the kind of extreme practices he described being part of Shinto, but maybe there is some sect that’s like this. No alcohol ever, he said (though Shinto uses sake for ritual purposes). No medications of any kind. When he broke his leg, he said, UNM Hospital wouldn’t treat him without an X-ray, and he wouldn’t allow radiation to be applied to his pristine body, so he went home and recovered on his own. I have no idea how he managed that, and I can’t see how any religion would require it, but that’s what he said.

He also reported that he had been through a case of COVID and therefore had less need of a vaccine. He was masking and being sensible otherwise. He appeared totally sincere.

If all that is true, his health strategy was inadvisable at best, but a person whose belief is strong enough to cause him to refuse a cast for a broken leg has a serious case for a religious exemption. And he said he was trying to get one, because he was working for UNM as an engineer, and they were requiring all employees to be vaccinated.

“Not only am I losing my job, they’re losing a good engineer,” he added. He then told us about his sister, who left a high-paying job with an airline that required vaccination, threw away her retirement, sold her house, and moved to Georgia.

I find this to be a strange hill to die on, but they have staked it out as theirs. I doubt there are very many people with this particular religious point of view, not enough of the population to have much effect on the pandemic. If we give religious exemptions to anyone, it seems to me that these purportedly Shinto folk deserve them. I would suppose that their horror of impurity would keep them vigilant against contagion, for whatever that’s worth.

Eventually the man finished saying his piece and moved on to cast his vote. For Eddy Aragon, I assume. Who had no chance of winning.

The nurse said, “Wow, you confronted him. I would never have done that.” I didn’t, exactly; I just quietly stated some facts, and I didn’t argue with him about his health— or point out that an engineer should be able to understand X-rays more clearly. Keeping a conversation going allowed me to find out about his unique point of view. And even though we volunteers had no special influence on city policies, I wanted to convey the sense that the campaign and the mayor himself valued him and were willing to listen. I’ve seen Mayor Tim treat people exactly that way. It didn’t occur to me till after the nurse’s comment that he could have done something dangerous. He didn’t seem like a person who wanted to cause trouble. He just seemed to want to be heard— and in a way, to apologize.

Conversation Two

A month later, we had an unusually mild day, and I took advantage of it to swim at Midtown Sports and Wellness, where they have only an outdoor pool but they keep it nice and warm. I had a blissful time with the pool and then the hot tub all to myself for a little while. Who would have expected a fun outdoor swim in early December? It was a real treat.

Then an older Hispanic man showed up to use the hot tub. We got to chatting about the just-passed Thanksgiving holiday, during which he’d gone to visit his daughter in San Diego. I commented that it was great to be able to do things like that again, unlike last year. Somehow in the process, vaccines came up.

The conversation remained cordial, but included such pronouncements as “[dismissive snort] Fauci doesn’t know anything.” (OK, only 40 years of experience heading a major medical organization… no opportunities to learn… whatever.) I knew playing the “I’m a health care provider and I know things” card wasn’t going to get me anywhere, so I kept that to a minimum.

He went on with typical right-wing talking points, including the classic “I did my own research.” None of it was surprising, though it was dismaying.

We were having a somewhat useful exchange when a friend of his came along. As he lowered himself into the bubbles, the friend said, “The way to solve all of this is to invite Jesus Christ into your heart.”

I did not try to tell him that I have a personal relationship with Jesus. I did mention that I had been raised Catholic, which was relevant to some point in the conversation that I don’t remember.

The first guy told me something that shed a little light on the attitude of evangelicals toward authorities and establishments. His mother, he said, had been Catholic, and she was brought up to do whatever the priest said and never think for herself nor read the Bible on her own. She had rejected this. I told him that the Catholicism I’d experienced had been much groovier and more open-minded, but that I’d heard about the kind of stifling situation his mother had grown up with and wouldn’t like it one bit.

I can easily understand why someone would want to leave that behind. It’s just that so many trade the conformity of the Catholic church for the same thing in an evangelical sect that is at least as rigid and paternalistic, if not more so.

This gentleman was toeing the party line in every way, but he did seem to have put thought into his point of view. Like so many Americans, he insisted that he was against mandates, not necessarily against vaccines. I keep wanting to tell them, “If more people would do what they’re supposed to, there wouldn’t be any need for mandates.” I can totally understand their discomfort with being told what to do, or possibly coerced, but I also think coercion could easily have been avoided.

To find his way through the conflicting advice, he was trying to use intuition.  “You know in your heart what’s true.”  This struck me as important and a sticky point.  I can’t really argue with it, as I feel my way along intuitively as well.   However, when facts staring me in the face don’t match my intuition, I’m going to look further.  The Q and militant-antivax people say similar things to justify themselves– trust yourself to know what’s best for yourself and your kids.  It’s also a very evangelical point of view, to lead with the heart instead of the head. I’d rather listen to both.

Along these lines, he started to tell me that there was an awakening going on among many groups of people. “Even the Moslems [sic],” he added. I didn’t get to hear any more of what he thought about that, and would have been curious to know what he meant. It may have been the typical Q sort of balderdash, but he seemed like a serious sort of person and he may have had something more profound in mind.

A young man came in and settled into the tub. After a few minutes of listening to the ongoing discussion, he asked us very politely to shut up. He just wanted to relax, he said, and we were making that impossible. I didn’t blame him for breaking in. The two evangelicals kept talking, and the unwilling listener cupped his hands over his heart to block out the discord. I tried to wrap up the conversation, acknowledging that a person who wanted to relax in a quiet space should be allowed to do so, and pointing out that we were causing him to feel a need to shield himself. I got up, saying, “I’ll leave, and that will end the controversy.” I hope they left the young guy alone after that. I apologized to him on the way out.

It was… exotic.

Conversation Three

Last week, I became that guy, the one asking someone to STFU in the tub. Interesting how that showed up. It was a different, indoor facility, and a different kind of discussion. Unlike the polite and affable evangelicals, this problem person was loud and vehement, went on nonstop, lectured instead of discussing, and was literally in someone’s face.

The someone was a young mother with a toddler boy playing next to her and an infant girl in a carrier nearby. I had already interacted with her a little earlier by sharing my lane in the pool with her and her son, and I felt a little connected with her.

There were a couple of other people in the tub as well, individual and silent. The rushing sound of the jets muffled conversation, but gradually I noticed that this 70-ish guy was going on and on with great intensity, and words like “variant” and “omicron” wafted through to me, in a strong German accent. He appeared to be expounding a mostly toxic mix of misinformation with a few actual facts sprinkled in.

Then I heard him make a pronouncement to the mom that she should definitely not get the current vaccine, but should wait for one that worked against omicron.

So. This was not my conversation and not my fight. I tried to size things up. The young mother appeared to be backed up against the side of the tub and quite uncomfortable, while the man was almost shouting at her from maybe a foot away. She wasn’t trying to counter what he was saying or get out of there, though. Was she engaging with him on purpose and OK with the whole thing, or was she too polite or too timid to tell him to leave her alone? It looked to me like the latter. And it looked like a kind of assault.

I would be wrong in some way whether I spoke up or not. I decided to go ahead and intervene, damn the torpedoes. “That’s bad advice, I’d say, speaking as a health care professional.”

Immediately the torpedoes were aimed at me. I replied, as nonconfrontationally as I could, that I was there to relax in the tub, as were the other people present, and didn’t want to argue with him, but that it would be nice if he would let us have some quiet. He said I didn’t have to listen— but in that environment, of course we were all forced to listen. He pulled out a collection of tired and debunked talking points, even insisting that over 18,000 people have been killed by the vaccines. I just kept repeating, “That’s not true.”

He shouted, “You believe all the bullshit!” and stormed out in a huff. The hot tub returned to tranquillity. Of course I didn’t feel particularly tranquil, and wondered if I had done a bad thing.

On the way out, the mom and I had another friendly exchange. At least she wasn’t upset with me.

It only occurred to me later that the German guy was masklessly spewing his possibly viral breath at the two unvaccinated little ones as well as their mom. So, so very not OK. Masks aren’t practical in the water, but most people are sensible enough not to yell in someone’s face without one (or at all). I thought, at least I helped limit their exposure. The area was well-ventilated, but such close-up and intense interactions don’t seem like a good idea.

And yet, chances are, he saw himself as a good and helpful person trying to save the mom and/or her kids from some terrible health consequence. The vehemence likely came from sincere, if misguided, care for others.

Glad I wasn’t part of this one….

The owners of another membership-based business where my husband and I are regulars reported an odd, rather disturbing situation. A woman inquired about becoming a member, and stated that she was not vaccinated and would absolutely not wear a mask in the building. She was told that she could not come in without a mask, because the business follows state health requirements. That’s pretty simple, isn’t it? The would-be customer started a lengthy argument— and one of the owners took the bait and let himself be drawn into it. This was a time when it was absolutely not worth engaging, but it can be hard to stop.

It turned out that this was the same woman who, not long before, had walked into the business and wandered around without a mask, so that she had to be told to leave.

My question is, what did she get out of this behavior? Is this sort of thing, which has become sadly common, simply a bid for attention? A need to feel important or significant? Is it some kind of crusade, battled one store or flight or meeting at a time? Does it come from the same corner of the psyche as the “Karen” behaviors? Is it a need to take out her overwhelming frustrations on someone? A symptom of a diagnosable mental illness?

I can come up with understandable motives for each of the people I described in the conversations above. To some extent I can put myself in their shoes. This one I just don’t get.  If you do, please comment.

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“Angel Mode” and Insect Visitors

A couple of weeks ago a patient was telling me how sensitive she is to picking up other people’s distress. She lives with someone who is dealing with anxiety and depression, and that person’s struggles add greatly to her own. I’m no stranger to the difficulties of being a natural empath, and I’ve never found a way to entirely shield myself, but I have learned a few tricks that help.

I think at one time I told you about “Angel Mode,” a phenomenon that showed up spontaneously in 2009, when I had taken a devastating empathic hit and was desperate to keep that from happening again. Suddenly, while doing energy work for a patient, I saw myself as turning into a golden angel with huge fluffy white wings. Seriously. That may sound like I was a bit full of myself, but it happened totally without my intending it and was quite a surprise. The image was vivid and persistent, and I felt expansive and much stronger, able to serenely rise above whatever was going on in the moment. It turned out that I was able to engage the angel image whenever I needed it, and for months I used that method pretty much every time I treated anybody, until eventually I didn’t feel so vulnerable anymore and gradually stopped.

The funniest part was that a number of patients mentioned seeing me as an angel. I hadn’t told any of them what I was trying to do.

So I suggested to this lady that we could try shifting her system into angel mode, if it was willing. She agreed. While working on her painful areas, I visualized wings sprouting from her back. Right away they did— lacy, shimmery dragonfly wings! A new kind of surprise.

“Your wings look different from mine,” I told her. “You have dragonfly wings.” She replied that dragonflies were very important to her. They had been her mother’s favorite, and she thought of them as symbolizing her. She used them all the time in her visual art. I was delighted to find that I had seen this accurately and that it was so meaningful for her.

As we continued to observe, a strongly delineated image of a complete dragonfly came into focus over the whole length of her body. A giant insect might seem disturbing to most people, but she was excited and pleased to think of it. She told me that she loves insects and wasn’t at all frightened by the idea that the dragonfly was covering her body. It seemed helpful and protective to me, too. I wondered whether it was a spirit animal manifesting itself, or simply an imaginary picture we were sharing. I didn’t have a sense of an actual entity being present.

This brought up a memory for the patient, though. When she was a child, she said, she often had dreams of giant grasshoppers who would come and take her away with them. They always went to the same place, a room she described as “gauzy.” The dreams were frightening, but the grasshoppers never hurt her, and she had the feeling they were trying to help in some way.

This gave me a start, because she seemed to be describing a common type of alien abduction experience (or what people commonly consider to be an alien abduction— not that anyone truly understands the nature of these things). I wasn’t sure if I should push for details, and I didn’t want to contaminate her memories, but I was so curious, I couldn’t restrain myself from asking.

“Um, could they possibly have looked more like mantises?” I asked.

 “Yes,” she replied, “mantises or grasshoppers.”

She confirmed that they were tall, like the insectoid types often reported in the UFO literature. But here’s the thing: she had never heard of anyone else having this kind of experience. She didn’t know that anyone else had memories of being taken somewhere by giant insects and having mysterious procedures done to them. She had never read or seen anything about abductions at all.

“I’m thinking those may not have been dreams,” I told her, gently. “If someone had looked for you, I wonder if you would have been in your bed.” Which is an open question. In some cases people who claimed to have had an abduction experience were observed to stay in one place the entire time, while psychologically they were being put through a major trauma. In others, they were verifiably, physically gone.

My patient seemed more fascinated than frightened by these concepts. I wonder if any more memories will come up for her, now that she’s been reminded of her childhood encounters. She has not had any such experiences as an adult, at least none that she knows of consciously.

The whole sequence, from the dragonfly wings through the insectoid visitors, was completely unexpected.

I have begun to wonder whether we create artistic representations of angels, humans with wings, because at some level we are all aware of our own invisible wings, just as we represent the subliminal glow of a powerful person with a halo. I’ve never figured out what angels “really” are, though I’ve met beings who were presented as angels or seemed like they must be such. I’ve never seen them with a clear image of wings, only felt them as energies or had a mind’s-eye sense of a person-sized patch of light and color. Usually I don’t see things as clearly as I did that dragonfly anyway. But the feeling of my own wings can be a lot like sensation of a physical body part. It feels like I can extend them or fold them, maybe even flap them a little.

I can hardly describe how exquisite it is to blossom into this powerful, glowing creature that is so much more than I usually am. I believe this phenomenon tells us something about our true nature. If we would pay better attention to it, perhaps it would help us to get past the pathetic pettiness of our daily interactions.

The angel mode experience is one reason I became such a fan of the Lucifer series. The gigantic, gorgeous, ultra-fluffy wings of the angel characters touched a chord in me. To manifest their wings, Lucifer and his siblings sort of shrug their shoulders, and the wings suddenly pop out. Each celestial being has an individual color and style of feathers; I note again that Lucifer’s wings are pure white, which makes total sense once you think about it for a moment.

In an episode of the final season, Lucifer suddenly gets a bout of alar erectile dysfunction, where he shrugs and shrugs and nothing happens. It has to do with doubting himself and his abilities. At about the same time, by coincidence (?) I found that my left wing was unwilling to show itself— apparently for a totally different reason, a musculoskeletal problem that blocked up the area. It was odd, another unexpected aspect of Angel Mode. Maybe it had occurred in the past as well and I hadn’t been paying attention. I think this deserves more study.

In the show, you can’t see the celestials’ wings until they intentionally unfurl them, but they’re always there in potential, just as ours appear to be. Why don’t you see if your own wings will show up? Let me know what you find.

Thanks to the late Babette Saenz for the dragonfly art; I don’t know the name of the artist.  I would like to acknowledge that person and the creator of the wings graphic if I can discover who they are.

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In Which Medicare Covers, but Also Does Not Cover, Acupuncture

Executive summary: Medicare sort of covers acupuncture for low back pain, but coverage is so limited as to be meaningless for most patients unless they have certain Medicare Advantage plans.

Every year, the fine folk at Medicare send out a thick book about coverage to all beneficiaries. The 2021 book contained extremely misleading wording about coverage for acupuncture. A person who didn’t know better would come away with the impression that they could get at least 12 covered sessions of acupuncture for chronic low back pain.

Except that’s not really the case.

Quite understandably, lots of people have called acupuncture offices trying to set up treatment and expecting to pay only small copays. Sometimes, when the office staff explain that we can’t make that happen, they get really upset. Sometimes they call Medicare, get further wrong information, and come back even more upset. A colleague in another state reported recently that a patient became loud and violent in her waiting room, abusing the staff and insisting that the acupuncturist had fraudulently taken his money when she treated him.

I think we can all agree that having violent tantrums in health care offices is generally not OK. It’s also not OK for a major government agency to give people totally wrong information, and I don’t blame anyone for being annoyed at that.

This mistake is likely not intentional, though. The regulation is written in such a mystifyingly nonsensical way that the people promulgating the information may have honestly failed to understand it. I’m willing to give them the benefit of the doubt to a certain extent.

Here’s what’s really going on:

In early 2020, a decision was made by the Powers That Be at Centers for Medicare & Medicaid Services (CMS) to add Medicare coverage for acupuncture for one well-studied condition, chronic low back pain. I don’t know precisely what the tipping point was that made this happen, but over many years there had been agitation from our profession and popular demand from patients, numerous positive studies, and recommendations from other government entities such as NIH to promote the use of non-opioid treatments for pain. Whatever it was, Medicare finally budged, and it even specified that those wielding the needles had to be licensed to do acupuncture. That is, such providers as physical therapists doing dry needling would not be included.

Here is the CMS decision memo describing the new coverage and the reasons it was chosen:

https://drive.google.com/file/d/1hoSyfCBMSXrjbIQRNA29S1NQmfFuLEzP/view

I must say that it’s a carefully and clearly written document. Some of the conclusions in it are astonishing, however, such as the contention that there is no convincing evidence for the use of acupuncture for osteoarthritis.

The trouble is that acupuncturists are not Medicare providers. We are essentially invisible to the Medicare system. There is no pathway for us to sign up to be providers, so we cannot bill for our services. In order to do this supposedly covered low back pain treatment, we must be supervised by a Medicare provider such as an MD or NP, with our treatment being “incident to” their care, and we must have billing done under that person’s name and get reimbursed through them.

This means that only acupuncturists who work in hospitals or mainstream medical clinics have any chance of this actually getting coverage to happen. It means, therefore, that there are hardly any acupuncturists who can provide treatment under Medicare. And I hear it’s been very difficult for even those few to ever collect payment.

This is an insane and completely unsustainable situation, but while we’ve been focused on the pandemic, it has gone on for nearly two years without any improvement that I know of. (And Medicare members who need help for something other than low back pain are out in the cold entirely.) Acupuncturists cannot become Medicare providers without Congress changing the law, something our profession has been trying to get them to do for a couple of decades now. So that is where our efforts are directed, but it does nothing to help patients in the near term.

Insurance companies have responded in some cases by adding similar coverage that allows patients to go to regular acupuncture offices. Different plans use different strategies, so if this includes your insurer, I can’t tell you anything about your specific plan. I can tell you that in central New Mexico, Presbyterian Senior Care has long covered acupuncture (though a limited number of sessions per year and with low reimbursement) for most if not all conditions, and Blue Cross Blue Shield and United also have some plans with reasonable or even quite good coverage. Presbyterian also now covers 12 sessions for dual eligibles, people with both Medicare and Medicaid, who are among the most vulnerable in our population. In most cases Medicaid gives no coverage at all for acupuncture— mostly because the lack of Medicare coverage means no federal dollars are available— so this is a small but significant step forward.

Despite its severe limitations, that CMS decision early last year was a sea change, much more than the baby step it has been in practical terms. Only a few years earlier, there was a petition to the federal government asking for Medicare coverage of acupuncture, which gained over 100,000 signatures and thus required a response. The response CMS gave was utterly dismissive, stating that acupuncture was not necessary or effective for any condition. This came from a milieu in which the government itself was sponsoring research on acupuncture and our work was becoming more and more common, accepted, and proven, so it felt like a painful and bizarre slap in our faces. And it made the sudden reversal at the beginning of 2020 all the more stunning.

(In contrast, the VA not only covers acupuncture but employs acupuncturists in its facilities, so you can see how far behind CMS is.)

Here is a memo from CMS to providers. This document doesn’t make it clear that acupuncturists cannot be Medicare providers, so it seems to me that it adds still more confusion. I suppose the providers to whom it is directed already understand this, though.
https://www.cms.gov/files/document/mm11755-national-coverage-determination-ncd-3033-acupuncture-chronic-low-back-pain-clbp.pdf

And here is a benefits summary for 2022 for a group of Presbyterian plans, which a number of my patients have:
https://contentserver.destinationrx.com/ContentServer/DRxProductContent/PDFs/177_0/2022%20Senior%20Care%20HMO%20Plans%20Summary%20of%20Benefits.pdf

You can see that there is a listing for “Medicare covered” acupuncture as separate from “Routine” acupuncture, but zero explanation of what that means or how many visits are allowed under that section. I assume that members receive a more complete description of their coverage as well, but this almost guarantees that they will be confused.

(You can also see that there are two tiers for chiropractic treatment. This, too, reflects what is covered by Medicare and what is not, but the typical reader would never know that from the way it’s worded.) 

I doubt you’ll be surprised to hear that we Doctors of Oriental Medicine were never told that Presbyterian was allowing any extra “Medicare covered” sessions— or even that the allowed “Routine” sessions had been increased from 20 to 25. A patient of mine found out about it quite recently and let me know. For those with severe, chronic problems, 25 treatments a year may not be enough, so this could be a real help.

I’m cautiously optimistic about the future of acupuncture access, but when people talk about Medicare for All, I advocate for Something Better than Medicare, for All.

You can help acupuncturists to become Medicare providers by learning about HR 4803, the Acupuncture for Our Seniors Act, and contacting your representative. Much more will be going on with this in the coming year.

https://www.asacu.org/wp-content/uploads/Medicare-Recognition-H.R.-4803.pdf

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Delta Blues, or how I spent my summer not being able to take a vacation

We still need all of these layers.

When I started writing this post, I was planning on a straightforward update on the current situation with the delta variant (sorry, I couldn’t resist the obvious title). And then a 13-year-old killed a classmate at a local middle school for no discernible reason. And then the Taliban took back Afghanistan.

The murdered boy was trying to talk his killer out of continuing to bully his friends. He stood up to him with words, doing exactly what most of us would teach our kids to do, what my daughter would do, what I would do. The right thing.

Going into Afghanistan was never the right thing. I remember writing “Can you say ‘quagmire’?” back then. Three quarters of Americans thought this war was a great idea. I was part of the other quarter. I take no pleasure in being right in this case. Afghanistan continues its reputation as the “graveyard of empires.”

In order to avenge the deaths of 3000 Americans, we killed or maimed tens of thousands more, plus tens of thousands of Afghans and then Iraqis, naturally including myriad children. We spent 20 years and a couple of trillion dollars and we accomplished what looks right now to be little or nothing.

And to begin with, the perpetrators of 9/11 were Saudis, and we never gave Saudi Arabia the slightest grief over that. We always fought the wrong battles for the wrong reasons. For so many years we, that is, our leaders knew we were failing and we just kept on going, perhaps in the belief that whenever we left things would be exactly as bad as they are now. And things were always worse than we realized.
https://www.washingtonpost.com/investigations/2021/08/10/afghanistan-papers-book-dick-cheney-attack/

I suppose I should not be surprised that instead of effectively fighting this pandemic and its wide-ranging ills, we spend so much of our energy fighting each other.

Pulling the Fangs Back

Anger at the unvaccinated and the irresponsible among us is real. While a more-transmissible strain like delta was bound to come along, wider uptake of vaccines and more stringent adherence to public health common sense would have helped limit the damage, and would still damp down the development of newer variants. Our US deniers and anti-vaxxers are only one aspect of this; many governments have been too poor or too inefficient to get vaccines out to the majority of their people. But seeing Americans die or cause others to get sick because they haven’t taken the most obvious steps to avoid it is maddening.

Dr. John Lapook said, on the Stephen Colbert show on 8/16, “We come into these conversations coiled.” He suggested “pulling the fangs back” when trying to convince someone that getting vaccinated would be a good idea. I didn’t realize how “coiled” I was until I ran into a certain friend at an outdoor event in July. She announced that she wasn’t hugging anyone because she wasn’t vaccinated, which she said was because of her health condition. She really does have a condition in which it’s reasonable to be extremely cautious about medications, but it could just as easily be said that she needs the vaccine all the more because of it— her situation is honestly a bit fuzzy and it’s not crazy that she has hesitated. She has also fallen for a lot of the misinformation, though, and that has been frustrating to deal with. Anyway, I lit into her. Without knowing I was going to do it, I snapped at her. That is, I snapped. She reacted just as badly. Not a productive exchange.

A doctor in Alabama has even refused to see patients who are not vaccinated. ‘“If they asked why, I told them covid is a miserable way to die and I can’t watch them die like that,” wrote Valentine, who has specialized in family medicine with Diagnostic and Medical Clinic since 2008.’ Alabama has the lowest vaccination rate in the US and a high number of residents hospitalized with COVID.


Summer Non-Vacation— Why Is This Happening?

What did you want to do this summer? I wanted to have the party I didn’t get for my 60th birthday last year. (Oh, well— at least I was alive to have another birthday!) It’s very unclear what to do now. Nothing involving a large group of people, certainly. Is it OK to have a small outdoor gathering with vaccinated family and friends? And should we stop attending any non-crucial indoor events of any kind, even with masks and good ventilation? How much have things changed now that delta has taken over?

Amanda Mull wrote a compassionate piece about where we stand with these questions, “Delta Has Changed the Pandemic Risk Calculus.”
‘Assessing risk pre-vaccination was often bleak, but at least the variables at play were somewhat limited: ventilation, masks, crowds, local spread. Now the number of additional, usually hyper-specific questions that people must ask themselves is itself a barrier to good decision making, says Jennifer Taber, a psychologist at Kent State University who studies health risk assessment. “When people feel like things are uncertain, they engage in avoidance,” Taber told me. That can manifest in disparate ways. An unwillingness to acknowledge that many new things are safe for the average vaccinated person is avoidance. So is a refusal to continue taking even minor precautions for the benefit of others.’
https://www.theatlantic.com/health/archive/2021/08/delta-variant-pandemic-risk-safety/619798/

A big part of my job as a clinician is helping patients to sort through all the available information to answer health questions like this, and it’s not easy these days. Just as we’ve been through the entire pandemic, we’re still flying by the seat of our pants, trying to keep up with ever-changing conditions and advice. The rise of delta has been a predictable but chaotic and confusing development that hit us with a bait and switch just when we thought we were getting our lives back. It’s still new and we’re still figuring it out.

What I mean by predictable is that this is normal virus behavior. A more transmissible variant will obviously outcompete others, and it would have been a surprise had we not seen a variant like this eventually. Viruses “want” to produce as many copies of themselves as possible, and any mutation that leads to more chances to replicate is great for them.

In general, causing less illness and death is also good for viruses, because having hosts walking around spreading viral particles results in far more replication than having hosts lying isolated in hospital beds, or in graves. So over time a viral species is likely to become more transmissible but less deadly. Sadly, delta seems to cause at least as much and as severe disease as earlier forms of COVID, maybe more.
https://www.cdc.gov/coronavirus/2019-ncov/variants/delta-variant.html

We had some small hope of getting enough people vaccinated quickly enough, as a planet, to limit the possibility of worse new variants popping up. We didn’t make it, and that too was predictable. Viruses can adapt much faster than we can. We can still hope to escape without a far more dangerous variant coming along, but time is not on our side. The more humans there are who cannot access or will not accept vaccines, and the more who refuse to take other precautions, the more opportunities the virus has to mutate.

Here’s a good way of putting it:
‘You might think of viral replication as buying lottery tickets, in which the virus accumulates random mutations that very occasionally help it spread. And the fewer lottery tickets the virus has, the less likely it is to hit the mutation jackpot. The appearance of troubling new variants may slow down.’*

The now-famous Provincetown outbreak around the 4th of July has taught us a great deal.
https://www.washingtonpost.com/health/2021/08/05/provincetown-covid-outbreak/
The area population was so highly vaccinated that the tens of thousands of visitors who descended on the place didn’t worry about getting sick. They even packed cheek by jowl into indoor venues, without a mask in sight. No one expected to need them. Here you can get a sense of just how packed together the revelers got:
https://theboatslip.com/tea-dance
Then some folks noticed they were feeling unwell or had lost their sense of smell. By that time it was dawning on us all that delta was different and that we had been wrenched into a yet another new reality where we had to learn the rules all over again.

The misinformation mill has seized on Provincetown’s experience as an example of vaccines not working. That’s not remotely the case. Yes, 74% of the infections were in vaccinated people, but with over 900 infections, there were only 7 hospitalizations and zero deaths. An unvaccinated population would have a very, very different outcome. This article explains everything you need to know about the outbreak and what it means for the rest of us:
https://www.factcheck.org/2021/08/scicheck-posts-misinterpret-cdcs-provincetown-covid-19-outbreak-report/

You could just read the article, and you should, but I’m going to summarize some key points:

— Imagine a population that was 100% vaccinated. Vaccines are not perfect, so there would be some infections, and 100% of them would occur in vaccinated people.
— Infections in vaccinated people are rare, but since the vaccinated population consists of hundreds of millions of people, a significant number of people do get infected.
— The most important thing: With current strains of the virus, even if one does become infected, vaccination means essentially no chance of dying and very little chance of becoming severely ill.
— It looks like vaccinated people may harbor as much viral material in their noses as unvaccinated ones if they get infected, but infection doesn’t get as far into the body and the viral load goes down quickly as the immune system responds.

Research is ongoing to try to determine how likely an infected vaccinated person is to transmit the virus. That may be less than some studies suggest. From the same article:
‘For one, these sorts of PCR tests are good at identifying viral RNA, but they can’t tell whether that genetic material is in an intact, infectious virus particle or not. That becomes especially relevant for vaccinated people, Deepta Bhattacharya, an immunologist at the University of Arizona College of Medicine, said.
‘“Antibodies from a vaccinated person can coat the released virus and keep it from infecting other cells,” he told us. “And T cells can kill infected cells, releasing viral genetic material but not infectious particles.”
‘Second, the tests are only looking for RNA present in the nose and throat, not the lungs — even though vaccines are likely to have more of an impact there, according to previous research.
‘“Though it isn’t entirely clear how much of transmission comes from the lungs vs. the nose and throat,” Bhattacharya said in an email, “it is almost certainly some.” That would also suggest a vaccinated person with a similar cycle threshold as an unvaccinated person would be less infectious.
‘Vaccinated people also likely aren’t infected as long, since their immune systems are quicker to respond to the virus, which would also make them less likely to infect as many people as an unimmunized person.’

Here is a similar explainer, with data from the UK, where delta has run rampant:
https://theconversation.com/covid-the-reason-cases-are-rising-among-the-double-vaccinated-its-not-because-vaccines-arent-working-164797

Another highly vaccinated place that’s weathered a recent surge is Iceland.
‘Iceland, the experts say, is providing valuable information about breakthrough infections in the fully inoculated. Yet it also remains a vaccine success story.’
https://www.msn.com/en-us/news/world/iceland-has-been-a-vaccination-success-why-is-it-seeing-a-coronavirus-surge/ar-AANl2dx +

As with the surge in England, soccer was involved. ‘The country’s top health officials linked most of the cases to nightclubs and to residents who traveled to London to attend Euro 2020 soccer matches that some warned would be “a recipe for disaster.”’

Epidemiologist Brandon Guthrie gave some perspective in the Iceland article:
‘“We’ve handicapped ourselves in what the definition of success is,” he said. Scientists originally hoped for vaccines that were 50 percent effective, he said, and the goal was to prevent death and severe disease — not to provide blanket protection against any chance of infection.’
That is, the current reduced effectiveness of the vaccines is about as good as we hoped vaccines would be in the first place. Keep that in mind whenever you feel like despairing.

Even if it’s been quite a while since you were vaccinated, and you don’t have a lot of antibodies circulating in your blood, your T and B cells still remember how to recognize and fight SARS-CoV-2. Infection won’t get into your lungs because it will have been fought off by that time. It may take as much as 5-6 days for the body to marshal a good crop of antibodies, but generally it would take 10 or more days for a COVID infection to get as far as the lungs.

But meanwhile, kids are getting sick and being hospitalized, and some of them are dying of this disease that too many adults insist is no big deal for them. Vaccines for the under-12 cohort are on the way, but at this point the behavior of adults is the only real protection younger kids have, and in too many places adults are doing a crappy job.

“This new variant is a major contributor, but a major issue is that people’s behavior has changed,” said Gigi Gronvall, a senior scholar at the Johns Hopkins Center for Health Security. “I don’t think we can absolve people and leaders of responsibility for this because it gives them a pass. The reason kids are getting infected is because we don’t have those precautions and parents and households are getting infected.”
https://www.nbcnews.com/news/us-news/kids-sick-covid-are-filling-children-s-hospitals-areas-seeing-n1276238

‘Kline said it is unclear what kind of long-term effects babies and children will face.
‘Specifically, Kline referenced the brain fog adults see after contracting the virus.
‘”How does that affect a baby who is still having a developing brain? We just don’t know.”
‘Kline said another concern is cardiac issues in children.
‘”It worries me a lot that people say sure, kids can get COVID-19 but most of them recover uneventfully,” said Kline. “We know almost nothing about what those infections could produce down the line. I think there is a real risk that a proportion of these kids will have some long-term effects.”’
https://www.wdsu.com/article/new-orleans-louisiana-children-sick-covid-19-unvaccianted-adults-responsible/37259391

And all this is before school starts in a lot of the country.

Conspiracy Theory Roundup

For the sake of readers who live in a bright future where this craziness is forgotten: Droves of parents are currently following right-wing leaders and fighting requirements to wear masks in schools, sometimes with physical violence against teachers, principles, health care providers, and other parents.

As far as I’m concerned, there is no excuse for willful failure to protect children; I suppose it relates to that tendency toward avoidance when things feel uncertain. Yet, even the parents who give the most insane reasons for refusing to let their kids wear masks believe they are doing their best for them. Some may have thought things through and come up with vaguely rational justifications, but most have surely spent too much time in the conspiracy-verse, where they find an endlessly creative cornucopia of crap being produced every day.

The funniest example going around is the claim that vaccinated people will grow tails. My first reaction to that was Cool!  Unlike the claim that we become magnetic, this one cleverly avoids being immediately disproven by saying that the tails will grow at some point in the future. At least that’s how I heard it. I hope it doesn’t take too long….

For a while we were hearing that women would become infertile if they were vaccinated. Now the same scary disinformation is being aimed at men.
https://www.factcheck.org/2021/06/scicheck-research-rebuts-baseless-claims-linking-covid-19-vaccines-to-male-infertility/

Oddly enough, sperm counts have actually been found to increase after vaccination! The reason is unclear, but it’s been a consistent effect.
https://jamanetwork.com/journals/jama/fullarticle/2781360
“Sperm Parameters Before and After COVID-19 mRNA Vaccination”

President Former Guy rejected masks and publicly visible vaccinations as making him look less manly, but hey, maybe vaccines make for more manliness. I think we should really hammer on this selling point!

(Stephen Colbert pointed out that the conspiracy theory that vaccines cause a drop in fertility must be true— all those elderly people were vaccinated first, and sure enough none of them have had kids since.)

A more insidious claim is the one that COVID is being brought in by people coming over the border from Mexico; this is in line with centuries of blaming “foreigners” for disease. And of course it neatly deflects blame from the GOP fearmongers and unvaccinated Americans who are actually driving the high case counts. But this too is easily disprovable. We know that the bulk of transmission is coming from people within the US, not those coming from elsewhere, because we can track the genomes of various strains of the virus and see who is carrying which and where those strains are prevalent.

The lieutenant governor of Texas, Dan Patrick, added further venom to this trope by disgustingly blaming Black Texans for the state’s horrific rise in COVID illness and deaths. Patrick is the same guy who last year said people over 70, like him, should be willing to sacrifice their lives in order to keep the economy going. And he’s only doubled down in the face of criticism of his racist statements, which again are easily disproven.
‘Patrick acknowledged Texas’ public-health crisis — rising cases, hospitalizations, and fatalities — and said he’s aware of the criticisms of the state’s Republican leadership. But the lieutenant governor insisted the blame be directed at unvaccinated African Americans, not the GOP officials who remain passive toward the pandemic.
‘”The Democrats like to blame Republicans,” Patrick said. “Well, the biggest groups in most states is African Americans who are not vaccinated. Last time I checked, over 90 percent of them vote for Democrats in their major cities and major counties.”’
‘…In fact, the latest data suggests unvaccinated White Texans outnumber unvaccinated Black Texans by a roughly three-to-one margin.’
https://www.msnbc.com/rachel-maddow-show/dan-patrick-falsely-blames-covid-surge-unvaccinated-black-texans-n1277307

Meanwhile, Patrick’s cohort Governor Greg Abbott continues to interfere with requirements for masks around the state in the name of “freedom.” He’s getting plenty of pushback, but why should anyone have to use up their energy— or money— fighting for the right to protect their or their children’s health? Meanwhile taxpayers’ funds are drained away in court battles the state need never have started, instead of meeting real human needs. If only we could immunize against stupidity and self-serving political posturing.

One way out of the mess is to make masking voluntary, but as pediatrician Dr. Danny Benjamin said, a voluntary masking policy is “like having a no-peeing section in a pool.”

Onward with Delta Force

A major development just occurred: the FDA approved the Pfizer vaccine, so it is no longer being given under an Emergency Use Authorization. Moderna was later to submit data but its approval will be coming along soon. Many of the vaccine-hesitant have said this would make a difference in their acceptance of the shots.

The biggest question among my patients right now is when and where boosters will be available. I’m in the camp that wonders whether large numbers of us privileged sorts should be getting a third dose when so much of the world hasn’t even had a first one. We’re told that there are plenty of doses to go around in the US and that we can both give extra protection to Americans and send vaccines to poorer countries, but I personally don’t feel great about using a dose someone else may desperately need, and I recognize that the only way to protect everyone is to protect everyone.**

Giving a third dose to organ transplant recipients on immunosuppressants and others who have not been able to mount a strong response to their original vaccination is a different matter and a clear benefit as far as we know. For the rest of us, we’re told that we should probably get a booster about 8 months after our second shot. For me and a lot of health care workers, that’s early October, so we’ll need to decide pretty soon.

Surprisingly, it appears that flu shots give some protective effect against a range of severe symptoms of COVID. I was figuring that since I would likely stay masked this winter, and that if pandemic limitations continued we might have little or no flu season last year, a flu shot would be pretty worthless. The risk/benefit calculation has changed again. The authors suggest that for populations that have not had access to COVID vaccines, flu vaccine might be better than nothing.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255541
“Examining the potential benefits of the influenza vaccine against SARS-CoV-2: A retrospective cohort analysis of 74,754 patients”

What about those who have already had COVID? Aren’t they immune? They do have some protection, though we aren’t sure how long it lasts. However, since the virus has ways to evade the immune system as part of its normal strategy, natural infection doesn’t confer immunity as well as the vaccine. If you have both a history of natural infection and the vaccine, you have the highest possible level of immune response. For you, a vaccine is essentially a booster. (Similarly, if you become infected despite being vaccinated, the disease has a booster effect.)
https://www.cidrap.umn.edu/news-perspective/2021/03/covid-19-survivors-may-be-able-skip-2nd-vaccine-dose

Last year when vaccines were being developed, there were breezy assurances that we would be able to tweak them to take new variants into account. Can’t we do that for delta? Well, yes, but no. The practical problem with creating vaccines against specific variants is that by the time studies are done and the product approved, that variant may be gone and another may be ascendant. If a variant comes along that completely evades current vaccines, though, we will need to meet that challenge.

Intranasal vaccines are being developed. Injecting a vaccine into the arm doesn’t teach the body to be on the lookout specifically for a respiratory virus. That is, giving a vaccine in the nose tells the body that the virus involved is going to enter through the nose and that’s where defenses need to be placed, so it’s a more efficient strategy. It should also be a bit easier on the needle-squeamish.

‘Charneau and a group of scientists in Paris have shown that natural SARS-CoV-2 infections trigger both systemic and mucosal immunity. But our current crop of COVID-19 vaccines offer only systemic protection. Developing vaccines that are sprayed up the nose, rather than injected into the arm, could change that, Charneau says. Mucosal immunity in our noses could be like a guard at the door, potentially helping stop even small infections of SARS-CoV-2 right where they start.’
https://cen.acs.org/pharmaceuticals/vaccines/Intranasal-nose-vaccines-stop-COVID/99/i21

I’ll leave you with another hopeful note, a story about former pastor Curtis Chang, who has been working within the vaccine-resistant evangelical community to dispel common myths.
https://www.motherjones.com/politics/2021/08/this-former-pastor-is-changing-evangelicals-minds-on-covid-vaccines/

‘Historically, the evangelical movement has baked into it a certain wariness of dominant secular institutions. And this can be captured in the saying that Jesus called us to be in the world, not of the world. We’re not of the world in the sense of just conforming automatically to the assumptions and beliefs the world. But what’s happened is that this orientation of being wary has gotten weaponized.

‘‘There’s been three main forces that I think have done that. One is that you can actually gain a lot of ratings by playing up those fears of what Washington is doing or what the left is doing. Christians are being bombarded by so much conservative media that they automatically just assume they’re out to get us. Another one is that conservative politicians have realized that you can gain a lot of votes by playing up these fears. And then the third is sort of outside conspiracy movements. QAnon, the anti-vaxxer movement—they have realized that evangelicals are fertile hunting grounds for their theories, because they are already primed to be distrustful of institutions, and so they can be easily kind of recruited into their deep conspiracies of distrust.’

Pastors, Chang says, are in a difficult position. Most of them are in favor of vaccination, but they risk backlash from their congregations if they speak too strongly about it— same problem GOP politicians have. (I would argue that both have helped create this problem.)

‘I understand that people are frustrated, that they’re losing patience, that they just want to make things via mandate, and give up trying to persuade these people. I think that’s short-sighted, for a couple of reasons. One, if you just resort to sheer coercion, it just confirms the narrative that they’re out to get us, that they are shoving things down our throat. You’re just laying the groundwork for a deepening divide. The second reason is that you have to realize that we’re still in the first or second inning of vaccine outreach, globally. You have to realize that parts of Africa and Asia are heavily influenced by Christian culture. A country like Uganda is like 90 percent Christian. Those churches, those places in Africa, they actually take their cultural cues to a great extent from American evangelicals, especially leading white evangelical voices. So America is—unfortunately, through evangelical culture—exporting its vaccine hesitancy. A lot of the same conspiracy theories and doubts and fears that we’ve been battling here, we are definitely seeing emerge and being replicated in the rest of the world. Changing American culture is not just about getting more American evangelicals to take the vaccine, it’s going to be critical to getting the rest of the world vaccinated. And ultimately, for all of us, if we don’t get the entire world vaccinated, we’re all at risk. ’

‘…What’s going to be really important is for Christians to convey to other Christians is that it’s okay to change your mind. The Christian virtues of grace and acceptance are going to be paramount here because people are going to be even more resistant if they think that in changing their mind they are going to be shamed.’

Grace and acceptance… those sure sound good right now.

***************************************************************
TAKEAWAYS for the Delta Era:
— You can still get infected even if you’re vaccinated, though most likely you won’t.
— Remember the Swiss cheese layer concept and take multiple precautions as reasonable and available.
— Be good to yourself and others and acknowledge the effects of the unrelenting pain and uncertainty of our time.
— WEAR THE DAMN MASK!

************************************************************

Original source: https://www.washingtonpost.com/world/europe/iceland-covid-surge-vaccines/2021/08/14/bdd88d04-fabd-11eb-911c-524bc8b68f17_story.html

Data from the UK, May to July 2021: 
https://spiral.imperial.ac.uk/bitstream/10044/1/90800/2/react1_r13_final_preprint_final.pdf

*https://www.theatlantic.com/science/archive/2021/08/how-we-live-coronavirus-forever/619783/
“The Coronavirus Is Here Forever. This Is How We Live With It.”

***https://www.npr.org/sections/goatsandsoda/2021/08/04/1019780576/why-who-is-calling-for-a-moratorium-on-covid-vaccine-boosters
Meanwhile, Israel is not waiting and has already given third doses to around 600,000 of their citizens— while Palestinians next door in Gaza and the West Bank have had so much trouble even getting a first dose. Here’s part of that sad tale, in which they were offered nearly-expired doses, for which Israel would have received fresh replacements:
 https://mondoweiss.net/2021/06/we-returned-them-palestinians-axe-1-million-pfizer-dose-deal-with-israel/

A new examination of the possible origins of COVID-19:
https://science.sciencemag.org/content/early/2021/08/16/science.abh0117
“The animal origin of SARS-CoV-2”

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I Don’t Know How the Pandemic Started, But I Do Know These Things

I got to thinking about what we do know for sure about this and other pandemics, trying to clarify it all in my mind. Here is the list I made for myself.

— New diseases arise all the time; most of them don’t spread far so most people don’t pay much attention.
— The warming climate has pushed disease-carrying insects and other creatures farther north. 
— The growth of the human population has pushed humans into new territories with more contact with animals in their habitats, and pushed the animals to migrate. Both of these movements make transmission of diseases more likely.
— It’s crucial that we study zoonotic diseases and their vectors, and do everything we can to prepare for the next ones that will come along.
— Tick-borne diseases are emerging as an issue of huge importance, again exacerbated by climate change.

— Plagues and pandemics of many kinds have happened commonly throughout history.
— The origins of most pandemics, including the 1918 flu, have never been definitively determined.
— More pandemics will arise in the future. This is the one fact of which we can be absolutely certain.

— Accidents happen, mistakes are made, and anything that can go wrong eventually will.
— Humans are tremendously creative and awfully smart in terms of developing things like new technologies, but also incredibly stupid in many important ways, and common sense is not common.
— Facilities such as microbiology labs are run by humans.
— More humans and more facilities mean more possibilities for error.

— People don’t like to be wrong, and they like admitting it even less.
— Mother Nature always has the last laugh.

***********************************************************************

Meanwhile, I was involved in discussions with a colleague who outlined some questions about the effects of the SARS-CoV-2 spike protein, both the natural version and the inactivated version coded for by the mRNA vaccines.  I tried to chase down some solid information and found a lot of fascinating stuff, which I’ve collected for you here:

 

https://www.theatlantic.com/science/archive/2021/05/spike-protein-vaccines-covid/618954/
“COVID-19 Vaccine Makers Are Looking Beyond the Spike Protein”

 

https://www.snopes.com/fact-check/vaccine-lung-damage/
“Will mRNA COVID-19 Vaccines Wreak ‘Havoc on The Lungs’ in 4 to 14 Months?” [Spoiler: NO.]

 

https://healthfeedback.org/claimreview/byram-bridles-claim-that-covid-19-vaccines-are-toxic-fails-to-account-for-key-differences-between-the-spike-protein-produced-during-infection-and-vaccination-misrepresents-studies/
“Byram Bridle’s claim that COVID-19 vaccines are toxic fails to account for key differences between the spike protein produced during infection and vaccination, misrepresents studies”
[Worth reading carefully.]
‘Ogata et al. found extremely low levels of the spike protein compared to the harmful levels reported in animal studies, as Uri Manor, one of the authors of the study in hamsters, pointed out on Twitter. The blog Deplatform Disease calculated that the amount of spike protein that the authors found in vaccinated people was about 100,000 times lower than the levels of viral spike protein shown to cause harm. This is “a situation that could hypothetically occur in severe COVID-19 patients, pending studies confirming it, but not achievable in vaccinated people, at least for those who received the Moderna vaccine, and unlikely to occur for the other vaccines”, explained Al-Ahmad.

‘While some of the vaccine might end up in the bloodstream, the body breaks it down over time. The European Medicines Agency (EMA) explained in a 23 March 2021 letter that the proportion of vaccine that enters the bloodstream is very small and almost all of that ends up in the liver:’

‘…I have personally discussed these biodistribution data (as obtained by Bridle and colleagues) on my blog, as I teach pharmacokinetics to pharmacy students. The data is pretty clear: the number of vaccines needed to be injected in a 12-year old to reproduce the findings observed in rats and reported as “terrifying” would be equivalent to 60,000 doses given at once, to reproduce the number of nanoparticles used in that study.’


https://www.sciencedaily.com/releases/2020/10/201029141941.htm
“SARS-CoV-2 spike proteins disrupt the blood-brain barrier, new research shows”  [Can this explain some or all of the neurological symptoms?]


https://www.sciencedirect.com/science/article/pii/S2211124720302928
“Route of Vaccine Administration Alters Antigen Trafficking but Not Innate or Adaptive Immunity”  [Where the vaccine goes after injection]
‘The transport of vaccine antigen to the local LNs [lymph nodes] is crucial for priming of T and B cell responses (Liang et al., 2017b). We and others have shown, using both flow cytometry and positron emission tomography (PET)/computed tomography (CT), that vaccine transport after i.m. injection is restricted to the local LNs and is not disseminated systemically (Liang et al., 2017a, Liang et al., 2017b, Lindsay et al., 2019).’


https://www.science20.com/w_glen_pyle/the_thorny_problem_of_covid19_vaccines_and_spike_proteins-254373
“The Thorny Problem Of COVID-19 Vaccines And Spike Proteins”
‘In addition to engineering the spike protein so it can not be fully activated, the protein is tagged with an extra piece called a “transmembrane anchor”. The transmembrane anchor allows the spike protein to appear on the surface – or membrane – of the cell, but it is held in place by the anchor. This prevents the spike protein from drifting away and creates a fixed target for the immune system to recognize the foreign protein.’
‘…Lei and colleagues conclude their paper by noting that their study “suggests that vaccination-generated antibody and/or exogenous antibody against [spike] protein not only protects the host from SARS-CoV-2 infectivity but also inhibits [spike] protein imposed endothelial injury.” In other words, the spike proteins used by currently available vaccines actually offer a double layer of protection.’


https://cen.acs.org/pharmaceuticals/vaccines/tiny-tweak-behind-COVID-19/98/i38
“The tiny tweak behind COVID-19 vaccines
Prepandemic coronavirus research by Jason McLellan and Barney Graham led to a trick for stabilizing the prefusion form of spike proteins”
[This one, linked in the article above, has drawings of the molecular structures of the natural and inactivated spike proteins to help us understand what was changed and why– good to nerd out on]


https://magazine.ucsf.edu/what-covid-doing-our-hearts
“What Is COVID Doing to Our Hearts?”
‘Healthy heart muscle (left) created from adult stem cells has long fibers that allow them to contract. SARS-CoV-2 infection causes these fibers to break apart into small pieces (right), which can cut off the cells’ ability to beat and may explain lasting cardiac defects in COVID-19 patients.’

 

 

 

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Don’t “Panic,” But We’re Not Done with This Yet. Not Even Close.

 

Best New Mexican conspiracy theory. The booster has microguacamole.

 

Last week we got the news that a little girl, under 10 years of age, died of COVID-19 in our state. Because of privacy concerns, all we know is that she had underlying conditions and was hospitalized. Kids her age are of course not being vaccinated as yet, one more reason we still need to be careful. This is not over, not by a long shot.

I started writing this post in early April, then ended up working on other matters and putting it off for an unconscionably long time. Many things about the pandemic have become clearer since then, while others have become muddier still.

At that time a few months ago, COVID-19 was doing its maximum damage in India, and Brazil was not far behind. There were still influential voices referring to the pandemic as a “panic,” implying that it is overblown and not really so bad. One of these voices belonged to someone I respect a great deal; you could actually hear the quotation marks when he said “panic,” and I was deeply disappointed to witness that. (Anyway, if you lived in India, wasn’t panic a pretty reasonable response?) That was what got me stirred up to write about the current state of play, and how things look from the perspective of a holistic health care provider.

That is, how things look from my own perspective. Quite a few people in my profession and other areas of “alternative” medicine have been caught up in conspirituality thinking. In general, these people are sincere, and they are promoting some empowering ideas: that the human body has the capability of fighting any disease on its own, and that what appears to be illness in the material world is not really what it seems and has causes quite different from the pathogens we (sort of) understand.

They’re not wrong.

However, I submit that they are impractical and that material-world measures still need to be taken at this point. Humanity as a whole is nowhere near a time when we can all throw off disease with a thought, and this pandemic is a very, very large field of reality-stuff, a huge mass to contend with. I note that some very aware and enlightened health-care gurus have themselves become infected, some with long-term consequences. Yes, I know that the material world isn’t what it seems*, but in consensus reality, if you jump off a cliff you are going to go splat. And in consensus reality, a pathogen your body has never learned to recognize has an excellent chance of making you very sick.

The V Word

I spend a lot of time somewhere other than consensus reality, myself, and don’t put a lot of stock in it for the most part. I’m so alternative that I often treat people from a distance, essentially by just thinking about them. Yet I am still saying that as things stand, our best chance of reducing transmission of this virus and the rise of worse variants is… the dreaded V word.

My best take on the whole situation is that whether we are infected ourselves, dealing with the illness or death of loved ones, affected by the biological challenges of vaccines, or “only” experiencing the heavy pall lowered over the planet by the pandemic and its economic fallout, we WILL be affected. To an extent you can choose your response, but you will necessarily respond in some way. You can’t isolate yourself from it.

As I write this, I’m doing something that until recently was a forbidden pleasure, sitting inside at Michael Thomas Coffee, nibbling a piece of spinach quiche and sipping some nice fair-trade light roast, with other humans in the same room. I owe this enjoyable hour first and foremost to the people who developed the Pfizer vaccine.

When I last wrote about pandemic issues and those who refuse to see reason, around Halloween 2020, COVID vaccines were still only theoretical. We did not expect the degree of efficacy that we’ve had, and for a while there was more room to debate about whether it was worthwhile for any given person to get their “Fauci ouchie.” Now there’s no more question. Cases among vaccinated Americans are practically nil, while among others the virus rages on at similar levels to what it was doing months ago.

A news story that went by as I was working on this concerned an outbreak with deaths and hospitalizations, all of unvaxxed folk, at a government office building in Florida. The vaccinated guy who was exposed didn’t get it.

https://www.cnn.com/2021/06/23/us/manatee-county-outbreak-spread/index.html

The wife of one of the deceased said she and her husband had considered the vaccine, but “we just wasn’t ready yet.” The virus refused to wait for them. So sad, so frustrating, so unnecessary!

And meanwhile, more transmissible variants take over. At this moment, the winner in the evolutionary race is the delta variant, the one that’s given India so much grief. It has even caused an outbreak in Australia, where the virus had seemed to be beaten— and where only a few percent of the population are fully vaccinated.

I wasn’t totally crazy about being among the first wave of vaccinees myself, both because I might have liked to see more about how the side effects played out and because a lot of other people were at higher risk than I. But as a health care provider, I was given the opportunity early on, in January, and I felt that I’d better take it while I could, for my patients’ sake as well as mine.

After I received my first shot, I experienced a major psychological boost, a sense of greater safety and freedom— along with a very sore arm that felt heavy and was difficult to use for a day or so. Since then I’ve treated some pretty significant vaccine side effects among my patients. With my patient population being small, I must conclude that they are common. Most of my patients reported no ill effects at all, though, and most of those who did got over them very quickly. Two who already had skin issues had increased inflammation and itching, which also resolved, but more slowly. Two others who had longer-lasting effects appeared to have lurking underlying illnesses which were brought to the surface. That was uncomfortable but not necessarily a bad thing, as those conditions could then be treated.

What bothers me most is that the majority people who do have significant ill effects will be left without meaningful treatment on the energetic level or even the deeper physical levels, as mainstream medicine may only apply band-aids like steroids. It’s been heartening to see that mainstream medicine has taken the matter very seriously, especially in the rare but quite dangerous cases of odd blood clots associated with the Astra-Zeneca vaccine. (For those who pointed out that birth control pills are more likely to cause clots than these vaccines, meaning it’s no big deal: these are very unusual clots and in more dangerous locations.)

‘In the new study, his team found that 15 weeks after the first vaccination, immune cells in the body were still organizing — becoming increasingly sophisticated and learning to recognize a growing set of viral genetic sequences.
“The longer these cells have to practice, the more likely they are to thwart variants of the coronavirus that may emerge. The results suggest that the vast majority of vaccinated people will be protected over the long term — at least, against the existing coronavirus variants.”
https://www.nytimes.com/2021/06/28/health/coronavirus-vaccine-immunity.html

An area of great interest is the interaction between immunity after infection and that after vaccination. It looks like people who have had both get the most robust and long-lasting immunity.

There has been a surprising and wonderful development in which COVID vaccination actually becomes a treatment. A significant percentage of people with “long COVID”— the ones who never get better— are improved or even cured after receiving a vaccine. And fascinatingly enough, the vaccine put a lymphoma patient into remission (which can also happen with a viral infection). I have seen reports of Lyme disease, lupus and other conditions improving as well.

https://www.forbes.com/sites/victoriaforster/2021/02/08/did-covid-19-cure-this-persons-cancer/?sh=7d18df674217

At the same time, people with autoimmune conditions and others who are on immunosuppressant drugs may not mount a sufficient immune reaction to a vaccine. Giving an extra dose to those people is an option currently being studied, and it looks like it helps.

Myocarditis has been seen, rarely but enough to worry, in young men after vaccination. So far we have been seeing it resolve and not cause a long-term problem. Myocarditis is also caused by COVID itself, so the vaccine is not causing an increased risk of it as far as I know.
https://jamanetwork.com/journals/jamacardiology/fullarticle/2780548
Note that this study concerned healthy college athletes, not a population whose health had already been compromised.  Heart damage from the virus is a real risk.

It should go without saying that vaccines aren’t 100% safe for every person every single time. No effective form of medicine is without problems when applied to millions of people. My guiding star is always the risk/benefit ratio. In the case of COVID vaccines, for most people, the benefits far, far outweigh the risks. I would contrast this with the annual flu shot, which I usually avoid on the basis of: its relatively poor efficacy, the existence of at least some immunity to these viruses and the ability to treat the illness, the small but nonzero risk of Guillain-Barre syndrome, and the fact that it has to be given over and over, putting more toxic crap in the system each time. I’m not laughing off flu in the least— I’ve had some really nasty cases. From what I know, and that’s always changing, I simply want to limit vaccines to those that make a serious difference.

In any case, we can’t vaccinate our way out of every conceivable epidemic. New pathogens come along all the time, as their nature is to evolve quickly and to evolve toward more transmissibility. It’s still crucial to continue all our basic public health measures such as tracking and isolating cases of outbreaks; that was how Ebola was contained, well before a vaccine was developed. Vigilance is still needed, all around the world. And that’s why those who demonize or laugh at laboratories that study potentially devastating viruses, like the one in Wuhan (I’m talking to YOU, Jon Stewart!) are doing great damage.

Disinformation (and some honest confusion)

A British gentleman, Chris Woollams, who publishes a very useful website that aggregates current information about cancer treatments is among those who fell into the current fashion of vilifying these efforts and Dr. Anthony Fauci personally. He was easily taken in by the right-wing campaign that paints Dr. Fauci as a liar who is somehow responsible for all we’ve been through in the past year and a half, which nicely deflects attention from the failures of the administration that was in power at the time. He even quoted Rand Paul as a reliable source of information in his article about this. (I’ll wait while you finish laughing. Take your time.) When I attempted to inject some facts into the discussion, he email-yelled at me, “Dr. Fauci is endangering me and my family!” Sadly, I can no longer consider him to be a reliable source himself, as he’s shown that his BS detector is malfunctioning.

The other day Woollams also insinuated on his website that some new research on DNA repair in human cells means that the mRNA in vaccines can become part of your DNA. That’s extremely irresponsible at best. Here’s where he got the idea:
 https://advances.sciencemag.org/content/7/24/eabf1771

The human genome is full of sections derived from viral RNA anyway; HIV famously uses its reverse transcriptase to write itself into our DNA. That’s normal biology. The question being explored recently is whether this mechanism might help explain why some people continue to test positive for COVID after recovery. So far, no.

Some researchers thought they did see evidence of SARS-CoV-2 integrating into the human genome:
https://www.pnas.org/content/118/21/e2105968118
“Reverse-transcribed SARS-CoV-2 RNA can integrate into the genome of cultured human cells and can be expressed in patient-derived tissues”
However that appears to be incorrect: https://journals.asm.org/doi/abs/10.1128/JVI.00294-21
“Host-virus chimeric events in SARS-CoV-2 infected cells are infrequent and artifactual”

From this last article: ‘”If the virus was able to integrate its genetic material into the human genome, that could have meant that any other mRNA could do the same. But because we have shown that this is not supported by current data, this should allay any concerns about the safety of mRNA vaccines,” he said.
‘It is possible for the genetic material of some viruses to be incorporated into the DNA of humans and other animals, resulting in what scientists call “chimeric events.” Human DNA contains approximately 100,000 pieces of DNA from viruses that our species have accumulated over millions of years of evolution. In total, this lost-and-found DNA from viruses makes up a bit less than 10% of the genetic material in our cells.’

So although research continues, you don’t have to worry about the mRNA in vaccines becoming part of your DNA. (If you really want to keep worrying about that, just get a different type of vaccine.)

At least Woollams’ contention is based in some sort of reality, and the underlying biology is important and fascinating, as well as confusing to the non-virologist. That can’t be said of the wacked-out statements we’ve heard from some other internet pundits.

I don’t know if anyone will ever exceed the, um, whimsy of Dr. Sherri Tenpenny’s insistence that vaccines make you magnetic, nor if any anti-vaccine concept will ever be easier to disprove. (I’m sitting on a chair made of ferrous metal right now. Nothing.) Yet, this got as far as testimony before the Ohio state legislature. Think about that for a moment. Lord, I’m glad I don’t live in Ohio anymore.

Second prize goes to the person who dreamed up the idea that the viral spike protein in the vaccine penetrates the uterine wall, thus explaining increased menstrual bleeding. Just how big do they think viruses are?

Sadly, a lot of the worst misleading statements, aka lies, about vaccines are coming from real health care providers who used to be trustworthy sources of solid medical information. I grieve particularly to see Christiane Northrup, MD in this group; I used to recommend her women’s health books to my patients. Some of these were called out by the Center for Countering Digital Hate under the title “The Disinformation Dozen,” in a presentation calling for more policing of misinformation by social media corporations. Some might find CCDH a little strident, but a number of the memes they collected are truly eye-popping and nearly at the level of the “magnetic” claim. Tenpenny, a DO, is included.
https://252f2edd-1c8b-49f5-9bb2-cb57bb47e4ba.filesusr.com/ugd/f4d9b9_b7cedc0553604720b7137f8663366ee5.pdf

There is not a hint here of sober consideration of potential side effects or of the risks of the disease itself. Instead there is idiocy like “masks make you get sick” and “vaccines have killed more people than the disease itself” and even “if you are getting tested you are part of the problem.” Huh? And if you sift through crap like this long enough, eventually you get to the hoary old “it’s the Rothschilds.”

I want to emphasize again that their claims are easily disprovable.

 

 

Just plain not true. 

 

Some of these folks, like Sayer Ji, have promulgated solid information about nutrition and other aspects of health in the past, before they went so far off the deep end. On the other hand, the Bollingers, of “The Truth about Cancer” fame, not only put out statements about cancer that don’t hold water, but now they also promote Mr. 45’s election fraud lies. Anyone who believes T. won the 2020 election has some obvious issues with critical thinking, and “truth” is not their strong suit.

Still, a lot of people have been burned by the medical establishment in one way or another, and they have reasons to be leery. They have trouble trusting anybody who tries to advise them about their health. So I was heartened to see that one’s personal doctor does still get named as a trustworthy source:

 

 

 

And trust is slowly ticking up.

 

 

These graphics come from the Zoom updates the UNM infectious disease department holds every week. The kind and supportive community of doctors and other health care personnel helps me stay on top of the latest developments in COVID prevention and treatment— including aspects like nutrition and exercise— and answer the many questions my patients bring up. It also helps me keep some semblance of sanity. The presenters put in a lot of effort to do this on top of their very demanding jobs. It’s clear to me that all these providers are doing everything they can to understand and act upon the best information they can get. When people talk trash about doctors, these are the people I think of, and it hurts my heart.

Unnecessary Deaths and Long-Term Debility

Those who refuse to take the pandemic seriously, and there still are plenty of those, often state that “only” 1% of those who are infected die. Leaving aside the question of whether that percentage is accurate, who would they like to choose for those unnecessary deaths? For a thought experiment, let’s take Albuquerque Public Schools, which has about 4000 employees. That’s a population you can probably imagine, and an appropriate one since schools have always been great places to pass diseases around. Now imagine them as 4000 people who get COVID. Imagine that 40 will die— 40 moms, dads, sisters, brothers, friends. And they’ll die miserably.

Are you OK with that? I’m not, not if we can prevent it.

But while relatively few may die, a great many who contract COVID will have long-term consequences. You know about the devastation of “long COVID,” but you may not have heard that an increased incidence of a variety of health problems and even a greater likelihood of death are seen in the months after infection, even in those who appear to recover normally.

“We show that beyond the first 30 days of illness, people with COVID-19 exhibit a higher risk of death and use of health resources. Our high-dimensional approach identifies incident sequelae in the respiratory system, as well as several other sequelae that include nervous system and neurocognitive disorders, mental health disorders, metabolic disorders, cardiovascular disorders, gastrointestinal disorders, malaise, fatigue, musculoskeletal pain and anaemia. We show increased incident use of several therapeutic agents—including pain medications (opioids and non-opioids) as well as antidepressant, anxiolytic, antihypertensive and oral hypoglycaemic agents—as well as evidence of laboratory abnormalities in several organ systems. Our analysis of an array of prespecified outcomes reveals a risk gradient that increases according to the severity of the acute COVID-19 infection (that is, whether patients were not hospitalized, hospitalized or admitted to intensive care). Our findings show that a substantial burden of health loss that spans pulmonary and several extrapulmonary organ systems is experienced by patients who survive after the acute phase of COVID-19.”
https://www.nature.com/articles/s41586-021-03553-9

Long COVID is something you do not want. It’s still poorly understood, it’s difficult to treat, and it can completely disable you. It often follows mild cases that had seemed to be of little consequence, and it happens even to young, athletic people with no previous health issues. Take it seriously!

The best article I have seen about long COVID is not from a medical journal, but in The Atlantic. I hope you can read it and not be paywalled away. (The Atlantic is superb and worth subscribing to in any case.) The gist is that long COVID involves a derangement of the autonomic nervous system that doesn’t fix itself, but that the brain and body can be retrained with measures as simple as breathing exercises. The cases described are terrifying, but the conclusion is hopeful. I am confident that studying long COVID is helping us to better understand other post-infection syndromes like chronic fatigue syndrome/myalgic encephalitis, something else you definitely do not want.
https://www.theatlantic.com/magazine/archive/2021/04/unlocking-the-mysteries-of-long-covid/618076/

Panic may not be helpful, but a certain degree of alarm is still appropriate. This is no time for complacency. Though a lot of us in the more-vaxxed parts of the USA are sitting pretty right now, with transmission still so high in so much of the world, the virus has millions upon millions of chances to mutate, and we have literally no idea what may happen. At this writing, the delta variant is taking over and causing havoc in a number of countries. Reducing the rate of transmission is the only way to prevent the development of variants that could resist our best efforts and prevention and treatment. And we are a long, long way off from knocking transmission down to a low level in a lot of places. Even Australia has started lockdowns again. Until everyone is safe, no one is really safe.

 

*”How I Know the Material World Isn’t”  https://elenedom.wordpress.com/2010/05/16/how-i-know-the-material-world

Related: “Sorting Medical Fact from Fiction, Part IV: Vaccination, Variolation, and What Doctors Do Tell You”  https://elenedom.wordpress.com/2020/11/01/sorting-medical-fact-from-fiction-part-iv-vaccination-variolation-and-what-doctors-do-tell-you/

 

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Sorting Medical Fact from Fiction, Part IV: Vaccination, Variolation, and What Doctors Do Tell You

encased in plastic bubbles

Will we see more of this?

I wrote most of this on 10/27, and the HHS update I’m referring to below happened on that date. By a couple of days later things looked massively worse, with a record one-day case count of 1082 and a real threat to our health care system and its exhausted workers. We knew fall was likely to be difficult, and it is, here and in so many places.

As I write on this scariest 10/31, I’m thinking of the Berlin Philharmonic’s concert earlier today. The full orchestra was on stage together for the first time in all these months; they had been using smaller ensembles only. More amazingly, the seats were packed with audience members, whereas last week they had been separated by empty seats in between. I was boggled and a bit jealous that they had managed this. Weren’t things a lot worse in Germany too? Then came the announcement at the end of the show telling us that the orchestra’s hall would be closed Nov. 2-30. It was fun while it lasted….

Last time I talked about the epic stupidity of the Great Barrington Declaration.  Then, a couple of days ago, I saw that someone I had long admired and followed, Lynne McTaggart, had endorsed it and was telling people to sign it.  I guess I should have expected that, but I was still in shock.

The reason I should have expected it is that Lynne’s long-term brand is What Doctors Don’t Tell You.  So when Doctors Do Tell You and what they say is actually true, if you have the point of view that doctors are always trying to deceive you, you can’t hear them.

I’m trying to come to terms with this and with the gigantic number of people who STILL, despite the catastrophic spike in COVID-19 cases across the country, refuse to understand that they need to change their behavior if we are ever to get through this.  It’s gotten to where we seem to be unintentionally running the experiment the Great Barrington people were advocating. And it’s not going well.

Something occurred to me this morning: Maybe the deniers and anti-maskers and open-everythingers are unwilling to believe the virus is really so bad because the truth is just too painful and hard to face.* I mean, every day at least once I experience a moment of shock when it hits me again that this is really happening. It’s been like a bad dream all along. Do you have that feeling, too, that you’re going to wake up any minute now, but then you never do?

If someone has that persistent feeling of unreality, and then they are bombarded with messages that the pandemic isn’t real, perhaps they can be forgiven— just a little— for trying to find refuge in the belief that it’s all a hoax, or at least the danger has been overblown, so that there’s no problem with their usual habits. Nothing having a beer with their friends in a crowded bar can’t solve.

Today [10/27] I attended the weekly web update from Dr. David Scrase, the head of the New Mexico Department of Health and Human Services. Dr. Scrase manages to inject some gentle humor into the march of facts, even when the numbers are looking as dire as they have lately, and he always speaks with compassion as well as honesty. I get to these meetings most Tuesdays, and whenever possible I also hang out with a bunch of infectious disease and public health experts on Mondays at a UNM ECHO session. These are good people, doing their best to navigate rough and uncharted seas. They are Doctors Who Do Tell Us— to the extent that anyone knows anything for sure.

I hope HHS won’t mind that I’ve grabbed a couple of today’s slides to show you. This one illustrates the dizzying rise in cases in the past couple of weeks. What I’d like you to look at here is the sharp upward swoop of the purple line, the one that shows cases in people ages 35-64. The green line showing those 18-34 is less dramatic, but it’s pretty substantial. And you can see that cases are also notably up in kids and teens as well. If you’re still thinking that only older people are vulnerable to this disease, well, you are wrong.

In some parts of the country the virus is considered to be out of control, including places like the Dakotas who hardly had it at all for so long. I hope New Mexico’s case counts don’t reach that level. I hope they haven’t already. But getting back to a better situation requires a population that is united in doing all the right things, and we aren’t seeing that.

Now for another denier contention, the idea that if you do get COVID you’ll just get over it and everything will be fine, no big deal. Uh-uh. The following slide makes it clear that long-term symptoms are not just happening to an unlucky few, but are actually very common even in “mild” cases.

Here’s more about the brain damage that can accompany all this unpleasantness:
https://www.reuters.com/article/health-coronavirus-brains-int/covids-cognitive-costs-some-patients-brains-may-age-10-years-idUSKBN27C1RN

Deniers also like to believe that if against all odds they somehow come down with the illness, it will be like the president told them, they’ll get the latest greatest treatments, which are miraculously effective. While I hope every patient will get the best possible treatments at the earliest possible time, the more patients need them at once, the less likely that becomes. The main limiting factor at this point is not so much hospital beds as skilled personnel to staff them. And one of the limitations on health care professionals being available is that some of them are getting COVID themselves.

Dr. Scrase told us that the health care personnel who get sick are usually not getting infected at work, but rather at social gatherings in the community— the same way that most of the laypeople are getting infected. The people who should know better are apparently doing the same dumb things as the rest.

At this point please imagine that I am shaking you and screaming that you don’t need to have a birthday party and invite 50 of your closest friends!

But pretty soon there is going to be a vaccine, you say, and we’re all going to be able to live our lives any way we want to again. Yes, in the next few months there is likely to be at least one vaccine that will be available to at least a few people, most likely front-line health care workers to begin with. That will start to help a little. But as you’ve probably heard, even in a best-case scenario of a very effective vaccine, it’s going to take ages to get shots to everybody who wants them. Not to mention the fact that many people will not want them. No matter how this goes, all that masking and distancing stuff that we hate is likely to be necessary for a very long time.

Now we’re going to look at how good a vaccine has to be in order to be useful, and how we can tell whether a vaccine candidate will meet that standard. What percentage of the time does a vaccine have to work in order to be considered effective? What percentage of the population needs to be vaccinated in order to create herd immunity (which is purely a vaccine-related concept, by the way)? There are formulas that can inform these decisions.

The following article is a month old, and that’s ages in COVID time. I’m including it because it gives a layperson-friendly explanation of how researchers decide whether a vaccine is working and whether it’s ready to be given to the public at large. Pfizer was supposed to have big news about its trial around the end of October, but that hasn’t happened as yet. Whether Pfizer’s effort pans out or not, this clarifies how to think about the process and what it all means.
https://www.propublica.org/article/a-real-vaccine-before-the-election-itd-take-a-miracle

I was surprised to see how few cases these momentous decisions may be based on. Especially with this unprecedentedly rushed research program, it’s hard to feel confident that we’re seeing real effectiveness, and even harder to feel confident about safety. About the same time that I read the ProPublica piece, I came across a September interview of Dr. Paul Offit by Dr. Eric Topol on Medscape, in which he expressed his own doubts. That really caught my eye. Dr. Offit has been a huge cheerleader of vaccines in general, very publicly gung-ho about them. If he is feeling cautious about COVID vaccines, I thought, there must really be something to be cautious about. He expressed some skepticism about both the drug companies’ promises and the politically compromised FDA.

“So you have this difficult-to-characterize, elusive virus that you are now about to meet with a handful of vaccine strategies for which you have no commercial experience,” he said. “I think you can assume that there may be a learning curve here.”

There are so many important points I wanted to quote in this interview that I have to ask you to go and read it for yourself. Honestly, you should. It’s a little unnerving, but it should also leave you with the feeling that there are some reasonable safeguards in place. Since it’s necessary to sign up with the Medscape site to read articles (although it is a free service), for your convenience I’ve parked a copy where you can get it easily:
https://app.box.com/s/rpammbltgrp4fbi9tmon1dzn1p6yhte0
‘Paul Offit’s Biggest Concern About COVID Vaccines’

If you don’t feel like going over to Box to grab that copy, this excerpt will give you some of the main points:

“[Offit:] We have two ways of stopping this virus: One is hygienic measures — face masks, social distancing, hand-washing — and the other is the vaccine. With those two, we will be able to bring this virus under control. But it will take both. What worries me is that if you had to pick which is the stronger of the two, I would go with hygienic measures. I mean, if I wear a mask and stand 6 feet away from you, and you wear a mask and stand 6 feet away from me, the chances that I’m going to get the virus from you or you from me is about zero. You have two things going for you. One, you have a mask, which is going to prohibit the virus’ small droplets from traveling very far. And two, even if I didn’t wear a mask and stand 6 feet away, the odds are also that you wouldn’t get it.

Topol: And by the way, if you do get it, you get a lower dose of virus, which is important.

Offit: That’s right. You might get more mild disease. On the other hand, if we have a vaccine and it’s 75% effective against moderate to severe disease, that means 1 out of every 4 people can still get sick, including very sick. It also means probably a larger percentage than that 25% could get mild infection, or asymptomatic infection, which they could still shed, even to the point of contagiousness. We’ve been asking these trials to look not only at whether they’re protecting against moderate to severe disease, but to what extent they are protecting against shed. I think that is important to know.
But people have such an unrealistic expectation of these vaccines that they see it as the panacea, as the magic bullet to make it all go away. [emphasis mine] If people have unrealistic expectations, such that they think “I’ve gotten the vaccine, I’m good. I don’t need to wear a mask. I don’t need to social distance. I can engage in high-risk activities,” then we’ve lost one of the important arms to bring this virus under control, arguably a more important arm. If, when we bring the vaccine up in terms of users, we move social distancing and masking down, we could end up having a sort of break-even effect.

Topol: Well, you’re bringing up a critical point and that is, the vaccine effect could actually increase the number of people who are asymptomatic carriers. Because they basically have protection from beyond their mucosa. But they still have the virus in their nose and their upper respiratory tract to spread. And that’s why this coupling of continued hygiene— masks, distance, and these other measures — is going to be important all the way through until we get a very dense immunity of the population, right?

Offit: There is a formula for this, actually. If you have a 75% effective vaccine against significant shedding, then you would need to immunize about two thirds of the American population to get the R0 to less than 1, meaning to stop spread, which is what you want.”

It may well be that a vaccine with 50% effectiveness will be the best we can do. It may be that there will be multiple vaccines available, with some being best for people of one age group or health status and others for other categories. Right now we don’t know much, so again I ask that everyone keep an open mind. No knee-jerk reactions, please! Whether you take every shot available or scrupulously avoid vaccinations, at this point you don’t have enough data to weigh risks against benefits. We have to have data, and we have to have clear messaging about it from the people in charge. That might be a tougher challenge than creating a vaccine to begin with.

In other sobering news this week, more evidence came in to show that immunity to COVID-19 does not appear to last very long— another blow against the Great Barrington mindset.
https://www.reuters.com/article/uk-health-coronavirus-britain-antibody-idUSKBN27C005
‘Antibodies against the novel coronavirus declined rapidly in the British population during the summer, a study found on Tuesday, suggesting protection after infection may not be long lasting and raising the prospect of waning immunity in the community.’

But all is not lost. Antibodies are not the entirety of the immune response. And with masking and distancing, those of us who don’t get sick may still be getting small doses of the virus as we go about our business, enough to teach the body how to recognize this pathogen and fight it to at least some degree. There is evidence that people who are exposed in this way tend to get infections that stay asymptomatic. Even if no really robust long-term immunity exists, some memory will develop in their immune systems, and they should be better off than they would be without any exposure. The author likens this to variolation, the strategy used to prevent smallpox before the vaccine was invented. The key would be small doses of the virus, not the uncontrolled onslaught of a big group event with no masks.
https://www.nejm.org/doi/full/10.1056/NEJMp2026913
‘Facial Masking for Covid-19 — Potential for “Variolation” as We Await a Vaccine’

So even if we have an effective vaccine, we’ll still need to do all this other stuff that we’re getting so tired of, and there’s no end to it in the near term. I’m sorry. I would like to be able to give you better news. We just have to keep muddling along as best we can. I implore you not to make the situation any worse! Don’t travel. Don’t get together with a bunch of people indoors, and be careful outdoors. No big Thanksgiving dinner with family from far and near. Wear the damn mask. Just do it. The more effort we make now, the sooner we can be done with all this.

I can’t remember where I saw this:
COMMUNITY
IMMUNITY
I’M UNITY

Unity. Let’s try it.

************************************************************************

* Later I came across this:
 ‘Left to their own devices, people chart their paths based on their personality, how they see the world, and how they relate to risk. According to Geller, many people presented with a barrage of contradictory instructions just grow tired and give up. Others become hypervigilant, their behavior calcifying against new information that might let them ease up and enjoy life a little more. Still others simply choose optimism, no matter how dangerously misguided—such as the belief that “herd immunity” is near, or the assumption that catching the virus will have no long-term consequences for them. “People will gravitate to the positive message because it’s convenient, and it’s not scary, it’s not fearful,” Geller said.’


https://www.theatlantic.com/health/archive/2020/10/pandemic-safety-america/616858/

And still later, an interview update came from Dr. Offit, in which he discusses what may happen with an emergency use authorization, and what distribution of a vaccine may look like:
https://edhub.ama-assn.org/jn-learning/video-player/18555773
He also demolishes the Great Barrington argument:
 ‘So now suddenly herd immunity induced by natural infection has become the plan, right? But the premise is wrong. The premise is that a virus could can affect enough people in the population, that would provide immunity such that that essentially the virus would put itself out of business. That’s never happened. That’s never happened for any virus. So historically there’s no support for it. Secondly, if you had to pick the perfect virus for which it would happen, it would be measles. I mean, measles is 10 times more contagious then this virus and SARS-COVID-2. It has an [inaudible], you know contagiousness index of close to 20, where this is less than two. Two, measles induces lifelong sterilizing immunity. You are protected against all manner of infection, including asymptomatic infection, that’s not going to be this virus. And nonetheless, despite that, before there was a measles vaccine every year there would be about one to two million cases of measles. There would be 50,000 hospitalizations, and there’d be 500 deaths from measles. So there’s no such thing as this Great Barrington declaration. Plus, about 30% to 40% of the population is really at high risk.’


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When We Used to Dance

An eerie interlude with magical music by Kitka.

We will do these things again!

2 Comments

November 1, 2020 · 12:30 am

Sorting Medical Fact from Fiction, Part III: Give Me Liberty AND Give Me Death

Patients have been asking me about “herd mentality,” which they then quickly correct to “herd immunity.” Herd mentality we’ve got plenty of. Herd immunity, not so much. In fact, it’s unclear whether widespread, lasting natural immunity to COVID-19 is even a biological possibility. It may turn out to be only a mirage.

But as the pandemic drags on and we are all getting weary, some of us are worn down enough to entertain some pretty crazy notions– or to take cynical advantage of our weariness.

The Great Barrington Declaration came out on October 4, made a splash, and is still being talked about. This is a letter which calls for letting the virus essentially run wild among the younger and healthier members of the population, in order to bring about a theoretical herd immunity, while in some way protecting those who are at high risk. It’s named for Great Barrington, Massachusetts, where it was written, not because it is actually great in any way.

This declaration amounts to magical thinking. It has irresponsibly injected more confusion into an already uncertain situation. It has made the already impossible jobs of public health workers and health care providers that much harder. And yet, some people have been taken in, even some in my own profession.

Although I wouldn’t usually use Wikipedia as a reference, in this case they have an excellent overview of the document, the responses to it, and the issues involved.
https://en.wikipedia.org/wiki/Great_Barrington_Declaration

If that’s TL;DR, here’s a simpler summary:
https://news.yahoo.com/white-house-backed-great-barrington-142700156.html?guccounter=1

The declaration is such utter balderdash (insert less polite term here) in so many ways that it’s amazing it’s gotten as far as it has. You can read all about the objections to it if you wish. I’ll give you a sketch to save you some time:
— Many younger people are immune-compromised or have conditions like asthma, diabetes or obesity, putting them at higher risk of severe COVID-19. With moderate overweight now added to the list of underlying conditions that matter, it’s been estimated that about 72% of Americans fall into the high-risk category!

— It is unrealistic at best, and likely impossible, to try to separate younger and older people. Even in nursing homes, the staff is largely composed of younger workers, and obviously they must go home to their families and come back. More generally, a great many people live in multigenerational extended families. The latest figures I’ve found, from 2018, put the number at over 20% of the US population, and growing.

— Even if we have sufficient hospital beds to manage out-of-control numbers of cases, we don’t have enough skilled staff to provide care. The avalanche of cases that would be likely to result from the Great Barrington non-strategy would be impossible to care for.

If these points haven’t convinced you, listen to a group of virologists, starting here at about 50 minutes in:

https://www.microbe.tv/twiv/
https://www.youtube.com/watch?v=8IjXzadiNaA&feature=emb_logo

As I write this, New Mexico is reeling from an unprecedented surge in cases, bigger than anything seen last spring at what we thought was the height of the pandemic. Much of the world is in far worse shape than a month ago. No one is sure why this has happened, when only a few short weeks before we seemed well on the way toward beating this thing.

The doctor who was interviewed in the TWiV segment above expressed the theory that having schools open encouraged a premature feeling that everything could go back to normal. He described an 80-year-old woman in his hospital who had caught the virus at her grandson’s birthday party. It was bad enough that 20 kids and their parents got together at all, but then it rained heavily and everyone crowded inside. Without masks.

To the Great Barrington people, that birthday party would have been fine. They wouldn’t have invited Grandma, I suppose, but they would have let the kids and parents infect each other freely. One might wonder what the motivation would be for such shortsighted idiocy. It turns out that the declaration came from a libertarian think tank funded by the Koch brothers. But even if one sympathizes with the libertarian objection to any kind of government control, ending current restrictions makes no practical sense. The longer people go around spreading infection, the longer it will be till the virus is damped down and we can get back to our lives and livelihoods. Which is what libertarians and everyone else would seem to want.

But political philosophies will be moot if it turns out that lasting natural immunity doesn’t happen, and it’s looking like that is the case. Back in the spring, I was thinking more like the libertarians, that it might be ideal to catch a mild case, become immune, and move on. That was before anyone realized the potential for long-term damage— and before we started getting reports of reinfections.

While there are not many known cases so far, there are definitely people who have had COVID-19, recovered, and later been infected with a different strain. We know this because the genomes of various strains have been sequenced, so they can easily be distinguished from each other. Worse, some of the patients became more severely ill the second time, and one died. The previous infection appeared to offer no protection. We don’t know what factors influenced any of this. We aren’t yet sure of the role of innate immunity (not mediated by antibodies). We can’t yet predict how long antibodies to SARS-CoV-2 last. We’re pretty sure it’s not more than a matter of months, though.

This is terrible, vexing news, but it’s not unexpected. The common cold coronaviruses can return to torment us again and again. The same goes for flu. And those are diseases that our bodies already know how to recognize, not a new one that’s hit us out of the blue.

That leaves us in need of a vaccine.

I’m not thrilled to say that, since all vaccines entail some level of risk, and not all are very effective— and a vaccine, even if it’s an especially good one, is not going to solve all our pandemic problems. But I would like to ask you to think clearly about where we are in terms of a potential vaccine and what we are likely to get.

In our current low-trust environment, it’s understandable that a lot of people are leery of accepting a new vaccine that may have God knows what side effects. I don’t want to be among the first to try any kind of medication, myself; I’d rather let some time go by and see if problems crop up. But some people in my profession have been insisting that they aren’t going to take any COVID vaccine, no way no how. Although I’m not gung-ho about vaccines, I don’t see the logic in deciding for or against taking something before one has any information about it. A great many vaccines are in development. They have different characteristics. Some will no doubt prove to be safer than others, and some more effective than others.

More on that next time.

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