Recently, after a week in which 2,789 Americans died of COVID-19, President Joe Biden proclaimed that “the pandemic is over.” Anthony Fauci described the controversy around the proclamation as a matter of “semantics,” but the facts we are living with can speak for themselves. COVID still kills roughly as many Americans every week as died on 9/11. It is on track to kill at least 100,000 a year--triple the typical toll of the flu. Despite gross undercounting, more than 50,000 infections are being recorded every day. The CDC estimates that 19 million adults have long COVID. Things have undoubtedly improved since the peak of the crisis, but calling the pandemic “over” is like calling a fight “finished” because your opponent is punching you in the ribs instead of the face. American leaders and pundits have been trying to call an end to the pandemic since its beginning, only to be faced with new surges or variants. This mindset not only compromises the nation’s ability to manage COVID, but also leaves it vulnerable to other outbreaks. Future pandemics aren’t hypothetical; they’re inevitable and imminent. New infectious diseases have regularly emerged throughout recent decades, and climate change is quickening the pace of such events. As rising temperatures force animals to relocate, species that have never coexisted will meet, allowing the viruses within them to find new hosts—humans included. Dealing with all of this again is a matter of when, not if. In 2018, I wrote an article in The Atlantic warning that the U.S. was not prepared for a pandemic. That diagnosis remains unchanged; if anything, I was too optimistic. America was ranked as the world’s most prepared country in 2019--and, bafflingly, again in 2021—but accounts for 16 percent of global COVID deaths despite having just 4 percent of the global population. It spends more on medical care than any other wealthy country, but its hospitals were nonetheless overwhelmed. It helped create vaccines in record time, but is 67th in the world in full vaccinations. (This trend cannot solely be attributed to political division; even the most heavily vaccinated blue state—Rhode Island—still lags behind 21 nations.) America experienced the largest life-expectancy decline of any wealthy country in 2020 and, unlike its peers, continued declining in 2021. If it had fared as well as just the average peer nation, 1.1 million people who died last year—a third of all American deaths--would still be alive. America’s superlatively poor performance cannot solely be blamed on either the Trump or Biden administrations, although both have made egregious errors. Rather, the new coronavirus exploited the country’s many failing systems: its overstuffed prisons and understaffed nursing homes; its chronically underfunded public-health system; its reliance on convoluted supply chains and a just-in-time economy; its for-profit health-care system, whose workers were already burned out; its decades-long project of unweaving social safety nets; and its legacy of racism and segregation that had already left Black and Indigenous communities and other communities of color disproportionately burdened with health problems. Even in the pre-COVID years, the U.S. was still losing about 626,000 people more than expected for a nation of its size and resources. COVID simply toppled an edifice whose foundations were already rotten. In furiously racing to rebuild on this same foundation, America sets itself up to collapse once more. Experience is reputedly the best teacher, and yet the U.S. repeated mistakes from the early pandemic when faced with the Delta and Omicron variants. It got early global access to vaccines, and nonetheless lost almost half a million people after all adults became eligible for the shots. It has struggled to control monkeypox—a slower-spreading virus for which there is already a vaccine. Its right-wing legislators have passed laws and rulings that curtail the possibility of important public-health measures like quarantines and vaccine mandates. It has made none of the broad changes that would protect its population against future pathogens, such as better ventilation or universal paid sick leave. Its choices virtually guarantee that everything that’s happened in the past three years will happen again. The U.S. will continue to struggle against infectious diseases in part because some of its most deeply held values are antithetical to the task of besting a virus. Since its founding, the country has prized a strain of rugged individualism that prioritizes individual freedom and valorizes self-reliance. According to this ethos, people are responsible for their own well-being, physical and moral strength are equated, social vulnerability results from personal weakness rather than policy failure, and handouts or advice from the government are unwelcome. Such ideals are disastrous when handling a pandemic, for two major reasons. First, diseases spread. Each person’s choices inextricably affect their community, and the threat to the collective always exceeds that to the individual. The original Omicron variant, for example, posed slightly less risk to each infected person than the variants that preceded it, but spread so quickly that it inundated hospitals, greatly magnifying COVID’s societal costs. To handle such threats, collective action is necessary. Governments need policies, such as vaccine requirements or, yes, mask mandates, that protect the health of entire populations, while individuals have to consider their contribution to everyone else’s risk alongside their own personal stakes. And yet, since the spring of 2021, pundits have mocked people who continue to think this way for being irrational and overcautious, and government officials have consistently framed COVID as a matter of personal responsibility. Second, a person’s circumstances always constrain their choices. Low-income and minority groups find it harder to avoid infections or isolate when sick because they’re more likely to live in crowded homes and hold hourly-wage jobs without paid leave or the option to work remotely. Places such as prisons and nursing homes, whose residents have little autonomy, became hot spots for the worst outbreaks. Treating a pandemic as an individualist free-for-all ignores how difficult it is for many Americans to protect themselves. It also leaves people with vulnerabilities that last across successive pathogens: The groups that suffered most during the H1N1 influenza pandemic of 2009 were the same ones that took the brunt of COVID, a decade later. America’s individualist bent has also shaped its entire health-care system, which ties health to wealth and employment. That system is organized around treating sick people at great and wasteful expense, instead of preventing communities from falling sick in the first place. The latter is the remit of public health rather than medicine, and has long been underfunded and undervalued. Even the CDC—the nation’s top public-health agency--changed its guidelines in February to prioritize hospitalizations over cases, implicitly tolerating infections as long as hospitals are stable. But such a strategy practically ensures that emergency rooms will be overwhelmed by a fast-spreading virus; that, consequently, health-care workers will quit; and that waves of chronically ill long-haulers who are disabled by their infections will seek care and receive nothing. All of that has happened and will happen again. America’s pandemic individualism means that it’s your job to protect yourself from infection; if you get sick, your treatment may be unaffordable, and if you don’t get better, you will struggle to find help, or even anyone who believes you. In the late 19th century, many scholars realized that epidemics were social problems, whose spread and toll are influenced by poverty, inequality, overcrowding, hazardous working conditions, poor sanitation, and political negligence. But after the advent of germ theory, this social model was displaced by a biomedical and militaristic one, in which diseases were simple battles between hosts and pathogens, playing out within individual bodies. This paradigm conveniently allowed people to ignore the social context of disease. Instead of tackling intractable social problems, scientists focused on fighting microscopic enemies with drugs, vaccines, and other products of scientific research—an approach that sat easily with America’s abiding fixation on technology as a panacea. The allure of biomedical panaceas is still strong. For more than a year, the Biden administration and its advisers have reassured Americans that, with vaccines and antivirals, “we have the tools” to control the pandemic. These tools are indeed effective, but their efficacy is limited if people can’t access them or don’t want to, and if the government doesn’t create policies that shift that dynamic. A profoundly unequal society was always going to struggle with access: People with low incomes, food insecurity, eviction risk, and no health insurance struggled to make or attend vaccine appointments, even after shots were widely available. A profoundly mistrustful society was always going to struggle with hesitancy, made worse by political polarization and rampantly spreading misinformation. The result is that just 72 percent of Americans have completed their initial course of shots and just half have gotten the first of the boosters necessary to protect against current variants. At the same time, almost all other protections have been stripped away, and COVID funding is evaporating. And yet the White House’s recent pandemic-preparedness strategy still focuses heavily on biomedical magic bullets, paying scant attention to the social conditions that could turn those bullets into duds. Technological solutions also tend to rise into society’s penthouses, while epidemics seep into its cracks. Cures, vaccines, and diagnostics first go to people with power, wealth, and education, who then move on, leaving the communities most affected by diseases to continue shouldering their burden. This dynamic explains why the same health inequities linger across the decades even as pathogens come and go, and why the U.S. has now normalized an appalling level of COVID death and disability. Such suffering is concentrated among elderly, immunocompromised, working-class, and minority communities—groups that are underrepresented among political decision makers and the media, who get to declare the pandemic over. Even when inequities are highlighted, knowledge seems to suppress action: In one study, white Americans felt less empathy for vulnerable communities and were less supportive of safety precautions after learning about COVID’s racial disparities. This attitude is self-destructive and limits the advantage that even the most privileged Americans enjoy. Measures that would flatten social inequities, such as universal health care and better ventilation, would benefit everyone—and their absence harms everyone, too. In 2021, young white Americans died at lower rates than Black and Indigenous Americans, but still at three times the rate of their counterparts in other wealthy countries. By failing to address its social weaknesses, the U.S. accumulates more of them. An estimated 9 million Americans have lost close loved ones to COVID; about 10 percent will likely experience prolonged grief, which the country’s meager mental-health services will struggle to address. Because of brain fog, fatigue, and other debilitating symptoms, long COVID is keeping the equivalent of 2 million to 4 million Americans out of work; between lost earnings and increased medical costs, it could cost the economy $2.6 trillion a year. The exodus of health-care workers, especially experienced veterans, has left hospitals with a shortfall of staff and know-how. Levels of trust--one of the most important predictors of a country’s success at controlling COVID--have fallen, making pandemic interventions harder to deploy, while creating fertile ground in which misinformation can germinate. This is the cost of accepting the unacceptable: an even weaker foundation that the next disease will assail. In the spring of 2020, I wrote that the pandemic would last for years, and that the U.S. would need long-term strategies to control it. But America’s leaders consistently acted as if they were fighting a skirmish rather than a siege, lifting protective measures too early, and then reenacting them too slowly. They have skirted the responsibility of articulating what it would actually look like for the pandemic to be over, which has meant that whenever citizens managed to flatten the curve, the time they bought was wasted. Endemicity was equated with inaction rather than active management. This attitude removed any incentive or will to make the sort of long-term changes that would curtail the current disaster and prevent future ones. And so America has little chance of effectively countering the inevitable pandemics of the future; it cannot even focus on the one that’s ongoing. If change happens, it will likely occur slowly and from the ground up. In the vein of ACT UP—the extraordinarily successful activist group that changed the world’s approach to AIDS--grassroots organizations of long-haulers, grievers, immunocompromised people, and others disproportionately harmed by the pandemic have formed, creating the kind of vocal constituency that public health has long lacked. More pandemics will happen, and the U.S. has spectacularly failed to contain the current one. But it cannot afford the luxury of nihilism. It still has time to address its bedrocks of individualism and inequality, to create a health system that effectively prevents sickness instead of merely struggling to treat it, and to enact policies that rightfully prioritize the needs of disabled and vulnerable communities. Such changes seem unrealistic given the relentless disappointments of the past three years, but substantial social progress always seems unfeasible until it is actually achieved. Normal led to this. It is not too late to fashion a better normal. from https://ift.tt/Qd58DrY Check out http://natthash.tumblr.com
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Academic philosophers these days do not tend to be the subjects of overwhelming attention in the national media. The Oxford professor William MacAskill is a notable exception. In the month and a half since the publication of his provocative new book, What We Owe the Future, he has been profiled or excerpted or reviewed or interviewed in just about every major American publication. MacAskill is a leader of the effective-altruism movement, whose adherents use evidence and reason to figure out how to do as much good in the world as possible. His book takes that fairly intuitive-sounding project in a somewhat less intuitive direction, arguing for an idea called “longtermism,” the view that members of future generations—we’re talking unimaginably distant descendants, not just your grandchildren or great-grandchildren—deserve the same moral consideration as people living in the present. The idea is predicated on brute arithmetic: Assuming humanity does not drive itself to premature extinction, future people will vastly outnumber present people, and so, the thinking goes, we ought to be spending a lot more time and energy looking out for their interests than we currently do. In practice, longtermists argue, this means prioritizing a set of existential threats that the average person doesn’t spend all that much time fretting about. At the top of the list: runaway artificial intelligence, bioengineered pandemics, nuclear holocaust. Whatever you think of longtermism or EA, they are fast gaining currency—both literally and figuratively. A movement once confined to university seminar tables and niche online forums now has tens of billions of dollars behind it. This year, it fielded its first major political candidate in the U.S. Earlier this month, I spoke with MacAskill about the logic of longtermism and EA, and the future of the movement more broadly. Our conversation has been edited for length and clarity. Jacob Stern: Effective altruists have been focused on pandemics since long before COVID. Are there ways that EA efforts helped with the COVID pandemic? If not, why not? William MacAskill: EAs, like many people in public health, were particularly early in terms of warning about the pandemic. There were some things that were helpful early, even if they didn't change the outcome completely. 1Day Sooner is an EA-funded organization that got set up to advocate for human challenge trials. And if governments had been more flexible and responsive, that could have led to vaccines being rolled out months earlier, I think. It would have meant you could get evidence of efficacy and safety much faster. [Read: How future generations will remember us] There is an organization called microCOVID that quantifies what your risk is of getting COVID from various sorts of activities you might do. You hang out with someone at a bar: What’s your chance of getting COVID? It would actually provide estimates of that, which was great and I think widely used. Our World in Data—which is kind of EA-adjacent—provided a leading source of data over the course of the pandemic. One thing I think I should say, though, is it makes me wish that we’d done way more on pandemics earlier. You know, these are all pretty minor in the grand scheme of things. I think EA did very well at identifying this as a threat, as a major issue we should care about, but I don’t think I can necessarily point to enormous advances. Stern: What are the lessons EA has taken from the pandemic? MacAskill: One lesson is that even extremely ambitious public-health plans won't necessarily suffice, at least for future pandemics, especially if one was a deliberate pandemic, from an engineered virus. Omicron infected roughly a quarter of Americans within 100 days. And there’s just not really a feasible path whereby you design, develop, and produce a vaccine and vaccinate everybody within 100 days. So what should we do for future pandemics? Early detection becomes absolutely crucial. What you can do is monitor wastewater at many, many sites around the world, and you screen the wastewater for all potential pathogens. We’re particularly worried about engineered pathogens: If we get a COVID-19-scale pandemic once every hundred years or so from natural origins, that chance increases dramatically given advances in bioengineering. You can take viruses and upgrade them in terms of their destructive properties so they can become more infectious or more lethal. It’s known as gain-of-function research. If this is happening all around the world, then you just should expect lab leaks quite regularly. There’s also the even more worrying phenomenon of bioweapons. It’s really a scary thing. In terms of labs, possibly we want to slow down or not even allow certain sorts of gain-of-function research. Minimally, what we could do is ask labs to have regulations such that there’s third-party liability insurance. So if I buy a car, I have to buy such insurance. If I hit someone, that means I’m insured for their health, because that’s an externality of driving a car. In labs, if you leak, you should have to pay for the costs. There’s no way you actually can insure against billions dead, but you could have some very high cap at least, and it would disincentivize unnecessary and dangerous research, while not disincentivizing necessary research, because then if it’s so important, you should be willing to pay the cost. Another thing I’m excited about is low-wavelength UV lighting. It’s a form of lighting that basically can sterilize a room safe for humans. It needs more research to confirm safety and efficacy and certainly to get the cost down; we want it at like a dollar a bulb. So then you could install it as part of building codes. Potentially no one ever gets a cold again. You eradicate most respiratory infections as well as the next pandemic. Stern: Shifting out of pandemic gear, I was wondering whether there are major lobbying efforts under way to persuade billionaires to convert to EA, given that the potential payoff of persuading someone like Jeff Bezos to donate some significant part of his fortune is just massive. MacAskill: I do a bunch of this. I’ve spoken at the Giving Pledge annual retreat, and I do a bunch of other speaking. It’s been pretty successful overall, insofar as there are other people kind of coming in—not on the size of Sam Bankman-Fried or Dustin Moskovitz and Cari Tuna, but there’s definitely further interest, and it is something I’ll kind of keep trying to do. Another organization is Longview Philanthropy, which has done a lot of advising for new philanthropists to get them more involved and interested in EA ideas. I have not ever successfully spoken with Jeff Bezos, but I would certainly take the opportunity. It has seemed to me like his giving so far is relatively small scale. It’s not clear to me how EA-motivated it is. But it would certainly be worth having a conversation with him. Stern: Another thing I was wondering about is the issue of abortion. On the surface at least, longtermism seems like it would commit you to—or at least point you in the direction of—an anti-abortion stance. But I know that you don’t see things that way. So I would love to hear how you think through that. MacAskill: Yes, I’m pro-choice. I don’t think government should interfere in women’s reproductive rights. The key distinction is when pro-life advocates say they are concerned about the unborn, they are saying that, at conception or shortly afterwards, the fetus becomes a person. And so what you’re doing when you have an abortion is morally equivalent or very similar to killing a newborn infant. From my perspective, what you’re doing when having an early-term abortion is much closer to choosing not to conceive. And I certainly don’t think that the government should be going around forcing people to conceive, and then certainly they shouldn’t be forcing people to not have an abortion. There is a second thought of Well, don’t you say it’s good to have more people, at least if they have sufficiently good lives? And there I say yes, but the right way of achieving morally valuable goals is not, again, by restricting people’s rights. Stern: I think there are at least three separate questions here. The first being this one that you just addressed: Is it right for a government to restrict abortion? The second being, on an individual level, if you’re a person thinking of having an abortion, is that choice ethical? And the third being, are you operating from the premise that unborn fetuses are a constituency in the same way that future people are a constituency? MacAskill: Yes and no on the last thing. In What We Owe the Future, I do argue for this view that I still find kind of intuitive: It can be good to have a new person in existence if their life is sufficiently good. Instrumentally, I think it’s important for the world to not have this dip in population that standard projections suggest. But then there’s nothing special about the unborn fetus. On the individual level, having kids and bringing them up well can be a good way to live, a good way of making the world better. I think there are many ways of making the world better. You can also donate. You can also change your career. Obviously, I don’t want to belittle having an abortion, because it’s often a heart-wrenching decision, but from a moral perspective I think it’s much closer to failing to conceive that month, rather than the pro-life view, which is it’s more like killing a child that’s born. Stern: What you're saying on some level makes total sense but is also something that I think your average pro-choice American would totally reject. MacAskill: It’s tough, because I think it’s mainly a matter of rhetoric and association. Because the average pro-choice American is also probably concerned about climate change. That involves concern for how our actions will impact generations of as-yet-unborn people. And so the key difference is the pro-life person wants to extend the franchise just a little bit to the 10 million unborn fetuses that are around at the moment. I want to extend the franchise to all future people! It’s a very different move. [Read: Is colonizing Mars the most important project in human history?] Stern: How do you think about trying to balance the moral rigor or correctness of your philosophy with the goal of actually getting the most people to subscribe and produce the most good in the world? Once you start down the logical path of effective altruism, it’s hard to figure out where to stop, how to justify not going full Peter Singer and giving almost all your money away. So how do you get people to a place where they feel comfortable going halfway or a quarter of the way? MacAskill: I think it’s tough because I don’t think there’s a privileged stopping point, philosophically. At least not until you’re at the point where you’re really doing almost everything you can. So with Giving What You Can, for example, we chose 10 percent as a target for what portion of people’s income they could give away. In a sense it’s a totally arbitrary number. Why not 9 percent or 11 percent? It does have the benefit of 10 percent being a round number. And it also is the right level, I think, where if you get people to give 1 percent, they’re probably giving that amount anyway. Whereas 10 percent, I think, is achievable yet at the same time really is a difference compared to what they otherwise would have been doing. That, I think, is just going to be true more generally. We try to have a culture that is accepting and supportive of these kinds of intermediate levels of sacrifice or commitment. It is something that people within EA struggle with, including myself. It’s kind of funny: People will often beat themselves up for not doing enough good, even though other people never beat other people up for not doing enough good. EA is really accepting that this stuff is hard, and we’re all human and we’re not superhuman moral saints. Stern: Which I guess is what worries or scares people about it. The idea that once I start thinking this way, how do I not end up beating myself up for not doing more? So I think where a lot of people end up, in light of that, is deciding that what’s easiest is just not thinking about any of it so they don’t feel bad. MacAskill: Yeah. And that’s a real shame. I don’t know. It bugs me a bit. It’s just a general issue of people when confronted with a moral idea. It’s like, Hey, you should become vegetarian. People are like, Oh, I should care about animals? What about if you had to kill an animal in order to live? Would you do that? What about eating sugar that is bleached with bone? You’re a hypocrite! Somehow people feel like unless you’re doing the most extreme version of your views, then it’s not justified. Look, it’s better to be a vegetarian than to not be a vegetarian. Let’s accept that things are on a spectrum. On the podcast I was just on, I was just like, ‘Look, these are all philosophical issues. This is irrelevant to the practical questions.’ It's funny that I am finding myself saying that more and more. Stern: On what grounds, EA-wise, did you justify spending an hour on the phone with me? MacAskill: I think the media is important! Getting the ideas out there is important. If more people hear about the ideas, some people are inspired, and they get off their seat and start doing stuff, that’s a huge impact. If I spend one hour talking to you, you write an article, and that leads to one person switching their career, well, that’s one hour turned into 80,000 hours—seems like a pretty good trade. from https://ift.tt/8Pc1EHO Check out http://natthash.tumblr.com Kira Stoops lives in Bozeman, Montana—a beautiful mountain town where it sometimes feels like everyone regularly goes on 50-mile runs. Stoops, however, can’t walk around her own block on most days. To stand for more than a few minutes, she needs a wheeled walker. She reacts so badly to most foods that her diet consists of just 12 ingredients. Her “brain fog” usually lifts for a mere two hours in the morning, during which she can sometimes work or, more rarely, see friends. Stoops has myalgic encephalomyelitis, or chronic fatigue syndrome (ME/CFS). “I’m considered a moderate patient on the mild side,” she told me. ME/CFS involves a panoply of debilitating symptoms that affect many organ systems and that get worse with exertion. The Institute of Medicine estimates that it affects 836,000 to 2.5 million people in the U.S. alone, but is so misunderstood and stigmatized that about 90 percent of people who have it have never been diagnosed. At best, most medical professionals know nothing about ME/CFS; at worst, they tell patients that their symptoms are psychosomatic, anxiety-induced, or simply signs of laziness. While ME/CFS patients, their caregivers, and the few doctors who treat them have spent years fighting for medical legitimacy, the coronavirus pandemic has now forced the issue. A wide variety of infections can cause ME/CFS, and SARS-CoV-2, the coronavirus that causes COVID-19, is no different: Many cases of long COVID are effectively ME/CFS by another name. The exact number is hard to define, but past studies have shown that 5 to 27 percent of people infected by various pathogens, including Epstein-Barr virus and the original SARS, develop ME/CFS. Even if that proportion is 10 times lower for SARS-CoV-2, the number of Americans with ME/CFS would still have doubled in the past three years. “We’re adding an immense volume of patients to an already dysfunctional and overburdened system,” Beth Pollack, a scientist at MIT who studies complex chronic illnesses, told me. The U.S. has so few doctors who truly understand the disease and know how to treat it that when they convened in 2018 to create a formal coalition, there were only about a dozen, and the youngest was 60. Currently, the coalition’s website lists just 21 names, of whom at least three have retired and one is dead, Linda Tannenbaum, the CEO and president of the Open Medicine Foundation, told me. These specialists are concentrated on the coasts; none work in the Midwest. American ME/CFS patients may outnumber the population of 15 individual states, but ME/CFS specialists couldn’t fill a Major League Baseball roster. Stoops, who is 39, was formally diagnosed with ME/CFS only four years ago, and began receiving proper care from two of those specialists—Lucinda Bateman of the Bateman Horne Center and David Kaufman from the Center for Complex Diseases. Bateman told me that even before the pandemic, she could see fewer than 10 percent of the patients who asked for a consultation. “When I got into those practices, it was like I got into Harvard,” Stoops told me. ME/CFS specialists, already overwhelmed with demand for their services, now have to decide how to best use and spread their knowledge, at a time when more patients and doctors than ever could benefit from it. Kaufman recently discharged many of the more stable ME/CFS patients in his care—Stoops among them—so that he could start seeing COVID long-haulers who “were just making the circuit of doctors and getting nowhere,” he told me. “I can’t clone myself, and this was the only other way to” make room for new patients. Bateman, meanwhile, is feverishly focused on educating other clinicians. The hallmark symptom of ME/CFS--post-exertional malaise, or PEM—means even light physical or mental exertion can trigger major crashes that exacerbate every other symptom. Doctors who are unfamiliar with PEM, including many now running long-COVID clinics, can unwittingly hurt their patients by encouraging them to exercise. Bateman is racing to spread that message, and better ways of treating patients, but that means she’ll have to reduce her clinic hours. These agonizing decisions mean that many existing ME/CFS patients are losing access to the best care they had found so far—what for Stoops meant “the difference between being stuck at home, miserable and in pain, and actually going out once or twice a day, seeing other humans, and breathing fresh air,” she told me. But painful trade-offs might be necessary to finally drag American medicine to a place where it can treat these kinds of complex, oft-neglected conditions. Kaufman is 75 and Bateman is 64. Although both of them told me they’re not retiring anytime soon, they also won’t be practicing forever. To make full use of their expertise and create more doctors like them, the medical profession must face up to decades spent dismissing illnesses such as ME/CFS—an overdue reckoning incited by long COVID. “It’s a disaster possibly wrapped up in a blessing,” Stoops told me. “The system is cracking and needs to crack.” Many ME/CFS specialists have a deep knowledge of the disease because they’ve experienced it firsthand. Jennifer Curtin, one of the youngest doctors in the field, has two family members with the disease, and had it herself for nine years. She improved enough to make it through medical school and residency training, which showed her that ME/CFS “just isn’t taught,” she told me. Most curricula don’t include it; most textbooks don’t mention it. Even if doctors learn about ME/CFS, America’s health-care system makes it almost impossible for them to actually help patients. The insurance model pushes physicians toward shorter visits; 15 minutes might feel luxurious. “My average visit length is an hour, which doesn’t include the time I spend going over the patient’s 500 to 1,700 pages of records beforehand,” Curtin said. “It’s not a very scalable kind of care.” (She works with Kaufman at the Center for Complex Diseases, which bills patients directly.) This also explains why the cohort of ME/CFS clinicians is aging out, with little young blood to refresh them. “Hospital systems want physicians to see lots of patients and they want them to follow the rules,” Kaufman said. “There’s less motivation for moving into areas of medicine that are more unknown and challenging.” ME/CFS is certainly challenging, not least because it’s just “one face of a many-sided problem,” Jaime Seltzer, the director of scientific and medical outreach at the advocacy group MEAction, told me. The condition’s root causes can also lead to several distinct but interlocking illnesses, including mast cell activation syndrome, Ehlers Danlos syndrome, fibromyalgia, dysautonomia (usually manifesting as POTS), and several autoimmune and gastrointestinal disorders. “I’m still amazed at how often patients come in with Complaint No. 1, and then I find five to seven of the other things,” Kaufman said. These syndromes collectively afflict many organ systems, which can baffle doctors who’ve specialized in just one. Many of them disproportionately affect women, and are subject to medicine’s long-standing tendency to minimize or psychologize women’s pain, Pollack told me: An average woman with Ehlers-Danlos syndrome typically spends 16 years getting a diagnosis, while a man needs only four. People with long COVID might have many of these conditions and not know about any—because their doctors don’t either. Like ME/CFS, they rarely feature in medical training, and it’s hard to “teach someone about all of them when they’ve never heard of any of them,” Seltzer said. Specialists like Bateman and Kaufman matter because they understand not just ME/CFS but also the connected puzzle pieces. They can look at a patient’s full array of symptoms and prioritize the ones that are most urgent or foundational. They know how to test for conditions that can be invisible to standard medical techniques: “None of my tests came back abnormal until I saw an ME/CFS doctor, and then all my tests came back abnormal,” said Hannah Davis of the Patient-Led Research Collaborative, who has had long COVID since March 2020. ME/CFS specialists also know how to help, in ways that are directly applicable to cases of long COVID with overlapping symptoms. ME/CFS has no cure but can be managed, often through “simple, inexpensive interventions that can be done through primary care,” Bateman told me. Over-the-counter antihistamines can help patients with inflammatory problems such as mast cell activation syndrome. Low doses of naltrexone, commonly used for addiction disorders, can help those with intense pain. A simple but rarely administered test can show if patients have orthostatic intolerance—a blood-flow problem that worsens other symptoms when people stand or sit upright. Most important, teaching patients about pacing—carefully sensing and managing your energy levels—can prevent debilitating crashes. “We don’t go to an ME/CFS clinic and walk out in remission,” Stoops told me. “You go to become stabilized. The ship has 1,000 holes, and doctors can patch one before the next explodes, keeping the whole thing afloat.” That’s why the prospect of losing specialists is so galling. Stoops understands why her doctors might choose to focus on education or newly diagnosed COVID long-haulers, but ME/CFS patients are “just so lost already, and to lose what little we have is a really big deal,” she said. Kaufman has offered to refer her to generalist physicians or talk to primary-care doctors on her behalf. But it won’t be the same: “Having one appointment with him is like six to eight appointments with other practitioners,” she said. He educates her about ME/CFS; with other doctors, it’s often the other way round. “I’m going to have to work much harder to receive a similar level of care.” At least, she will for now. The ME/CFS specialists who are shifting their focus are hoping that they can use this moment of crisis to create more resources for everyone with these diseases. In a few years, Bateman hopes, “there will be 100 times more clinicians who are prepared to manage patients, and many more people with ME/CFS who have access to care.” For someone who is diagnosed with ME/CFS today, the landscape already looks very different than it did just a decade ago. In 2015, the Institute of Medicine published a landmark report redefining the diagnostic criteria for the disease. In 2017, the CDC stopped recommending exercise therapy as a treatment. In 2021, Bateman and 20 other clinicians published a comprehensive guide to the condition in the journal of the Mayo Clinic. For any mainstream disease, such events—a report, a guideline revision, a review article—would be mundane. For ME/CFS, they felt momentous. And yet, “the current state of things is simply intolerable,” Julie Rehmeyer, a journalist with ME/CFS, told me. Solving the gargantuan challenge posed by complex chronic diseases demands seismic shifts in research funding, medical training, and public attitudes. “Achieving shifts like that takes something big,” Rehmeyer said. “Long COVID is big.” COVID long-haulers have proved beyond any reasonable doubt that acute viral infections can leave people chronically ill. Many health-care workers, political-decision makers, and influencers either know someone with long COVID or have it themselves. Even if they still don’t know about ME/CFS, their heightened awareness of post-viral illnesses is already making a difference. Mary Dimmock’s son developed ME/CFS in 2011, and before the pandemic, one doctor in 10 might take him seriously. “Now it’s the flip: Only one doctor out of 10 will be a real jerk,” Dimmock told me. “I attribute that to long COVID.” But being believed is the very least that ME/CFS patients deserve. They need therapeutics that target the root causes of the disease, which will require a clear understanding of those causes, which will require coordinated, well-funded research—three things ME/CFS has historically lacked. But here, too, “long COVID is going to be a catalyst,” Amy Proal, the president of the Polybio Research Foundation, told me. She is leading the Long Covid Research Initiative—a group of scientists, including ME/CFS researchers, that will use state-of-the-art techniques to see exactly how the new coronavirus causes long COVID, and rapidly push potential treatments through clinical trials. The National Institutes of Health has also committed $1.15 billion to long-COVID research, and while some advocates are concerned about how that money will be spent, Rehmeyer notes that the amount is still almost 80 times greater than the paltry $15 million spent on ME/CFS every year--less than any other disease in the NIH’s portfolio, relative to its societal burden. “Even if 90 percent is wasted, we’d be doing a lot better,” she said. While they wait for better treatments, patients also need the medical community to heed the lessons that they and their clinicians have learned. For example, the American Association for Family Physicians website still wrongly recommends exercise therapy and links ME/CFS to childhood abuse. “That group of doctors is very important to these patients,” Dimmock said, “so what does that say to them about what this disease is all about?” Despite all evidence to the contrary, many clinicians and researchers still don’t see ME/CFS as a legitimate illness and are quick to dismiss any connection between it and long COVID. To ensure that both groups of patients get the best possible treatments, instead of advice that might harm them, ME/CFS specialists are working to disseminate their hard-won knowledge. Bateman and her colleagues have been creating educational resources for clinicians and patients, continuing-medical-education courses, and an online lecture series. Jennifer Curtin has spent two years mapping all the decisions she makes when seeing a new patient, and is converting those into a tool that other clinicians can use. As part of her new start-up, called RTHM, she’s also trying to develop better ways of testing for ME/CFS and its related syndromes, of visualizing the hefty electronic health records that chronically ill patients accumulate, and of tracking the treatments they try and their effects. “There are a lot of things that need to be fixed for this kind of care to be scalable,” Curtin told me. Had such shifts already occurred, the medical profession might have had more to offer COVID long-haulers beyond bewilderment and dismissal. But if the profession starts listening to the ME/CFS community now, it will stand the best chance of helping people being disabled by COVID, and of steeling itself against future epidemics. Pathogens have been chronically disabling people for the longest time, and more pandemics are inevitable. The current one could and should be the last whose long-haulers are greeted with disbelief. New centers that cater to ME/CFS patients are already emerging. RTHM is currently focused on COVID long-haulers but will take on some of David Kaufman’s former patients in November, and will open its waiting list to the broader ME/CFS community in December. (It is currently licensed to practice in just five states but expects to expand soon.) David Putrino, who leads a long-COVID rehabilitation clinic in Mount Sinai, is trying to raise funds for a new clinic that will treat both long COVID and ME/CFS. He credits ME/CFS patients with opening his eyes to the connection between long COVID and their condition. Every ME/CFS patient I’ve talked with predicted long COVID’s arrival well before most doctors or even epidemiologists started catching up. They know more about complex chronic illnesses than many of the people now treating long COVID do. Despite having a condition that saps their energy, many have spent the past few years helping long-haulers navigate what for them was well-trodden terrain: “I did barely anything but work in 2020,” Seltzer told me. Against the odds, they’ve survived. But the pandemic has created a catalytic opportunity for the odds to finally be tilted in their favor, “so that neither patients nor doctors of any complex chronic illness have to be heroes anymore,” Rehmeyer said. from https://ift.tt/MK07OCX Check out http://natthash.tumblr.com For about 60 years, health authorities in the United States have been championing a routine for at least some sector of the public: a yearly flu shot. That recommendation now applies to every American over the age of six months, and for many of us, flu vaccines have become a fixture of fall. The logic of that timeline seems solid enough. A shot in the autumn preps the body for each winter’s circulating viral strains. But years into researching flu immunity, experts have yet to reach a consensus on the optimal time to receive the vaccine—or even the number of injections that should be doled out. Each year, a new flu shot recipe debuts in the U.S. sometime around July or August, and according to the CDC the best time for most people to show up for an injection is about now: preferably no sooner than September, ideally no later than the end of October. Many health-care systems require their employees to get the shot in this time frame as well. But those who opt to follow the CDC current guidelines, as I recently did, then mention that fact in a forum frequented by a bunch of experts, as I also recently did, might rapidly hear that they’ve made a terrible, terrible choice. “There’s no way I would do what you did,” one virologist texted me. “It’s poor advice to get the flu vaccine now.” Florian Krammer, a virologist at Mount Sinai’s Icahn School of Medicine, echoed that sentiment in a tweet: “I think it is too early to get a flu shot.” When I prodded other experts to share their scheduling preferences, I found that some are September shooters, but others won’t juice up till December or later. One vaccinologist I spoke with goes totally avant-garde, and nabs multiple doses a year. [Read: Should your flu and COVID shots go in different arms?] There is definitely such a thing as getting a flu shot too early, as Helen Branswell has reported for Stat. After people get their vaccine, levels of antibodies rocket up, buoying protection against both infection and disease. But after only weeks, the number of those molecules begins to steadily tick downward, raising people’s risk of developing a symptomatic case of flu by about 6 to 18 percent, various studies have found. On average, people can expect that a good portion of their anti-flu antibodies “are meaningfully gone by about three or so months” after a shot, says Lauren Rodda, an immunologist at the University of Washington. That decline is why some researchers, Krammer among them, think that September and even October shots could be premature, especially if flu activity peaks well after winter begins. In about three-quarters of the flu seasons from 1982 to 2020, the virus didn’t hit its apex until January or later. Krammer, for one, told me that he usually waits until at least late November to dose up. Stanley Plotkin, a 90-year-old vaccinologist and vaccine consultant, has a different solution. People in his age group—over 65--don’t respond as well to vaccines in general, and seem to lose protection more rapidly. So for the past several years, Plotkin has doubled up on flu shots, getting one sometime before Halloween and another in January, to ensure he’s chock-full of antibodies throughout the entire risky, wintry stretch. “The higher the titers,” or antibody levels, Plotkin told me, “the better the efficacy, so I’m trying to take advantage of that.” (He made clear to me that he wasn’t “making recommendations for the rest of the world”—just “playing the odds” given his age.) Data on doubling up is quite sparse. But Ben Cowling, an epidemiologist and flu researcher at Hong Kong University, has been running a years-long study to figure out whether offering two vaccines a year, separated by roughly six months, could keep vulnerable people safe for longer. His target population is Hong Kongers, who often experience multiple annual flu peaks, one seeded by the Northern Hemisphere’s winter wave and another by the Southern Hemisphere’s. So far, “getting that second dose seems to give you additional protection,” Cowling told me, “and it seems like there’s no harm of getting vaccinated twice a year,” apart from the financial and logistical cost of a double rollout. [Read: The strongest sign that Americans should worry about flu this winter] In the U.S., though, flu season is usually synonymous with winter. And the closer together two shots are given, the more blunted the effects of the second injection might be: People who are already bustling with antibodies may obliterate a second shot’s contents before the vaccine has a chance to teach immune cells anything new. That might be why several studies that have looked at double-dosing flu shots within weeks of each other “showed no benefit” in older people and certain immunocompromised groups, Poland told me. (One exception? Organ transplant recipients. Kids getting their very first flu shot are also supposed to get two of them, four weeks apart.) Even at the three-ish-month mark past vaccination, the body’s anti-flu defenses don’t reset to zero, Rodda told me. Shots shore up B cells and T cells, which can survive for many months or years in various anatomical nooks and crannies. Those arsenals are especially hefty in people who have banked a lifetime of exposures to flu viruses and vaccines, and they can guard people against severe disease, hospitalization, and death, even after an antibody surge has faded. A recent study found that vaccine protection against flu hospitalizations ebbed by less than 10 percent a month after people got their shot, though the rates among adults older than 65 were a smidge higher. Still other numbers barely noted any changes in post-vaccine safeguards against symptomatic flu cases of a range of severities, at least within the first few months. “I do think the best protection is within three months of vaccination,” Cowling told me. “But there’s still a good amount by six.” For some young, healthy adults, a decent number of flu antibodies may actually stick around for more than a year. “You can test my blood right now,” Rodda told me. “I haven’t gotten vaccinated just yet this year, and I have detectable titers.” Ali Ellebedy, an immunologist at Washington University in St. Louis, told me he has found that some people who have regularly received flu vaccines have almost no antibody bump when they get a fresh shot: Their blood is already hopping with the molecules. Preexisting immunity also seems to be a big reason that nasal-spray-based flu vaccines don’t work terribly well in adults, whose airways have hosted far more flu viruses than children’s. Getting a second flu shot in a single season is pretty unlikely to hurt. But Ellebedy compares it to taking out a second insurance policy on a car that’s rarely driven: likely of quite marginal benefit for most people. Plus, because it’s not a sanctioned flu-vaccine regimen, pharmacists might be reluctant to acquiesce, Poland pointed out. Double-dosing probably wouldn’t stand much of a chance as an official CDC recommendation, either. “We do a bad enough job,” Poland said, getting Americans to take even one dose a year. [Read: America’s flu-shot problem is also its next COVID-shot problem] That’s why the push to vaccinate in late summer and early fall is so essential for the single shot we currently have, says Huong McLean, a vaccine researcher at the Marshfield Clinic Research Institute in Wisconsin. “People get busy, and health systems are making sure that most people can get protected before the season starts,” she told me. Ellebedy, who’s usually a September vaccinator, told me he “doesn’t see the point of delaying vaccination for fear of having a lower antibody level in February.” Flu seasons are unpredictable, with some starting as early as October, and the viruses aren’t usually keen on giving their hosts a heads-up. That makes dillydallying a risk: Put the shot off till November or December, and “you might get infected in between,” Ellebedy said—or simply forget to make an appointment at all, especially as the holidays draw near. In the future, improvements to flu-shot tech could help cleave off some of the ambiguity. Higher doses of vaccine, which are given to older people, could rile up the immune system to a greater degree; the same could be true for more provocative vaccines, made with ingredients called adjuvants that trip more of the body’s defensive sensors. Injections such as those seem to “maintain higher antibody titers year-round,” says Sophie Valkenburg, an immunologist at Hong Kong University and the University of Melbourne—a trend that Ellebedy attributes to the body investing more resources in training its fighters against what it perceives to be a larger threat. Such a switch would likely come with a cost, though, McLean said: Higher doses and adjuvants “also mean more adverse events, more reactions to the vaccine.” For now, the only obvious choice, Rodda told me, is to “definitely get vaccinated this year.” After the past two flu seasons, one essentially absent and one super light, and with flu-vaccination rates still lackluster, Americans are more likely than not in immunity deficit. Flu-vaccination rates have also ticked downward since the coronavirus pandemic began, which means there may be an argument for erring on the early side this season, if only to ensure that people reinforce their defenses against severe disease, Rodda said. Plus, Australia’s recent flu season, often a bellwether for ours, arrived ahead of schedule. Even so, people who vaccinate too early could end up sicker in late winter—in the same way that people who vaccinate too late could end up sicker now. Plotkin told me that staying apprised of the epidemiology helps: “If I heard influenza outbreaks were starting to occur now, I would go and get my first dose.” But timing remains a gamble, subject to the virus’s whims. Flu is ornery and unpredictable, and often unwilling to be forecasted at all. from https://ift.tt/z7MGAd1 Check out http://natthash.tumblr.com A few months ago, I got food poisoning. The sequence of events that led to my downfall began with a carton of discounted grocery-store sushi purchased and consumed on a Thursday, which led to me waking up a little queasy on a Friday, which devolved into a 12-hour stretch of me vomiting and holding myself in a fetal position, until my legs ached from dehydration. On Saturday the smell of my partner cooking breakfast still made me gag; I sipped water, napped fitfully, and nibbled little golf balls of white rice. But Sunday, glorious Sunday, I awoke to a marvelous lack of pain and fatigue. The brain fog was gone. My skin felt plump with fluids. Enthralled by recovery, I found myself behaving with uncharacteristic serenity. When I dropped and broke a ceramic bowl while unloading the dishwasher, I didn’t curse and freak out. Instead, I swept up the shards with cheer. I wouldn’t sweat the small stuff. I was my normal self again, and it felt sublime. Yet as I relished in my newfound bliss, a foreboding thought gnawed at me: I knew that as the hours passed and the specter of illness retreated, my fresh perspective, too, would fade. So much of my exuberance was defined by absence, the lifting of the burden of aches and puking. It would only be a matter of time until normal felt normal again, and I’d be back to worrying about all the petty minutiae I always worry about. People have different baselines of health, and some might be more or less appreciative of whatever condition they’re in. Even so, humans have long lamented the ephemeral joy of relief. The feeling manifests in all kinds of circumstances: meeting a deadline, passing a test, finishing a marathon. And it can be especially acute in matters of wellness. “Health is not valued, till sickness comes,” wrote the 17th-century British scholar Thomas Fuller. Or as the 19th-century German philosopher Arthur Schopenhauer bemoaned: “Just as we do not feel the health of our entire body but only the small place where the shoe pinches, so too we do not think of the totality of our well-functioning affairs, but of some insignificant trifle that annoys us.” So many of us, in other words, are very bad at appreciating good health when we’re fortunate enough to have it. And anyone experiencing this transcendent gratitude is unlikely to hold on to it for long. Indeed, by Monday morning, the afterglow of recovery had worn off; I was engrossed in emails and work again, unaware that just 60 hours prior I could barely sit upright in bed, let alone at my desk. This troubled me. Am I cursed to be like this forever? Or is there anything I can do to change? To some extent, I’m sad to report, the answer might well be no. While certainly some people can have experiences of major illness or injury that change their entire outlook on life, the tendency to revert to forgetfulness seems to run pretty deep in the human psyche. We have limited attentional resources, the UC Davis psychology professor Robert Emmons told me, so in the interest of survival, our brain tends not to waste them focusing on systems that are working well. Instead, our mind evolved to identify threats and problems. Psychologists call this negativity bias: We direct our attention more to what’s wrong than what’s right. If your body’s in check, your brain seems to reason, better to stress about the project that’s overdue or the conflict with your friend than sit around feeling like everything’s fine. [Read: Does ‘counting your blessings’ work?] A second psychological phenomenon that might work against any enduring joy in recovery from illness is hedonic adaptation, the notion that after positive or negative life events we, basically, get used to our new circumstances and return to a baseline level of subjective well-being. Hedonic adaptation has been used to explain why, in the long term, people who won the lottery were no happier than those who didn’t; and why romantic partners lose passion, excitement, and appreciation for each other over time. Arguably, adaptation need not be seen as any great tragedy. For health, in particular, there’s an element of practicality in the human capacity to exist without fussy attentiveness. This is how we’re supposed to operate. “If our body isn’t causing us problems, it doesn’t actually pay to walk around being grateful all the time. You should be using your mental energy on other things,” Amie Gordon, an associate professor of psychology at the University of Michigan, told me. If we had to sense our clothes on our bodies all day, for example, we’d constantly be distracted, she said. (This is actually a symptom of certain chronic disorders, like fibromyalgia—Lauren Zalewski, a writer who was diagnosed with both fibromyalgia and lupus 22 years ago, told me that it makes her skin sensitive to the touch, as if she constantly has the flu.) All that said, there are real costs to taking health for granted. For one, it can make you less healthy, if as a result you don’t take care of yourself. For another, maintaining some level of appreciation is a good way to avoid becoming an entitled jerk. Throughout the pandemic, for instance, there has been “this language around how the ‘only’ people dying are ‘old people’ or people with pre-existing conditions,” as if these deaths were more acceptable, Emily Taylor, a vice president for the Long-COVID Alliance, a group that advocates for research into post-viral illnesses, told me. Acknowledging that our own health is tenuous—and that certainly, many of us are going to get old—could counter this kind of callousness and encourage people to treat the elderly and those with chronic conditions or disabilities with more respect and kindness, Taylor argued. In my view, there’s something to be gained on an individual level, too. In recent years I’ve seen friends and loved ones deal with life-altering injuries and diagnoses. I know that one’s circumstances can turn on a phone call or a moment of inattention. To be healthy, to have basic needs met—to have life be so “normal” that it’s even a little boring—is a luxury. While I am living in those blessedly unremarkable times, I don’t want my fortune to escape my notice. When things are good, I want to know how good I’ve got it. [Read: How to be thankful when you don’t feel thankful] What I want, really, is to hold on to a sense of gratitude. In the field of psychology, gratitude can be something of a loaded term. Over the past decade or so, articles, podcast episodes, self-help books, research papers, celebrities, and wellness influencers alike have all extolled the benefits of being thankful. (Oprah famously kept a gratitude journal for more than a decade.) At times, gratitude’s popularity has been to its own detriment: The modern-day gratitude movement has been criticized for overstating its potential benefits and pushing a Western, wealthy, and privileged perspective that can seem to ignore the realities of extreme suffering or systemic injustices. It’s also annoying to constantly be told that you should really be more thankful for stuff. But part of the reason gratitude has become such a popular concept is due to bountiful research that does point to genuine emotional upsides. Feeling grateful has been associated with better life satisfaction, an increased sense of well-being, and a greater ability to form and maintain relationships, among other benefits. (The research on gratitude’s effects on physical health is inconclusive.) For me, though, the pull is less scientific and more commonsense anyway: Learning to genuinely appreciate day-to-day boons like having good health, or food in the fridge, seems like being able to tap into a renewable source of contentment. It’s always so easy to find stress in life. Let me remember the things to smile about, too. One way to make the most of gratitude may be to reframe how people tend to think of it. A popular misconception, Emmons told me over email, is that gratitude is a positive emotion that results from something good happening to us. (This might also be part of the reason it can be hard to appreciate conditions like health that for many people remain stable day after day.) Gratitude is an emotion, but it can also be a disposition, something researchers call “trait gratitude.” Some people are more predisposed to feeling thankful than others, by virtue of factors like genetics and personality. But Emmons says this kind of “undentable thankfulness” can also be learned, by developing habits that contribute to more of a persistent, ambient awareness, rather than a conditional reaction to ever-changing circumstances. What does this look like, practically speaking? “I don’t know that we can, with every breath we have every moment, feel grateful that we’re breathing. That’s a pretty tall order,” says Gordon. “But that’s not to say that you don’t build in a moment for it at some point in your day.” If you’re recovering from a cold, for example, you can practice pausing whenever you’re walking out the door to appreciate that your nose isn’t stuffy before just barreling on with life. Another tactic, from Emmons, is to reflect upon your worst moments, such as times you’ve been ill. “Our minds think in terms of counterfactuals,” he said, which are comparisons between the way things are and how they might have been. “When we remember how difficult life used to be and how far we have come, we set up an explicit contrast in our mind, and this contrast is fertile ground for gratefulness.” [Read: Don’t teach your kids to fear the world] You can also think of gratitude as an action, Emmons has written. This hews closer to the historical notion of gratitude, which as far back as the Roman days was associated with ideas like duty and reciprocity—when someone does something kind for us, we’re expected to return the favor, whether that’s thanking them, paying them back, or paying it forward. In that sense, being grateful for your body probably means doing your best to care for it (and, probably, refraining from risky behaviors like rolling the dice on discounted grocery-store sushi). In 2015, Lauren Zalewski, the writer with fibromyalgia, founded an online community that supports people living with chronic pain by helping them to cultivate a grateful mindset. She tells me that before her diagnosis, she took her health for granted and “beat her body up.” Now, she eats vegan, takes supplements, does yoga, stretches, sleeps more, and gets sun regularly—these are the small things she has personally found helpful for managing her constant pain. “So while I am a chronically ill person,” she muses, “I consider myself pretty healthy.” Looking back on my food-poisoning incident, I think I was primed to ruminate more deeply than usual on the topics of sickness and health. In the past two and a half years, I’ve watched COVID-19 show that anyone can get ill, perhaps seriously so. Now, as the head of the World Health Organization tells us that “the end is in sight” for the pandemic (and President Joe Biden controversially declares the pandemic over), it’s tempting to imagine that humanity is on the brink of waking up the morning after a hellish sickness. It’s probably delusional to hope that even a global pandemic could prompt some kind of long-term collective mental shift about the impermanence of health, and of life. I didn’t become a radically different person after recovering from puking my guts out a few months ago either. But maybe the simple act of remembering the health we still have in the pandemic’s wake can make a small difference in how we go forward—if not as a society, then at least as individuals. I’m sure I’ll never fully override my tendency to take my body for granted until it’s too late. But for now, each day, I still get the golden opportunity to try. And I’d like to take it. from https://ift.tt/7IND38u Check out http://natthash.tumblr.com When is the pandemic “over”? In the early days of 2020, we envisioned it ending with the novel coronavirus going away entirely. When this became impossible, we hoped instead for elimination: If enough people got vaccinated, herd immunity might largely stop the virus from spreading. When this too became impossible, we accepted that the virus would still circulate but imagined that it could become, optimistically, like one of the four coronaviruses that cause common colds or, pessimistically, like something more severe, akin to the flu. Instead, COVID has settled into something far worse than the flu. When President Joe Biden declared this week, “The pandemic is over. If you notice, no one’s wearing masks,” the country was still recording more than 400 COVID deaths a day—more than triple the average number from flu. This shifting of goal posts is, in part, a reckoning with the biological reality of COVID. The virus that came out of Wuhan, China, in 2019 was already so good at spreading—including from people without symptoms—that eradication probably never stood a chance once COVID took off internationally. “I don’t think that was ever really practically possible,” says Stephen Morse, an epidemiologist at Columbia. In time, it also became clear that immunity to COVID is simply not durable enough for elimination through herd immunity. The virus evolves too rapidly, and our own immunity to COVID infection fades too quickly—as it does with other respiratory viruses—even as immunity against severe disease tends to persist. (The elderly who mount weaker immune responses remain the most vulnerable: 88 percent of COVID deaths so far in September have been in people over 65.) With a public weary of pandemic measures and a government reluctant to push them, the situation seems unlikely to improve anytime soon. Trevor Bedford, a virologist at the Fred Hutchinson Cancer Center, estimates that COVID will continue to exact a death toll of 100,000 Americans a year in the near future. This too is approximately three times that of a typical flu year. I keep returning to the flu because, back in early 2021, with vaccine excitement still fresh in the air, several experts told my colleague Alexis Madrigal that a reasonable threshold for lifting COVID restrictions was 100 deaths a day, roughly on par with flu. We largely tolerate, the thinking went, the risk of flu without major disruptions to our lives. Since then, widespread immunity, better treatments, and the less virulent Omicron variant have together pushed the risk of COVID to individuals down to a flu-like level. But across the whole population, COVID is still killing many times more people than influenza is, because it is still sickening so many more people. Bedford told me he estimates that Omicron has infected 80 percent of Americans. Going forward, COVID might continue to infect 50 percent of the population every year, even without another Omicron-like leap in evolution. In contrast, flu sickens an estimated 10 to 20 percent of Americans a year. These are estimates, because lack of testing hampers accurate case counts for both diseases, but COVID’s higher death toll is a function of higher transmission. The tens of thousands of recorded cases—likely hundreds of thousands of actual cases every day—also add to the burden of long COVID. The challenge of driving down COVID transmission has also become clearer with time. In early 2021, the initially spectacular vaccine-efficacy data bolstered optimism that vaccination could significantly dampen transmission. Breakthrough cases were downplayed as very rare. And they were—at first. But immunity to infection is not durable against common respiratory viruses. Flu, the four common-cold coronaviruses, respiratory syncytial virus (RSV), and others all reinfect us over and over again. The same proved true with COVID. “Right at the beginning, we should have made that very clear. When you saw 95 percent against mild disease, with the trials done in December 2020, we should have said right then this is not going to last,” says Paul Offit, the director of the Vaccine Education Center at Children's Hospital of Philadelphia. Even vaccinating the whole world would not eliminate COVID transmission. This coronavirus has also proved a wilier opponent than expected. Despite a relatively slow rate of mutation at the beginning of the pandemic, it soon evolved into variants that are more inherently contagious and better at evading immunity. With each major wave, “the virus has only gotten more transmissible,” says Ruth Karron, a vaccine researcher at Johns Hopkins. The coronavirus cannot keep becoming more transmissible forever, but it can keep changing to evade our immunity essentially forever. Its rate of evolution is much higher than that of other common-cold coronaviruses. It’s higher than that of even H3N2 flu—the most troublesome and fastest-evolving of the influenza viruses. Omicron, according to Bedford, is the equivalent of five years of H3N2 evolution, and its subvariants are still outpacing H3N2’s usual rate. We don’t know how often Omicron-like events will happen. COVID’s rate of change may eventually slow down when the virus is no longer novel in humans, or it may surprise us again. In the past, flu pandemics “ended” after the virus swept through so much of the population that it could no longer cause huge waves. But the pandemic virus did not disappear; it became the new seasonal-flu virus. The 1968 H3N2 pandemic, for example, seeded the H3N2 flu that still sickens people today. “I suspect it’s probably caused even more morbidity and mortality in all those years since 1968,” Morse says. The pandemic ended, but the virus continued killing people. Ironically, H3N2 did go away during the coronavirus pandemic. Measures such as social distancing and masking managed to almost entirely eliminate the flu. (It has not disappeared entirely, though, and may be back in full force this winter.) Cases of other respiratory viruses, such as RSV, also plummeted. Experts hoped that this would show Americans a new normal, where we don’t simply tolerate the flu and other respiratory illnesses every winter. Instead, the country is moving toward a new normal where COVID is also something we tolerate every year. In the same breath that President Biden said, “The pandemic is over,” he went on to say, “We still have a problem with COVID. We’re still doing a lot of work on it.” You might see this as a contradiction, or you might see it as how we deal with every other disease—an attempt at normalizing COVID, if you will. The government doesn’t treat flu, cancer, heart disease, tuberculosis, hepatitis C, etc., as national emergencies that disrupt everyday life, even as the work continues on preventing and treating them. The U.S.’s COVID strategy certainly seems to be going in that direction. Broad restrictions such as mask mandates are out of the question. Interventions targeted at those most vulnerable to severe disease exist, but they aren’t getting much fanfare. This fall’s COVID-booster campaign has been muted. Treatments such as bebtelovimab and Evusheld remain on shelves underpublicized and underused.
from https://ift.tt/IaoOd2c Check out http://natthash.tumblr.com Several days after President Joe Biden declared that “the pandemic is over,” Anthony Fauci weighed in on the president’s controversial remarks during an interview at The Atlantic Festival, an annual live event in Washington, D.C. “He was saying we’re in a much better place with regard to the fulminant stage of the pandemic,” Fauci, the president’s chief medical adviser, said. “It really becomes semantics and about how you want to spin it.” By “the fulminant stage,” he meant the phase of the coronavirus pandemic during which we saw sudden, unpredictable spikes in disease and death. Thanks in large part to vaccines and antivirals, Fauci explained, we are now in a new phase, one in which even as case counts and hospitalization numbers fluctuate, death tolls hold fairly constant. The United States is no longer seeing thousands of deaths a day, and for many Americans, the risk of serious illness has declined dramatically. [Read: Are we really getting COVID boosters every year forever?] Still, the idea that declaring the pandemic over is truly a matter of semantics is a fraught message coming from the nation’s top public-health communicator. Especially during the rollout of the country’s first Omicron-specific boosters, some experts and insiders worry that the declaration could have real consequences: Six administration officials told The Washington Post that the president’s comments would likely make the tasks of persuading Americans to get shots and securing funding from Congress even more challenging than they already were. Fauci is not the only administration official who has walked back the president’s remarks, which came just a few days after Tedros Adhanom Ghebreyesus, the head of the World Health Organization, said, “We are not there yet, but the end is in sight.” According to Politico, Biden’s remarks caught senior administration health officials off guard, and indeed, in the following days, the White House clarified that the president was referring to public sentiment, not epidemiological reality. “The president,” Health and Human Services Secretary Xavier Becerra told Yahoo Finance, “was reflecting what so many Americans are thinking and feeling.” (In today’s interview, Fauci built on Ghebreyesus’s sentiment with a trademark Fauci-ism: Easing up on our efforts to fight the pandemic now, he said, would be like saying, “Just because I see what the finish line is, I’m gonna stop and get a hotdog. No, you don’t want to do that.”) Fauci himself is no stranger to the delicate art of discussing the pandemic’s end. In a late-April interview with PBS NewsHour, he said that the United States was “out of the pandemic phase,” only to reverse course the next day and say that the country (along with the entire world) was “still experiencing a pandemic.” Last month, when he announced that he would step down from his government position by the year’s end, Fauci said that he was not satisfied with this state of affairs. “I’m not happy about the fact that we still have 400 deaths per day,” he said. “We need to do much better than that … But I hope that over the next couple of months, things will improve.” So far, they have not. Statistically speaking, not a whole lot has changed since last month—or, for that matter, since late April: Average daily cases, which Fauci acknowledged are an underestimate, are up slightly, from about 50,000 to just under 60,000. The numbers of people hospitalized and in ICUs rose to a peak in late July and have slowly declined since. Death tolls have held fairly constant, as Fauci said, at about 400 a day. And modelers think they may remain there for a while yet. “I’ll say it even today,” Fauci repeated. “Four hundred deaths per day is not an acceptable number as far as I’m concerned.” [Read: Hundreds of Americans will die from COVID today] Meanwhile, America has done away with nearly all of its pandemic precautions, and Congress has declined to renew funding for vaccines and therapeutics. Whether or not the pandemic really is behind us, many people are living as if it is. An Axios/Ipsos poll released last week found that nearly half of Americans have returned to their pre-COVID lives, and 66 percent only occasionally or never wear a mask in public indoor spaces—by far the highest percentage that has given that answer since pollsters first posed the question in May 2021. In his wide-ranging interview at The Atlantic Festival, Fauci touched on a number of other topics, including his decades of work on the HIV/AIDS crisis, the politicization of public health, and how during the pandemic he’s become something of a larger-than-life figure—to both those who adore him and those who despise him. He laughed about the Dr. Fauci–themed candles, bobbleheads, and other paraphernalia that are sent to him. “That is as unrealistic in many respects as the craziness of people who want to decapitate me because I’m ruining the economy,” he said. Fauci also addressed the origins of the coronavirus, repeating his oft-cited position that while he keeps an open mind to theories that the virus leaked out of a lab in Wuhan, China, evidence points toward natural spillover from animals in a market in the city. It’s unlikely that we’ll ever get definitive proof in either direction, he said, but one thing that would help is greater transparency from the Chinese government, beginning with answers to the question of what exactly happened at the Wuhan wet market to which some of the earliest COVID cases have been traced. “The thing I think would be the best thing to do would be to open up those markets,” which are now closed to investigation, Fauci said. “If we were able to go and do surveillance easily in China, we would get a lot more information than we have now.” from https://ift.tt/bKRTDn5 Check out http://natthash.tumblr.com Many, many millions of years ago, an HIV-like virus wriggled its way into the genome of a floofy, bulgy-eyed lemur, and got permanently stuck. Trapped in a cage of primate DNA, the virus could no longer properly copy itself or cause life-threatening disease. It became a tame captive, passed down by the lemur to its offspring, and by them down to theirs. Today, the benign remains of that microbe are still wedged among a fleet of lemur genes—all that is left of a virus that may have once been as deadly as HIV is today. Lentiviruses, the viral group that includes HIV, are an undeniable scourge. The viruses set up chronic, slow-brewing infections in mammals, typically crippling a subset of immune cells essential to keeping dangerous pathogens at bay. And as far as scientists know, these viruses are pretty uniformly devastating to their hosts—or at least, that’s true of “all the lentiviruses that we know of,” says Aris Katzourakis, an evolutionary virologist at the University of Oxford. Which means, a long time ago, that lemur lentivirus was likely devastating too. But somewhere along the way, the strife between lemur and lentivirus dissipated enough that their genomes were able to mix. It’s proof, says Andrea Kirmaier, an evolutionary virologist at Boston College, that lentivirus and host “can coexist, that peace can be made.” Détentes such as these have been a fixture of mammals’ genomic history for countless millennia. Scientists have stumbled across lentiviruses embedded in the DNA of not just lemurs, but rabbits, ferrets, gliding mammals called colugos, and most recently, rodents—all of them ancient, all of them quiescent, all of them seemingly stripped of their most onerous traits. The infectious versions of those viruses are now extinct. But the fact that they posed an infectious threat in the past can inform the strategies we take against wild lentiviruses now. Finding these defunct lentiviruses tells us which animals once harbored, or might still harbor, active ones and could potentially pass them to us. Their existence also suggests that, in the tussle between lentivirus and host, the mammal can gain the upper hand. Lemurs, rabbits, ferrets, colugos, and rodents, after all, are still here; the ancient lentiviruses are not. Perhaps humans could leverage these strange genetic alliances to negotiate similar terms with HIV—or even extinguish the modern virus for good. When viruses assimilate themselves into animal genomes in a heritable way, a process called endogenization, scientists generally see it as “kind of a mistake,” says Daniel Blanco-Melo, a virologist at the Fred Hutchinson Cancer Center. Once cemented into one host, the virus can no longer infect others; much of its genome may even end up degrading over time, which is “certainly not what it evolved to do.” The blunders usually happen with retroviruses, which have RNA-based genomes that they convert into DNA once they enter cells. The flip allows the viruses to plug their genetic material into that of their host, which is then forced to manufacture its pathogen’s proteins alongside its own. Sometimes, a retrovirus will inadvertently stitch itself into the genome of a sperm or an egg, and its blueprints end up passed to its host’s progeny. If the melding doesn’t kill the animal, the once-pathogen can become a permanent fixture of the creature’s DNA. Over time, the human genome has amassed a horde of these viral hitchhikers. Our DNA is so riddled with endogenous retroviruses, ERVs for short, that they technically occupy more space in our genomes than bona fide, protein-manufacturing genes do. But on the long list of ERVs that have breached our borders, lentiviruses are conspicuously absent, in both our genomes and those of other animals; up until the mid-aughts, some scientists thought lentiviruses might not endogenize at all. It wasn’t a totally wonky idea: Lentiviruses have complex genomes, and are extremely picky about the tissues they invade; they’re also quite dangerous, not exactly the kind of tenant that most creatures want occupying their cellular real estate. Or perhaps, some researchers posited, lentiviruses were endogi-capable, but simply too young. If they had only begun infecting mammals within the past few hundreds of thousands of years, there might not have been time for such accidents to occur. Then, some 15 years ago, a team led by Katzourakis and Rob Gifford, an evolutionary virologist at the University of Glasgow, discovered an endogenous lentivirus called RELIK in the genomes of rabbits and then in hares, a hint that it had lodged itself in the animals’ mutual ancestor at least 12 million years before. In an instant, the lentivirus timeline stretched, and in the years since has kept growing. Scientists have now identified endogenous lentiviruses in a wide enough array of mammals, Gifford told me, to suspect that lentiviruses may have been a part of our history for at least 100 million years—entering our very distant ancestors’ genomes before the demise of the dinosaurs, before the rise of primates, before the land masses of North and South America kissed. “That tells us just how long virus and host have been connected,” Katzourakis told me. Through those eons, lentiviruses and the mammals they afflict have been evolving in concert—the pathogen always trying to infect better, the animal always trying to more efficiently head its enemy off. Knowing that lentiviruses are so deeply laced into our past can help us understand how other mammals are faring against the ones that are still around today. Two species of monkeys, sooty mangabeys and African green monkeys, have spent so much evolutionary time with a lentivirus called SIV—the simian version of HIV—that they’ve grown tolerant of it. Even when chock-full of virus, the monkeys don’t seem to suffer the severe, immunocompromising disease that the pathogen induces in other primates, says Nikki Klatt, a microbiologist and an immunologist at the University of Minnesota. The key seems to be in the monkeys’ ultra-resilient, fast-healing guts, as well as their immune systems, which launch more muted attacks on SIV, keeping the body from destroying itself as it fights. Such immunological shrugs could enable certain retroviruses to eventually endogenize, says Lucie Etienne, an evolutionary virologist at the International Center for Infectiology Research, in Lyon, France. Many mammals have also developed powerful tools to prevent lentiviruses from reproducing in their bodies in the first place—proteins that can, for instance, mess with viral entry or replication, or prevent new viral particles from busting out of already infected cells. Viruses, too, can mutate and evolve, far faster than animals can. That’s given the pathogens plenty of chances to counteract these defenses; HIV, for instance, has no trouble sidestepping or punching through many of the shields that human cells raise against it. [Read: Could genetics be the key to never getting the coronavirus?] But take the equivalent immune-defense protein from a monkey, and HIV “cannot degrade that,” says Michael Emerman, a virologist at the Fred Hutchinson Cancer Center. Other primates have had different infectious histories from ours, which have shaped their immune evolution in distinct ways. Studying those primates’ genomes—or maybe even the genomes of mammals that are carrying lentiviruses as neutered genetic cargo—might eventually inspire therapies that “augment our immunity,” Emerman told me. At the very least, such experiments could point scientists to lentiviruses’ common weak spots: the parts of the virus that ancient immune systems once targeted successfully enough that their hosts survived to tell the tale. “Evolution has already taught us the best places to target retroviruses,” says Maria Tokuyama, a virologist at the University of British Columbia. “Why not push for the types of interactions that we already know have worked?” Another, perhaps more radical idea might yet give way to an HIV cure: speeding the path toward endogenization—allowing lentiviruses to tangle themselves into our genomes, in the hopes that they’ll stay permanently, benignly put. “We could figure out a way to silence the virus, such that it’s there but we don’t care about it,” says Oliver Fregoso, a virologist at UCLA. One of the holy grails of HIV research has always been cooking up a vaccine that could prevent infection—an extraordinarily difficult thing to do. But if some sort of gentle armistice can be reached, Boston College’s Kirmaier told me, “maybe we don’t need to go that far.” Cedric Feschotte and Sabrina Leddy, virologists at Cornell, are among those pushing for such an intervention. They’re capitalizing on HIV’s tendency to go dormant inside cells, where it can hide from some of our most powerful antiretroviral drugs. The virus essentially “plays dead,” Leddy told me, then reawakens when the coast is clear. But if HIV could be silenced stably, its rampage would end when it jammed itself into the genome. “We’re hoping to emulate this natural path that ERVs have taken,” where they’re effectively locked in place, Leddy said. The imprisoned viruses could then be excised from cells with gene editing. The idea’s ambitious and still a way off from yielding usable treatments. But if it works, it could produce an additional perk. After setting up shop inside us, our viral tenants can start to offer their landlord benefits—such as fighting off their own active kin. In recent years, researchers have found that some animals, including cats, chickens, mice, primates, sheep, and even humans, have been able to co-opt proteins from certain endogenous retroviruses to create blockades against incoming viruses of similar ilk. Blanco-Melo and Gifford were part of a team that made one such discovery in 2017, describing an ERV that ancient monkeys and apes might have used to strip viral entryways off the surfaces of their cells. When encountering an ERV-ed-up host, the infectious, still-pathogenic version of that ERV would no longer have been able to get in.
from https://ift.tt/c3KdTQ4 Check out http://natthash.tumblr.com In the months since the Supreme Court overturned Roe v. Wade, demand for medication abortion has soared. The method already accounted for more than half of all abortions in the United States before the Court’s decision; now reproductive-rights activists and sites such as Plan C, which shares information about medication abortion by mail, are fielding an explosion in interest in abortion pills. As authorized by the FDA, medication abortion consists of two drugs. The first one, mifepristone, blocks the hormone progesterone, which is necessary for a pregnancy to continue. The second, misoprostol, brings on contractions of the uterus that expel its contents. The combination is, according to studies conducted in the U.S., somewhere between 95 percent and 99 percent effective in ending a pregnancy and is extremely safe. The second drug, misoprostol, can also safely end a pregnancy on its own. That method has long been considered a significantly less effective alternative to the FDA-approved protocol. But a growing body of research has begun to challenge the conventional thinking. In situations where people use pills to end a pregnancy at home, studies have found far higher rates of success for misoprostol-only abortions than were found in clinical settings. One recent study in Nigeria and Argentina showed misoprostol-only abortion to be 99 percent effective. Even before new restrictions began to ripple across the U.S., mifepristone—often referred to as “the abortion pill”—was tightly controlled by the FDA, which requires that the drug be dispensed only by doctors certified to prescribe it and only to patients who’ve signed an agency-approved agreement. As efforts to ban that drug intensify, the relative availability of misoprostol, which can be obtained at pharmacies in every state and prescribed by any doctor, could make misoprostol alone a more common option for women seeking abortions, legally or clandestinely. [Read: The future of abortion in a post-Roe America] Already, the Austria-based nonprofit Aid Access, which helps women in the U.S. order pills through the mail, helped thousands of women procure misoprostol-only regimens in the first months of the coronavirus pandemic, when shipments of mifepristone were disrupted. At least one U.S. abortion provider, Carafem, has been offering its patients a misoprostol-only option for close to two years, and other reproductive-health groups are now considering offering the same regimen. This approach follows a path that has been well established in places around the world, where mifepristone has been scarce or unavailable, but in the U.S., it represents a real shift in abortion provision. If in the past mifepristone has garnered the bulk of attention from politicians and the public in the U.S., that focus may owe in part to an oft-told story about the origins of “the abortion pill” and its lone inventor, the renowned French researcher Dr. Étienne-Émile Baulieu. The reality is that of the two drugs, misoprostol has always mattered more. For his work on mifepristone, Baulieu won one of the most prestigious prizes in medicine, whose recipients tend to be discussed as candidates for a Nobel Prize, and received France’s Legion of Honor. A lengthy profile in The New York Times Magazine called him “a different kind of scientist.” And though the chemists George Teutsch and Alain Belanger actually synthesized the compound, Baulieu became, to American audiences, “the father of the abortion pill.” Yet mifepristone is not, by itself, a highly effective abortifacient. Taken alone, the drug ends a pregnancy only about two-thirds of the time, which is why it has always been administered in combination with a prostaglandin—a drug that mimics the function of hormones that promote menstrual cramping and inflammation. For years, doctors in Europe had been administering mifepristone with a prostaglandin called sulprostone. The combination was nearly 100 percent effective, but required multiple in-person visits to a clinic or hospital because sulprostone could only be given by injection. “Everyone had been looking for a prostaglandin that didn’t have to be either injected or kept frozen,” says Beverly Winikoff, the founder of Gynuity Health Projects, whose research on medication abortion helped win FDA approval in the United States. In Brazil, women had already found one. No individual, or individuals, have ever been widely credited for that discovery, the way Baulieu is credited for mifepristone. But scholars agree that the practice began in the country’s impoverished northeast soon after the drug went on the market in 1986. Manufactured by G.D. Searle & Company, misoprostol was developed to treat stomach ulcers. To women in Brazil, where abortion was and remains severely restricted, the warning on the label, to avoid taking the drug while pregnant, advertised its potential as an abortifacient. And when they found the drug safer and more effective than other clandestine methods, misoprostol’s popularity exploded. (To state the obvious, no one should interpret drug warnings for pregnant people as covert advertisements for effective abortion alternatives.) Soon, doctors in Brazil reported seeing fewer women with severe abortion-related complications, and Brazilian researchers began documenting the drug’s off-label use. The first such study appeared in a 1991 letter to the editor of The Lancet: Helena Coelho and her colleagues at the University of Ceara had found that knowledge of misoprostol’s capacity to induce abortion had “spread rapidly” among both women and pharmacy personnel. But it had also reached government officials, who limited sales to authorized pharmacies and, in one state, banned misoprostol entirely. [Read: Women in the U.S. can now get safe abortions by mail] That same year, Baulieu, the French researcher, announced that he had devised a simpler way to use mifepristone—by combining it with misoprostol, which, unlike sulprostone, could be taken by mouth. Writing in The New England Journal of Medicine, Baulieu did reference misoprostol’s use in Brazil, but only as an example of what not to do. Citing anecdotal reports of cranial malformations in infants exposed to misoprostol in utero, he and colleagues claimed that administering misoprostol alone would risk “embryonic abnormalities,” adding that G.D. Searle “strongly disapproved” of the practice. The reports of cranial anomalies were never confirmed. But Searle did take pains to prevent the use of misoprostol for abortion, at one point publicly warning doctors in the U.S. against administering the drug to pregnant women. Over time, researchers established other important uses for misoprostol, such as treating miscarriage and preventing postpartum hemorrhage. Yet during the lifetime of its patent, the company refused to research or register the drug for any reproductive-health indication. Meanwhile, Brazilian newspapers had seized on the dangers that Baulieu had cited, fueling fears that failed abortions would create “a generation of monsters.” That in turn provided Brazilian authorities with a public-health rationale for regulating misoprostol as a controlled substance, the “possession or supply” of which carries penalties even more punitive than those for drug trafficking. But through informal networks, feminist activists continued helping women access both misoprostol and information about how to safely use it at home. More than three decades later, experts now credit Brazil as the birthplace of self-managed medication abortion. In the past few years, researchers have more formally documented what these informal networks established. In clinical trials, medication abortion with misoprostol alone was effective in completing first-trimester abortion roughly 80 percent of the time. As a rule, “We think about clinical-trials data as the gold standard,” says Caitlin Gerdts, a vice president at Ibis Reproductive Health and a senior author on the study in Nigeria and Argentina. Yet when researchers have examined misoprostol’s use in nonclinical settings, they have found far higher rates of success, with 93 to 100 percent of participants reporting complete abortions using only misoprostol. Given the many studies showing high effectiveness in self-managed settings, Gerdts says, “I think it’s time to reconsider the idea of the clinical trials data as being paramount.” One reason for the greater effectiveness of misoprostol alone in studies of self-managed abortion may have to do with how the studies were designed. “The problem with clinical trials is that often when we ask somebody to follow up in a week or two weeks, the body hasn’t had enough time to expel all of the products of conception,” says Dr. Angel Foster, a health-science professor at the University of Ottawa, whose work on the Thailand-Myanmar border was the first to rigorously investigate the effectiveness of misoprostol alone for abortion outside a formal health system. “If there’s a smudge on an ultrasound, it’s not that there’s a continuing pregnancy—it’s just debris. But rather than let the uterus absorb it or expel it, we do an evacuation procedure and we count it as a failure.” In studies of self-managed abortion, she says, the follow-up period tends to be longer—three or four weeks—and surgical intervention may not always be an option. “I do think because of the way it’s been treated in clinical trials, misoprostol has been defined as much less effective than we now believe it to be,” Foster says. “We talk about mifepristone as ‘the abortion pill,’ but I think it’s more appropriate to think of it as a pretreatment or an adjunct therapy. Because it’s really the misoprostol that’s doing the lion’s share of the work.” Elizabeth Raymond, a senior medical associate at Gynuity and the lead author of a systematic review of clinical trials on the use of misoprostol alone for early abortion, acknowledges that the clinical studies may have been too quick to intervene. But she says the shorter follow-up period was not without reason. Using ultrasound and a blood test to measure the amount of hCG, or human chorionic gonadotropin, doctors can diagnose a complete abortion “quite quickly, certainly within one or two weeks,” she says, “and the researchers wanted to do the assessments as soon as reasonable. They saw no sense in delaying.” Raymond suspects that misoprostol alone isn’t quite as effective as reported in the study in Nigeria and Argentina, in part because that study relied on its subjects to self-report whether the abortion was complete. “I think it’s an intriguing study, and it’s true that misoprostol alone is more effective than we thought,” she says, “but I think the general feeling is, if you can get both drugs, you should do that. The combination is more effective, and it may cause less cramping and bleeding.” Those side effects aren’t a safety concern, says Dr. Julie Amaon, the medical director of Just the Pill, which delivers abortion medication to people in Wyoming, Montana, Colorado, and Minnesota. “But it’s something to keep in mind,” she says, adding that anyone self-managing an abortion at home should adhere to the WHO-recommended protocol and follow up with a doctor, whether in person, by phone, or by text, to ensure that the process is complete. In the U.S., the FDA has approved only the two-drug regimen; although the WHO’s recommendations also suggest a preference for medication abortion with both drugs, that agency does recommend misoprostol-only abortion “in settings where mifepristone is not available.” [Read: The abortion pill can be used later than the FDA says] Right now, lawmakers across the U.S. are working to put both drugs out of reach. Fourteen states now fully or partially ban both mifepristone and misoprostol. Of the two drugs, though, misoprostol is still more easily obtained, either by prescription in pharmacies or via nonprofit groups in the U.S. and overseas. The Biden administration has said that it intends to maintain access to medication abortion, but so far has not acted to ease the stricter regulations on mifepristone. As long as those restrictions remain in place, ending a pregnancy with misoprostol alone could become a more common choice for people with few options. According to the Guttmacher Institute, a reproductive-health-research group that supports abortion rights, though the rate is difficult to measure, in the past self-managed abortions probably haven’t occurred in the U.S. on a large scale. But as conditions in red states come to resemble those in Brazil, the practice could become more and more common. In this way, says Mariana Prandini Assis, a Brazilian social scientist who has written extensively on abortion, the fall of Roe may well lead to the normalization in America of self-managed abortion with pills—a choice once thought of as a last resort or an act of desperation. For that reason, she says, the Brazilian women who pioneered the use of misoprostol for abortion should be considered the “other inventors of ‘the abortion pill.’” from https://ift.tt/JVv4HMs Check out http://natthash.tumblr.com Over the past week, an average of 491 Americans have died of COVID each day, according to data compiled by The New York Times. The week before, the number was 382. The week before that, 494. And so on. For the past five months or so, the United States has trod along something of a COVID-death plateau. This is good in the sense that after two years of breakneck spikes and plummets, the past five months are the longest we’ve gone without a major surge in deaths since the pandemic’s beginning, and the current numbers are far below last winter’s Omicron highs. (Case counts and hospital admissions have continued to fluctuate but, thanks in large part to the protection against severe disease conferred by vaccines and antivirals, they have mostly decoupled from ICU admissions and deaths; the curve, at long last, is flat.) But though daily mortality numbers have stopped rising, they’ve also stopped falling. Nearly 3,000 people are still dying every week. We could remain on this plateau for some time yet. Lauren Ancel Meyers, the director of the University of Texas at Austin’s COVID-19 Modeling Consortium, told me that as long as a dangerous new variant doesn’t emerge (in which case these projections would go out the window), we could see only a slight bump in deaths this fall and winter, when cases are likely to surge, but probably—or at least hopefully—nothing too drastic. In all likelihood, though, deaths won’t dip much below their present levels until early 2023, with the remission of a winter surge and the additional immunity that surge should confer. In the most optimistic scenarios that Meyers has modeled, deaths could at that point get as low as half their current level. Perhaps a tad lower. [Read: How did this many deaths become normal?] By any measure, that is still a lot of people dying every day. No one can say with any certainty what 2023 might have in store, but as a reference point, 200 deaths daily would translate to 73,000 deaths over the year. COVID would remain a top-10 leading cause of death in America, in this scenario roughly twice as deadly as either the average flu season or a year’s worth of motor-vehicle crashes. COVID deaths persist in part because we let them. America has largely decided to be done with the pandemic, even though the pandemic stubbornly refuses to be done with America. The country has lifted nearly all of its pandemic restrictions, and emergency pandemic funding has been drying up. For the most part, people have settled into whatever level of caution or disregard suits them. A Pew Research survey from May found that COVID did not even crack Americans’ list of the top 10 issues facing the country. Only 19 percent said that they consider it a big problem, and it’s hard to imagine that number has gone anywhere but down in the months since. COVID deaths have shifted from an emergency to the accepted collateral damage of the American way of life. Background noise. On one level, this is appalling. To simply proclaim the pandemic over is to abandon the vulnerable communities and older people who, now more than ever, bear the brunt of its burden. Yet on an individual level, it’s hard to blame anyone for looking away, especially when, for most Americans, the risk of serious illness is lower now than it has been since early 2020. It’s hard not to look away when each day’s numbers are identically grim, when the devastation becomes metronomic. It’s hard to look each day at a number—491, 382, 494—and experience that number for what it is: the premature ending of so many individual human lives. People grow accustomed to these daily tragedies because to not would be too painful. “We are, in a way, victims of our own success,” Steven Taylor, a psychiatrist at the University of British Columbia who has written one book on the psychology of pandemics and is at work on another, told me. Our adaptability is what allowed us to weather the worst of the pandemic, and it is also what’s preventing us from fully escaping the pandemic. We can normalize anything, for better or for worse. “We’re so resilient at adapting to threats,” Taylor said, that we’ve “even habituated to this.” [Read: America was in an early-death crisis long before COVID] Where does that leave us? As the nation claws its way out of the pandemic—and reckons with all of its lasting damage—what do we do with the psychic burden of a death toll that might not decline substantially for a long time? Total inurement is not an option. Neither is maximal empathy, the feeling of each death reverberating through you at an emotional level. The challenge, it seems, is to carve out some sort of middle path. To care enough to motivate ourselves to make things better without caring so much that we end up paralyzed. Perhaps we will find this path. More likely, we will not. In earlier stages of the pandemic, Americans talked at length about a mythic “new normal.” We were eager to imagine how life might be different—better, even—after a tragedy that focused the world’s attention on disease prevention. Now we’re staring down what that new normal might actually look like. The new normal is accepting 400 COVID deaths a day as The Way Things Are. It’s resigning ourselves so completely to the burden that we forget that it’s a burden at all. In the time since you started reading this story, someone in the United States has died of COVID. I could tell you a story about this person. I could tell you that he was a retired elementary-school teacher. That he was planning a trip with his wife to San Diego, because he’d never seen the Pacific Ocean. That he was a long-suffering Knicks fan and baked a hell of a peach cobbler, and when his grandchildren visited, he’d get down on his arthritic knees, and they’d play Connect Four, and he’d always let them win. These details, though hypothetical, might sadden you—or sadden you more, at least, than when I told you simply that since you started this story, one person had died of COVID. But I can’t tell you that story 491 times in one day. And even if I could, could you bear to listen? from https://ift.tt/QLfvn61 Check out http://natthash.tumblr.com |
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April 2023
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