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Now Is Not the Time to Forget About the AIDS Epidemic

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By SOMA SEN

I keep hearing the voices of colleagues and friends that have been part of the AIDS epidemic compare it to the current COVID-19 pandemic. In fact Dr. Kathy Creticos, Director of Infectious Disease at Howard Brown Health spoke about the politicization of both the pandemics. 

“Here we are in 2020 with this disease that kills people, that we don’t have any treatments for, that we really don’t understand the full manifestation and presentation biology of the virus,” Creticos said In the final segment of an interview with Contagion during International AIDS Society (IAS) AIDS 2020 Virtual Sessions. “We’re really dealing in the same situation as in the HIV epidemic.” 

Her words make me reflect on the levity with which the Raegan administration treated the AIDS epidemic and it’s parallel to the Trump administration’s treatment of the current pandemic. However, she makes an important distinction between the two when she says, “I think a lot of it has to do with the fact that COVID affects everybody, but HIV was certainly perceived as not affecting everybody.”

As an Asian American researcher with more than 15 years of experience in this area, whenever, I bring up the issue of the scourge of HIV/AIDS in our community, the common response both from inside and outside the community is “It’s not a problem in this community.” 

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Doctors and Democracy: Why Vote-By-Mail is Good Public Health

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Rob Palmer
Josh Hyman
Isaac Freedman

By ROB PALMER, ISAAC FREEDMAN, and JOSH HYMAN

Suppose tomorrow you were informed that patients could no longer have medications delivered to their homes. Thus, in the midst of the worst pandemic in recent history, your patients would have to go to pharmacies to get essential medications. Undoubtedly, you’d be puzzled, wondering why your patients must needlessly put themselves and others in harms’ way to care for their own health. In light of the change, you might even debate if it’s worth the risk of getting your own medications. 

Thankfully, the common-sense practice of delivering medication to people’s homes seems here to stay. Yet many people will face a similar issue on election day this November: Fifteen states severely restrict who can vote by mail. In these states, millions of citizens will be forced to choose between exercising their right to vote and safeguarding their own health. 

So long as SARS-CoV-2 remains a threat, in-person voting is a public health crisis. Unless we want to risk a spike in new COVID-19 cases, with the concomitant deaths and strain on the healthcare system, it is critical to ensure that anyone who wants to vote in the upcoming general election can use mail-in voting. Indeed, a peer-reviewed study published in May found a statistically significant increase in COVID-19 cases in the weeks after the Wisconsin primary, specifically in counties with higher in-person votes per voting location. The study also found a decrease in COVID-19 cases in counties with the highest rates of absentee ballots. Unsurprisingly, the study’s authors exhort policy makers to “expand the number of polling locations or encourage absentee voting for future elections.”

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Will the Public Health Emergency Policy Changes for Telehealth & Remote Monitoring Stick?

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By JESSICA DaMASSA, WTF HEALTH

With about one month left on the existing 90-day Public Health Emergency that’s eased regulations and improved reimbursement to help make telehealth, remote monitoring, and other virtual care services easier for providers to implement and patients to use, health tech companies across the US are wondering what it will take to make these changes permanent. One of digital health’s few ‘DC Insiders,’ Livongo Health’s VP of Government Affairs, Leslie Krigstein, gets us up-to-speed on what’s happening on Capitol Hill and what we can expect moving forward. What changes will (literally) require an Act of Congress? And what can be handled by HHS and CMS? From codes and co-pays to e-visits and licensing, Leslie breaks it down and tells us whether or not we can continue to expect a ‘health tech-friendly’ agenda in Washington DC.

TikTok Teen’s Time

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By KIM BELLARD

I knew about TikTok, but not “TikTok Teens.”  I was vaguely aware of K-Pop, but I didn’t know its fans had common interests beyond, you know, K-Pop.  I’d been tracking Gen X and Millennials but hadn’t really focused on Gen Z.  It turns out that these overlapping groups are quite socially aware and are starting to make their influence felt.  

I can’t wait for them to pay more attention to health care.  

This is the generation that has grown up during/in the wake of 9/11, the War on Terror, the War on Drugs, the 2008 recession, the coronavirus pandemic, and the current recession — not to mention smartphones, social media, online shopping, and streaming.  Greta Thunberg is Gen Z, as is Billie Eilish, each of whom is leading their own social movements.  This generation has a lot to protest about, and a lot of ways to do it.

They were in the news this past weekend due to, of all things, President Trump’s Tulsa rally.  His campaign had boasted about having a million people sign up for the rally, only to find that the arena was less than a third filled.  An outdoor rally for the expected overflow crowd was cancelled.  

It didn’t take long for the TikTok Teens/K-Pop fans to boast on social media about their covert — to us older folks — campaign to register for the rally as a way to gum up the campaign efforts.  Steve Schmidt, an anti-Trump Republican strategist, tweeted: “The teens of America have struck a savage blow against @realDonaldTrump.”

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Defund Health Care!

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By KIM BELLARD

In the wake of the protests related to George Floyd’s death, there have been many calls to “defund police.”  Those words come as a shock to many people, some of whom can’t imagine even reducing police budgets, much less abolishing entire police departments, as a few advocates do indeed call for.

If we’re talking about institutions that are supposed to protect us but too often cause us harm, maybe we should be talking about defunding health care as well.  

America loves the police.  They’re like mom and apple pie; not supporting them is essentially seen as being unpatriotic.  Until recent events, it’s been political suicide to try to attack police budgets.  It’s much easier for politicians to urge more police, with more hardware, even military grade, while searching for budget cuts that will attract less attention.  

It remains to be seen whether the current climate will actually lead to action, but there are faint signs of change.  The mayor of Los Angeles has promised to cut $150 million from its police budget, the New York City mayor vowed to cut some of its $6b police budget, and the Minneapolis City Council voted to “begin the process of ending the Minneapolis Police Department,” perhaps spurred by seeing the mayor do a “walk of shame” of jeers from protesters when he would not agree to even defunding it.  

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A Vigilante in Statistical Badlands

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By ANISH KOKA, MD

Something didn’t seem right to epidemiologist Eric Weinhandl when he glanced at an article published in the venerated Journal of the American Medical Association (JAMA) on a crisp fall evening in Minnesota. Eric is a smart guy – a native Minnesotan and a math major who fell in love with clinical quantitative database-driven research because he happened to work with a nephrologist early in his training. After finishing his doctorate in epidemiology, he cut his teeth working with the Chronic Disease Research Group, a division of the Hennepin Healthcare Research Institute that has held The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) contract for the United States Renal Data System Coordinating Center.  The research group Eric worked for from 2004-2015 essentially organized the data generated from almost every dialysis patient in the United States.  He didn’t just work with the data as an end-user, he helped maintain the largest, and most important database on chronic kidney disease in the United States. 

For all these reasons this particular study published in JAMA that sought to examine the association between dialysis facility ownership and access to kidney transplantation piqued Eric’s interest.  The provocative hypothesis is that for-profit dialysis centers are financially motivated to keep patients hooked to dialysis machines rather than refer them for kidney transplantation.  A number of observational trials have tracked better outcomes in not-for-profit settings, so the theory wasn’t implausible, but mulling over the results more carefully, Eric noticed how large the effect sizes reported in the paper were. Specifically,  the hazard ratios for for-profit vs. non-profit were 0.36 for being put on a waiting list, 0.5 for receiving a living donor kidney transplant, 0.44 for receiving a deceased donor kidney transplant.  This roughly translates to patients being one-half to one-third as likely to get referred for and ultimately receiving a transplant.  These are incredible numbers when you consider it can be major news when a study reports a hazard ratio of 0.9.  Part of the reason one doesn’t usually see hazard ratios that are this large is because that signals an effect size that’s so obvious to the naked eye that it doesn’t require a trial. There’s a reason there are no trials on the utility of cauterizing an artery to stop bleeding during surgery. 

But it really wasn’t the hazard ratios that first struck his eye.  What stuck out were the reported event rates in the study. 1.9 million incident end-stage kidney disease patients in 17 years made sense. The exclusion of 90,000 patients who were wait-listed or received a kidney transplant before ever getting on dialysis, and 250,000 patients for not having any dialysis facility information left ~1.5 million patients for the primary analysis.  The original paper listed 121,000 first wait-list events, 23,000 living donor transplants and ~50,000 deceased donor transplants.  But the United Network for Organ Sharing (UNOS), an organization that manages the US organ transplantation system, reported 280,000 transplants during the same period. 

The paper somehow was missing almost 210,000 transplants.

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Is the COVID-19 Antibody Seroprevalence in Santa Clara County really 50-85 fold higher than the number of confirmed cases?

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By CHRISTOS ARGYROPOULOS

I am writing this blog post (the first after nearly two years!) in lockdown mode because of the rapidly spreading SARSCoV2 virus, the causative agent of the COVID19 disease (a poor choice of a name, since the disease itself is really SARS on steroids).

One interesting feature of this disease is that a large number of patients will manifest minimal or no symptoms (“asymptomatic” infections), a state which must clearly be distinguished from the presymptomatic phase of the infection. In the latter, many patients who will eventually go on to develop the more serious forms of the disease have minimal symptoms. This is contrast to asymptomatic patients who will never develop anything more bothersome than mild symptoms (“sniffles”), for which they will never seek medical attention. Ever since the early phases of the COVID19 pandemic, a prominent narrative postulated that asymptomatic infections are much more common than symptomatic ones. Therefore, calculations such as the Case Fatality Rate (CFR = deaths over all symptomatic cases) mislead about the Infection Fatality Rate (IFR = deaths over all cases). Subthreads of this narrative go on to postulate that the lockdowns which have been implemented widely around the world are overkill because COVID19 is no more lethal than the flu, when lethality is calculated over ALL infections.

Whereas the politicization of the lockdown argument is of no interest to the author of this blog (after all the virus does not care whether its victim is rich or poor, white or non-white, Westerner or Asian), estimating the prevalence of individuals who were exposed to the virus but never developed symptoms is important for public health, epidemiological and medical care reasons. Since these patients do not seek medical evaluation, they will not detected by acute care tests (viral loads in PCR based assays). However such patients, may be detected after the fact by looking for evidence of past infection, in the form of circulating antibodies in the patients’ serum. I was thus very excited to read about the release of a preprint describing a seroprevalence study in Santa Clara County, California. This preprint described the results of a cross-sectional examination of the residents in the county in Santa Clara, with a lateral flow immunoassay (similar to a home pregnancy kit) for the presence of antibodies against the SARSCoV2 virus. The presence of antibodies signifies that the patient was not only exposed at some point to the virus, but this exposure led to an actual infection to which the immune system responded by forming antibodies. These resulting antibodies persist for far longer than the actual infection and thus provide an indirect record of who was infected. More importantly, such antibodies may be the only way to detect asymptomatic infections, because these patients will not manifest any symptoms that will make them seek medical attention, when they were actively infected. Hence, the premise of the Santa Clara study is a solid one and in fact we need many more of these studies. But did the study actually deliver? Let’s take a deep dive into the preprint.

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COVID-19 Pandemic Puts Rural and Tribal Communities at Great Risk

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Connie Chan
Brooke Warren
Phuoc Le

By PHUOC LE MD, CONNIE CHAN and BROOKE WARREN

Since the World Health Organization (WHO) officially declared COVID-19 a pandemic on March 11, 2020, we have been changing our daily lives to protect the highest-risk populations: older adults and people with chronic medical conditions. We are asked to follow sensible guidelines like social distancing and thorough hand-washing. Although one may have a gut-reaction to put their own safety at the forefront during these times of crisis, it is essential that we are taking the necessary steps to protect populations with additional vulnerabilities – rural tribal communities.

With the announcement that COVID-19 reached the Confederated Tribes of Umatilla Indian Confederation on March 9, 2020, it was evident the virus would not stay confined to urban and metropolitan centers like some previously predicted. The experience in China with COVID-19 clearly reflects the vulnerability of rural communities because many people travel routinely from urban to rural. Experts who conducted an epidemiological study in Hubei province, the initial epicenter of the COVID-19 pandemic, noted in their report: “…most public medical resources are concentrated in cities but are relatively scarce in rural areas. Therefore, prevention and treatment of 2019-nCoV in rural areas will be more challenging if new phases of the epidemic emerge.”

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Still Fighting the Wrong Wars

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By KIM BELLARD

What do the coronavirus and Navy ships have in common?  For that matter, what do our military spending and our healthcare spending have in common?  More than you might think, and it boils down to this: we spend too much for too little, in large part because we tend to always be fighting the wrong wars.  

Photo by STR/AFT via Getty Images

I started thinking about this a couple weeks ago due to a WSJ article about the U.S. Navy’s “aging and fragmented technology.”  An internal Navy strategy memo warned that the Navy is “under cyber siege” by foreign adversaries, leaking information “like a sieve.”  It grimly pointed out:

Our adversaries gain an advantage in cyberspace through guerrilla tactics within our defensive perimeters.  Once inside, malign actors steal, destroy and/or modify critical data and information. 

This is the Navy, after all, that proudly tried to modernize by installing touch screen technology on some of its ships, only to have the disaster that hit the USS McClain.  Its vaunted Integrated Bridge and Navigation System was, ProPublica found, “was a welter of buttons, gauges and software that, poorly understood and not surprisingly misused, helped guide 10 sailors to their deaths.”  And that wasn’t the only technology-enabled naval disaster in recent years.

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A System that Fails Migrant and Seasonal Agricultural Workers

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Connie Chan
Brooke Warren
Phuoc Le

By PHUOC LE, MD, CONNIE CHAN, and BROOKE WARREN

I recently took care of Rosaria[1], a cheerful 60-year-old woman who came in for chronic joint pain. She grew up in rural Mexico, but came to the US thirty years ago to work in the strawberry fields of California. After examining her, I recommended a few blood tests and x-rays as next steps. “Lo siento pero no voy a tener seguro hasta el primavera — Sorry but I won’t have insurance again until the Spring.” Rosaria, who is a seasonal farmworker, told me she only gets access to health care during the strawberry season. Her medical care will have to wait, and in the meantime, her joints continue to deteriorate.

Migrant and seasonal agricultural workers (MSAW) are people who work “temporarily or seasonally in farm fields, orchards, canneries, plant nurseries, fish/seafood packing plants, and more.”[2] MSAW are more than temporary laborers, though— they are individuals and families who have time and time again helped the US in its greatest time of need. During WWI, Congress passed the Immigration and Nationality Act of 1917[3] because of the extreme shortage of US workers. This allowed farmers to bring about 73,000 Mexican workers into the US. During WWII, the US once again called upon Mexican laborers to fill the vacancies in the US workforce under the Bracero Program in 1943. Over the 23 years the Bracero Program was in place, the US employed 4.6 million Mexican laborers. Despite the US being indebted to the Mexican laborers, who helped the economy from collapsing in the gravest of times, the US deported 400,000 Mexican immigrants and Mexican-American citizens during the Great Depression.

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