Health Systems

Pertussis (Whooping Cough): Resurgence of a Deadly Disease

A recent article in the journal Pediatrics reported a surge in cases of pertussis, commonly known as whooping cough. Unfortunately the article is only available to subscribers to the journal. Here is a link to a description of that article in a medical news service called Medscape. Pertussis is a bad disease. See below.

History of pertussis

Pertussis is caused by a bacterium, Bordatella Pertussis. Prior to the advent of pertussis vaccines, pertussis was one of the leading US causes of death of children under 5 years of age. There were over 200,00 cases and 9000 childhood deaths in the US from pertussis every year (a rate of 4.5 deaths per thousand children). Pertussis was especially lethal in infants, and was probably the leading cause of death in this age group. Worldwide, pertussis prior to vaccines was just as bad as in the US or worse. Worldwide there were 24.1 million cases and 160,700 deaths in children under five every year.

Epidemiology of pertussis

In un-immunized people pertussis is extremely infectious, almost as much as measles. One infected person on average infects 12-18 other people. In adolescents and adults pertussis is unlikely to cause death or hospitalization, but it is an extremely unpleasant disease. Older children and adults have paroxysms of coughing, followed by a loud, wheezing inspiration (the whoop of whooping cough). These symptoms can last for weeks or months. The coughing is sometimes so severe that people break ribs or develop hernias. Treatment with antibiotics is used to prevent transmission. Antibiotics are also given to contacts to prevent them from getting infected. Antibiotics do not have any effect on the length or severity of the disease. Those who have symptomatic pertussis just have to wait for it to go away. Here is an audio file of a child with pertussis. You should listen to it realize what a severe disease pertussis is. Let me warn you that it is distressing to listen to.

Pertussis vaccines

Whole cell pertussis vaccines

Whole cell pertussis vaccine combined with vaccines for tetanus and diphtheria was widely introduced and given to infants and children in the 1940’s. This was a highly effective vaccine. It not only prevented disease, but also prevented colonization and therefore stopped transmission of pertussis. It reduced the cases of pertussis by 75%. Unfortunately, the whole cell vaccine had rare but concerning side effects.These iincluded persistent crying, febrile seizures and hypotonic-hypoeresponive episodes (HHE). Children with HHE had sudden onset of reduced muscle tone, decreased responsiveness to verbal or other stimuli, and change in skin color (pallor or cyanosis) that occurred shortly after vaccination. These adverse events, though temporary were obviously distressing to parents. There were also rare cases of encephalopathy (Inflammation of the brain) that caused permanent disability. These cases were so rare that it was impossible to know whether these permanent disabilities were caused by the vaccine, or were simply associated but not causal. Controversy over whether the vaccine had any role in these cases continues even today.

Acellular pertussis vaccine

Because of the rare but distressing side effects of whole cell pertussis vaccine, a new vaccine was developed that had components of the pertussis bacterium, but not whole cells. This was called the acellular vaccine. This acellular vaccine had far fewer and milder adverse reactions than the whole cell vaccine. The combination vaccine is abbreviated DTaP (diptheria-tetanus-acellular pertussis). This is the vaccine used for children today. Unfortunately the acellular pertussis vaccine is less effective than the previous whole cell vaccine. It does prevent children from getting ill with pertussis, but it does not prevent colonization of the nose and throat. Children who are colonized in this way are not sick, but they are infectious and can pass on the virus to other children and adults. This keeps the bordatella pertussis bacteria circulating in communities.

Waning Immunity

Neither the whole cell nor the acellular vaccine provides lifetime immunity, unlike the Measles-Mumps-Rubella vaccines, which do provide lifetime immunity. Even people who have pertussis do not get lifetime immunity. Immunity from vaccines and infection wane over time. It appears that the acellular pertussis vaccine gives good protection from getting sick from pertussis for about 4 years, and starts to wane after that. The result is that we still see pertussis even in fully immunized children and adults starting about 5 years after the last routine immunization, which occurs at between 4 and 6 years of age. A booster TDaP is also recommended at around 12 years of age. This means that the most vulnerable children, that is children 5 or under are protected from getting ill from pertussis. Infants below 2 months of age (too early for vaccination) are protected by the recommendation that all pregnant women get a booster TDaP vaccine in the third trimester of every pregnancy. Anyone who is going to have extended contact with an infant under 2 months should also get a booster TDaP.

Risk of resurgence of severe pertussis

Bordatella pertussis continues to circulate in communities because of colonization of immunized children. Resistance to vaccinating children with DTap can quickly cause a resurgence of pertussis in infants and young children. This would be disastrous and is already happening. In 2024, there were 35,435 documented cases of pertussis across the U.S., including 655 in Colorado. That was a huge jump over the 7063 cases in all of 2023. Large states, including New York and California, logged high numbers of pertussis infections in 2024. So did some less-populated states like Idaho, Washington and Oregon, each of which reported more than 1,000 cases of pertussis. There were 10 deaths from pertussis in 2024. Cases are on track to be even higher in 2025.

Research on new pertussis vaccines

The search is on for a new pertussis vaccine that prevents colonization but that also does not cause the distressing side effects that happened with the whole cell pertussis vaccine. The best candidate at the moment is a live vaccine that has been genetically modified to eliminate the toxins produced by the bacterium. If and when approved this vaccine will be administered nasally. In rhesus monkeys it prevented colonization with bordatella pertussis and had no significant side effects. It is currently in phase 3 trials in humans.

Bottom Line

Pertussis is a serious disease and is life threatening to infants and young children. The severity and duration of pertussis are not affected by antibiotics that are given to limit the spread of the disease. The only effective treatment of pertussis is prevention through immunization. Acellular pertussis vaccine is much safer but also less effective than the old whole cell vaccine. It allows bordatella pertussis to continue to circulate in communities. Resistance to immunization of children has led to a marked increase in serious pertussis infections in 2024 with 10 deaths reported. Pertussis cases are on track to be even higher in 2025. A promising new attenuated live pertussis vaccine is in phase 3 trials and may soon be approved assuming research funding is not withheld by the Trump administration.

Assault on Science

I recently read a very interesting book called Science Under Siege. The authors are Peter Hotez, pediatrician and vaccine researcher at Texas Children’s Hospital in Houston, Texas and Michael Mann, the prominent climate researcher who found strong evidence for manmade global warming. It is an excellent book and I highly recommend reading it. Public confidence in science has significantly declined since the pandemic, but the majority of polls continue to show strong support for science (see this link to the Pew Research Center). On the other hand, there is a well funded, sophisticated effort to discredit science and scientists. Many people do not understand how science is done, how it is funded, and its contributions to society. In this post I will write about all of those things, as well as the people and groups who are funding the assault on science and scientists.

What is the Scientific Method?

The scientific method is a systematic way to advance knowledge. Here are the steps of the scientific method: This excellent formulation is copied from a webpage from American Journal Experts.

  1. Define a question: Constructing a clear and precise problem statement that identifies the main question or goal of the investigation is the first step. The wording must lend itself to experimentation by posing a question that is both testable and measurable.
  2. Gather information and resources: Researching the topic in question to find out what is already known and what types of related questions others are asking is the next step in this process. This background information is vital to gaining a full understanding of the subject and in determining the best design for experiments. 
  3. Form a hypothesis: Composing a concise statement that identifies specific variables and potential results, which can then be tested, is a crucial step that must be completed before any experimentation. An imperfection in the composition of a hypothesis can result in weaknesses to the entire design of an experiment.
  4. Perform the experiments: Testing the hypothesis by performing replicable experiments and collecting resultant data is another fundamental step of the scientific method. By controlling some elements of an experiment while purposely manipulating others, cause and effect relationships are established.
  5. Analyze the data: Interpreting the experimental process and results by recognizing trends in the data is a necessary step for comprehending its meaning and supporting the conclusions. Drawing inferences through this systematic process lends substantive evidence for either supporting or rejecting the hypothesis.
  6. Report the results: Sharing the outcomes of an experiment, through an essay, presentation, graphic, or journal article, is often regarded as a final step in this process. Detailing the project’s design, methods, and results not only promotes transparency and replicability but also adds to the body of knowledge for future research.
  7. Retest the hypothesis: Repeating experiments to see if a hypothesis holds up in all cases is a step that is manifested through varying scenarios. Sometimes a researcher immediately checks their own work or replicates it at a future time, or another researcher will repeat the experiments to further test the hypothesis.

This is clearly not an easy process. There must be transparency at every step so that other researchers can evaluate the methods and repeat the experiments to be sure they get the same results.

How are scientific findings published?

Once results are obtained from a scientific study, a paper describing the results is prepared by the authors. There are usually several authors for any scientific paper. The principal investigator prepares the initial draft and sends it to his/her colleagues. There are usually many drafts and modifications before a final paper is ready to submit. The final paper as agreed upon by the authors is submitted to a peer reviewed scientific journal. The paper is first reviewed by the editor of the journal. If the editor feels there is significant problem with the paper or if he/she thinks it is not appropriate for readers of the journal then the editor can reject the paper. If the paper passes editorial review, then it is sent to at least 3 scientists in the same field for evaluation. These are called peer reviewers. Each reviewer writes a review of the paper, which are sent to the editors of the journal and to the authors of the paper. The reviewers often suggest modifications to the paper. The journal editor may reject the paper based on the reviewers comments, may suggest that modifications be made and the paper be resubmitted, or much more rarely may accept the paper for publication based on positive reviews from the peer reviewers.

As I can attest from my own numerous scientific publications, the acceptance of a paper by a peer reviewed journal is a long and rigorous process. I have also had papers rejected by the editor and after review by peer reviewers.

Very rarely, investigators publish papers based on fraudulent data. This is usually discovered eventually and the editors then publicly retract the paper. This happened to Andrew Wakefield with his publications about a connection between MMR vaccine and autism in the medical journal the Lancet. All of these papers were found to be based on fraudulent data and were retracted. He actually lost his medical license in the UK because of this. Subsequent large very well designed studies showed no connection between vaccines and autism. This is an example of how the scientific method advances knowledge.

Double blind randomized controlled trials

This kind of trial is the gold standard of scientific research. Subjects for the research are recruited and are randomly assigned to either the experimental group or the control group. Great care is taken to be sure that the selection for either group is completely random. The size of the two groups has to be large enough to ensure that any factors that might bias the results should be balanced out in the two groups by the random selection. The intervention being tested (usually a medicine or other treatment) is given to the experimental group and an identical placebo (inactive) pill or intervention is given to the control group. The investigators administering the treatment don’t know whether they are administering the experimental treatment or the placebo, and they also don’t know which people are in the experimental or the control group. That’s why this kind of trial is called “double blind.” The code for which patients got the experimental treatment and which got the placebo treatment is not broken until the end of the trial. Double blind randomized controlled trials give the most reliable bias free results, but they are very expensive to conduct. There are other kinds of trials as well, because not every research question lends itself to a randomized controlled trial. Almost all well designed research is expensive to conduct. In the next section I will write about how research is funded.

How research is funded

Most research is conducted at academic institutions. Funding for research has to cover the salaries of the researchers and their staff, and the research infrastructure of the institution. All of that is very expensive. Almost all research is funded by grants, either federal (National Institutes of Health (NIH) or National Science Foundation (NSF) or private foundations. Most large grants are federal.

Grant application process

Some grants are designed for application by institutions themselves but most grants are applied for by research scientists. Application for a scientific grant is a major involved process. There is a 12 page limit for the main application for an NIH grant, but supplementary documents required like budgets and investigator bio sketches can run to 150 pages. Each federal grant application is evaluated by a study section composed of eminent scientists in the field. Funding is only available for a small number of grants so most grant applications are rejected. If the study section gives the grant a good score the grant may be awarded to the institution or the investigator. Even if the grant is awarded to the investigator, the grant money is administered by the institution. It never goes directly to the investigator. A percentage of each grant is used by the institution to pay for its research infrastructure. The rest is used by the institution to pay the investigator’s salary and to pay for the costs of the research. Private foundations each have their own rules for grant applications, but they are also difficult to get. Grants from private foundations are usually, but not always smaller than federal grants.

Are scientific results truth?

Science is a systematic way to search for truth about how the world works and how we can successfully manipulate it to get desired results. It is a mistake to put too much emphasis on the results of one study. When many studies find the same or similar results, we have increasing confidence that the results represent truth, but never absolute. Scientific results are always to some degree provisional. That does not mean they are not useful.

Benefits of science to society

Rather than enumerate the benefits, here is a link to a University of California website that explains the benefits much better than I can. As the webpage points out, the benefits of science to society are substantial.

Attacks on science and scientists

Because science is a systematic search for knowledge, the findings of some scientific studies are often inconvenient for certain groups or individuals with ideological beliefs. Some scientific findings also threaten some wealthy people whose wealth comes from industries that scientific results threaten. The fossil fuel industry, for example, has created huge wealth for companies and individuals. Climate science has clearly shown that CO2 emissions from fossil fuels is causing rapid global warming that will be catastrophic if CO2 emissions are not drastically reduced. Scientific research has also been instrumental in developing alternative energy sources such as solar, wind, and others that have become economically viable. The fossil fuel industry has invested tremendous amounts of money to attack these findings. They work at creating the idea that these well validated scientific results are controversial. They hire people with academic credentials who question that CO2 emissions are causing climate change. This kind of opposition research is rarely published in peer reviewed journals. Front groups are created as well as PACs to lobby legislators that are funded without revealing the source of those funds. This is so-called dark money, but it has been shown to come primarily from people who get their wealth from fossil fuels. Koch industries is a good example. There also is a large industry that promotes supplements, vitamins, and alternative medicines that have no basis in science. This industry attacks legitimate health research as well as proven preventive treatments, particularly vaccines for children and adults.

These attacks on science are sophisticated, coordinated, and so far unfortunately very effective. In addition prominent scientists have been subpoenaed to appear before hostile congressional committees, harassed and threatened with arrest and/or bodily harm. These things are well documented in the book by Hotez and Mann.

Bottom Line

Science is a systematic way to advance knowledge. As results are validated by multiple well designed studies we find out more about the world and how to manipulate it to our benefit. Publication of scientific results in peer reviewed journals is a difficult and rigorous process. Almost all science is done in academic institutions and is almost entirely funded by federal grants and grants from private foundations. Obtaining grant funding is also a very rigorous process. Grants are administered by institutions and grant money is never given directly to investigators.

Wealthy people who stand to lose money because of scientific findings are conducting a sophisticated, well funded campaign to attack scientific results they don’t like and to discredit, harass, and threaten legitimate scientists.

mRNA Vaccines – Truth vs Misinformation

Robert F Kennedy Jr has stopped funding for research to develop new mRNA vaccines because he says they don’t work well for respiratory diseases. He also claims that mRNA vaccines induce mutations in respiratory viruses. He says that even one mutation makes mRNA vaccines ineffective. Here is a link to his video post on X where he makes these claims. He also claims that he has consulted science experts who agree with him about mRNA vaccines.

In this post I will review the real science about mRNA vaccine technology, how mRNA vaccines differ from traditional vaccine technology and also discuss how viruses mutate and why (spoiler alert: they don’t mutate because of mRNA vaccines). Here is a link to a STAT news article that deconstructs Kennedy’s arguments: Kennedy’s case against mRNA vaccines collapses under his own evidence.

Traditional vaccines

There are two types of traditional vaccines, live vaccines and killed vaccines. Both types require growing the target virus in tissue culture. In a live vaccine, the virus is weakened so that infection does not cause the disease when injected into people with healthy immune systems. The MMR vaccine is an example of a live vaccine. It contains weakened strains of measles virus, mumps virus and rubella virus. Killed vaccines use some proteins from the virus to sensitize the immune system to kill the virus when it detects those proteins. the DPT vaccine is an example of a killed vaccine. It contains protein fragments from the diphtheria virus, pertussis (whooping cough) virus and tetanus virus. It is very labor intensive to create a vaccine using these traditional methods. To make enough weakened virus or virus protein fragments to immunize a large population takes a lot of tissue culture and a long time. It usually takes 10-15 years of research and development before new traditional vaccines are ready to use. Manufacturing those already approved vaccines is still very labor intensive.

What is mRNA?

The m in mRNA stands for messenger RNA. The genes in your DNA can’t do anything by themselves. They don’t directly make proteins. Instead they code for messenger RNA. Messenger RNA does the work of making proteins that determine hair color, eye color and all other genetic traits. Each type of messenger RNA is specific for a particular protein. Messenger RNA does not last very long in animal (or human) cells. It lasts from a few minutes to a few hours and then it disappears. The DNA makes more messenger RNA as needed.

How does an mRNA vaccine work?

The advantage of an mRNA vaccine is that the body does all the work of manufacturing the virus protein fragment. No intensive tissue culture is required. mRNA is synthesized in a laboratory. The synthesized mRNA codes for a specific virus protein. In the case of the COVID mRNA vaccine, the mRNA codes for the spike protein. When that mRNA is injected into a muscle, the muscle cells start to make many copies of the spike protein. The immune system recognizes this as a foreign protein and makes antibodies against it as well as sensitizing killer lymphocytes so that they recognize the protein too. Just like the body’s own mRNA, the injected mRNA only lasts for a few minutes to a few hours and then disappears. It never changes the DNA in the cell, because DNA makes mRNA, not the other way around.

How does mRNA vaccine speed up the vaccine development process?

We now have the technology to rapidly determine all the genetic code of a new virus. That sequencing can happen within a few weeks of discovering a new virus. That genetic code allows us to determine which proteins make up the virus particle. We can then decide which viral protein is the best to stimulate immunity to the virus and synthesize an mRNA molecule that will make that protein in human muscle cells. That process is much faster than the traditional method. We had an effective mRNA COVID vaccine within a year of the beginning of the pandemic. That is an absolutely unprecedented time scale in new vaccine development.

Do mRNA vaccines induce mutation in viruses

This is what Kennedy claims and it is absolutely not true. Some viruses, like COVID and flu virus mutate frequently and some like measles virus and polio virus are stable and do not mutate or mutate rarely.. The mutation rate depends on the nature of the virus, not on the vaccine. All vaccines, not just mRNA vaccines for viruses that mutate frequently lose some efficacy over time and the vaccine has to be modified. The viruses that mutate frequently would continue to do that whether a vaccine is available or not. Vaccines do not make viruses mutate faster. Most mutations make the virus less infectious, but the occasional mutation makes the virus more infective. The mutations that are more infective become more frequent and crowd out the older versions of the virus. Measles and polio vaccines prevent infection because the measles and polio viruses stay exactly the same over time.

Safety of mRNA vaccines

The only mRNA vaccine that we have extensive experience with are the ones developed for COVID. Mild reactions were common (sore arm, fever. myalgias) more commonly with the second dose. Rare cases of myocarditis (inflammation of the heart muscle) were reported in younger people. All of these were transient and completely resolved. There is a very tiny chance of having a severe allergic reaction to the vaccine. Out of 8 billion doses administered death due to allergic reaction occurred in 14 people. That is a risk of death of 1.75 x10-9 (1.75 preceded by 9 zeros!).That risk is much, much smaller than the risk of being killed in an auto accident. The risk of death from COVID in unvaccinated people is of course much higher. mRNA vaccines are safe with a minuscule risk of severe side effects.

Why do people still get influenza or COVID even after they have been vaccinated.

Antibodies induced by flu and COVID vaccines are in the blood stream and not as much on the mucus membranes. Although vaccinated people are less likely to get infected with influenza or COVID, the protection rate from infection is less than 100%. Vaccinated people can still get infected with influenza or COVID. The vaccine induced antibodies immediately start fighting the infection. This means that vaccinated people who get infected are much less likely to get severe infections, much less likely to be hospitalized and are much more likely to have mild symptoms. You get a great deal of protection from the vaccine even if you get infected with the virus. Kennedy asserts that if you get infected with the virus, then the vaccine does not work. That is poppycock!

Research into new mRNA vaccines

Researchers can now use AI to develop universal mRNA vaccines for COVID and influenza that could develop immunity to multiple genetic variants at the same time. This technology would mean that new vaccines don’t have to be developed every year to deal with new genetic variants. This technology also might make it possible to develop vaccines for malaria and leptospirosis. It may also be possible to use this technology to develop vaccines that sensitize the immune system to destroy cancer cells.

All of the federal funding for research using this promising technology has been blocked by HHS secretary Robert F Kennedy Jr.

Bottom Line

mRNA vaccines can be developed much faster than traditional vaccines. They are safe and effective at both preventing disease and making disease much milder when infection does occur. mRNA technology has the potential to make universal flu and COVID vaccines, vaccines for malaria and leptospirosis and even vaccines to prevent cancer. It is unconscionable that federal funding for this important research has been halted.

Empathy vs Compassion

I recently read a fascinating book by psychologist Paul Bloom called Against Empathy: The Case for Rational Compassion. In this post I will discuss this book in more detail as well as review other evidence about the difference between empathy, theory of mind, and compassion. I will also discuss how Bloom’s book has been misused by some right wing Christians.

Empathy

Definition of Empathy

Most definitions of empathy include vicariously feeling the same emotions as another person and understanding another person’s perspective. Psychologists separate these two things. Vicariously feeling another person’s emotions or pain is called emotional empathy. It is neurologically distinct from understanding another person’s perspective, which is called cognitive empathy or theory of mind. Bloom focuses his critique on emotional empathy, not theory of mind.

Emotional Empathy

Emotional empathy is hard wired into us. It is a mostly unconscious response to another person’s distress. It can motivate us to be kind and helpful to the person or people who elicit this response. It can also lead to harm and even violence. Much more about that later in this post. Emotional empathy is a system 1 response. I’ll explain what that means below.

System 1 and System 2 modes of thinking

System 1 and system two are descriptions of of two ways that our minds operate. It is a somewhat simplified model, but it is consistent with current neuroscientific research. The best accessible description of system 1 and system 2 is a book by Daniel Kahneman called Thinking, Fast and Slow. I highly recommend reading it.

System 1 is what we use for most routine tasks in our lives. It is our fast, automatic, intuitive and emotional mode of thinking. It operates without conscious awareness and relies on mental shortcuts to make quick judgments and decisions. System 1 is essentially our brain’s “autopilot” mode, constantly monitoring our surroundings and making rapid assessments. It is essential to our lives, but , it’s also important to be aware of its limitations. It can sometimes lead to errors in judgment, particularly when dealing with complex or unfamiliar situations. 

System 2 thinking is a deliberate, conscious, and effortful process used for complex tasks and decisions. It is characterized by logical reasoning, careful analysis, and consideration of multiple factors. Unlike System 1 (fast, intuitive thinking), System 2 requires focused attention and effort.

Emotional empathy as a system 1 mode of thinking

Emotional empathy happens without our conscious awareness. It is contextual. Bloom cites research that emotional empathy is influenced by what we think about the person we are empathizing with and how we judge the situation that person is in. In one study subjects were shown videos of people in pain said to be suffering from AIDS. Some of the people in the videos were described as having gotten AIDS from intravenous drug use and some were described as having gotten AIDS from a blood transfusion. Subjects showed much more empathy for the people who were described as having gotten AIDS from a blood transfusion than those described as having gotten AIDS from intravenous drug use.

Emotional empathy is also influenced by the group to which the other person belongs. Is it one of Us or one of Them? There was a study of a painful shock to the hand in European soccer fans. One person was shocked while others witnessed the person who was shocked. Subjects showed more empathy if the person was a fan of the subject’s team and much less empathy if the person was a fan of the opposing team. All of these responses were shown to be below the level of consciousness. When subjects were asked about the reason for the difference in their empathy scores, they denied that there was any bias.

Does high emotional empathy correlate with good behavior?

People do vary in how empathic they are. On one end of the spectrum are people who have a high emotional empathy response, and on the other end of the spectrum are people who have very little emotional empathy. We would expect that people with a high emotional empathy response would be more likely to take action to help. People with high emotional empathy feel peoples’ distress more strongly and this should motivate them to help if for no other reason than to reduce their own distress. Another way that they could reduce their distress, however, is to escape rather than help. We would also expect that people with very low emotional empathy would have more cruel or violent behavior.

It turns out that there is almost no correlation with empathy and good or bad behavior. A meta-analysis of all the studies showed that low empathy has no association with aggression, and high empathy has minimal to no effect on good behavior. To quote Bloom, “Being high in empathy doesn’t make one a good person and being low in empathy doesn’t make one a bad person.”

Emotional empathy as a spotlight

Emotional empathy acts like a spotlight. To quote Bloom again, “making visible the suffering of others making their troubles real, salient and concrete.” The spotlight effect is a weakness as well as a strength. When you point a spotlight at something, everything else is in darkness. What you see depends on where you point the spotlight. This focus effect makes you more vulnerable to bias. It also leads to something called “the identifiable victim effect.” This sets up a situation where one identifiable victim elicits more emotional empathy than than a thousand victims. Stalin once said “One death is a tragedy; one million deaths is a statistic.” We also see this effect in deaths from the COVID pandemic. Eighty percent of Americans do not know anyone who died from COVID, though over a million Americans died from the COVID pandemic. The people who died were disproportionately elderly, black or poor. For people outside of those groups there was no emotional empathy spotlight effect. That is likely why so many people were not convinced that COVID was a serious disease.

The dark side of emotional empathy

Emotional empathy where there is conflict between groups can exacerbate conflict, even wars. People on one side feel empathy for members of their group who feel they have been harmed by the other side. Empathy with your side leads to the desire to punish the perpetrators. Of course people in the group on the other side of the conflict feel emotional empathy for the people on their side and therefore want to punish the other group. In these kind of situations emotional empathy exacerbates rather than mediates conflict between groups.

Burnout

People in the helping professions (doctors, nurses, therapists) do not do well when they experience high emotional empathy with all their clients. Experiencing the pain and suffering of patients, even though empathic suffering is not as severe as the suffering of the patient, is not pleasant. Over time, symptoms of burnout can develop. These include fatigue, poor concentration, lack of energy and effectiveness, cynicism and detachment.

Manipulating emotional empathy

The emotional empathy response can be manipulated for good causes, but also for things that are morally suspect or wrong.

Charities

Charities understand that eliciting emotional empathy will increase donations. They do this by showing images of individual people or animals who are obviously in distress. Stories go with the images about the suffering of this individual person or animal. Since we have an increased emotional empathy response to children in distress, the charity ads often use images of children. The emotional empathy response is not a good way to decide which charities should get your donations. Some charities do much more good for a lot more people than others. All charities, both good and not so good use the same techniques to manipulate emotional empathy. There is a better way to decide which charities should get your donations. More about that later in this post.

Politicians

Politicians often highlight individual people to manipulate the emotional empathy response to recruit people to vote for them or to take one side or the other in political and policy battles. Once again, this is not a good way to choose which politician or which policies you want to support.

The Christian right

There have been several recent books by right wing Christian authors who have cherry picked Paul Bloom’s critique of emotional empathy. Essentially anything or anyone that elicits empathy that contradicts their view of Christianity is termed “toxic empathy.” This is just another manipulation of empathy in a negative sense that promotes a particular religious viewpoint.

Compassion

Definition of compassion

Psychologist Paul Gilbert defines compassion as basic kindness with a deep awareness of the suffering of oneself and of other living things coupled with the wish and the effort to relieve that suffering.

Compassion as system 2 thinking

Understanding (rather than feeling) the suffering of a person or group of people uses system 2 thinking. That understanding facilitates the desire to help in the most effective way possible. Determining the most effective way to help requires logical reasoning, analysis, and consideration of multiple factors. These are characteristics of system 2 thinking.

Awareness of the vast amount of suffering in the world does not mean that an individual person can help relieve the suffering of all sentient beings. Compassion involves choosing both how and whom one can help the most.

Compassion in the helping professions

As noted above, emotional empathy alone can lead to burnout. It can also lead to less than ideal doctor-patient relationships. Patients are not interested in doctors or nurses feeling their pain. They want compassionate competent care. Doctors, nurses and therapists must of necessity maintain a certain emotional distance from their patients in order to provide that compassionate care. Compassionate care clearly involves mostly system 2 thinking. Unlike emotional empathy, understanding and compassion lead to the opposite of burnout. Multiple studies have shown that compassionate care is good for both patients and their clinicians. Here is a link to a review of a book by Dr. Anthony Mazzarelli and Dr. Stephen Trzeciak: Wonder Drug: Scientific evidence that serving others is best medicine.

Compassion training

It is possible to enhance compassion through training. For over a thousand years buddhists have practiced a form of meditation on compassion called “loving kindness” meditation. It involves both compassion for self and then expanding to family, friends, and eventually all sentient beings. Here is a link to a website that describes this kind of meditation: Metta Meditation: A Complete Guide to Loving-Kindness. There are many other ways to enhance one’s ability to be compassionate including cognitively based compassion training, Stanford multidisciplinary research based training, as well as many others. They have all been shown to increase compassion, which in turn leads to helping others. Once again compassion for self and others is as good for the helper as it is for the one who is helped

Bottom Line

You cannot turn off emotional empathy, nor should you even try. It is an automatic system 1 response. When combined with understanding and compassion it is always a good thing. It makes suffering visible and salient. The important thing is to learn to recognize your emotional empathy system 1 response and then engage your system 2 understanding and compassion. Emotional empathy by itself is not good or bad, but can be either. Your capacity for understanding and compassion (which is essentially kindness) can be enhanced by training. We definitely need more kindness in our world today.

MAHA Fact and Fiction

We have all lately heard a lot about MAHA (Make America Healthy Again) from Robert F Kennedy Jr. Some of the things he is advocating probably would improve the health of Americans, but many would not only not improve health, but would make it worse. In this post I’m going to try to identify the good parts and debunk the rest.

Food Dyes

Kennedy wants to eliminate “synthetic” food dyes except for “natural” ones. Food dyes have no nutritional value and many have never been adequately tested in humans. That does not mean they are toxic or cause disease. The only food dye that has been shown to be possibly toxic to humans is red dye #3 also known as erythrosine. It has already been banned in food and cosmetics. For other food dyes we simply do not know how safe they are for human consumption. . The FDA has recently approved 3 plant based food dyes:

  • Galdieria extract blue, a blue color derived from the unicellular red algae Galdieria sulphuraria.
  • Butterfly pea flower extract, a blue color that can be used to achieve a range of shades including bright blues, intense purple, and natural greens. This dye is produced through the water extraction of the dried flower petals of the butterfly pea plant
  • Calcium phosphate, a white color approved for use in ready-to-eat chicken products, white candy melts, doughnut sugar, and sugar for coated candies.

We don’t know any more about the safety of long term use of these plant-based dyes in food than we know about synthetic dyes. Just because they are extracted from plants does not make them safer. The drug digoxin was originally extracted from the foxglove plant. Taking too much of that can kill you. The most conservative thing to do is to ban food dyes, period. That would take congressional action, which is most unlikely in the current congress.

There is no evidence, by the way, that any currently used food dyes cause cancer or other diseases. There is just very little evidence about whether they are safe or not.

Emulsifiers

Emulsifiers are added to foods to prevent separation of oil and water in foods. They also can increase shelf life. Some are natural products like guar gum and some are synthetic. Emulsifiers are not new and have been used for hundreds of years. There is some evidence that certain emulsifiers may adversely affect the gut microbiome. Most of this work has been done in mice, so it is not clear whether emulsifiers have the same effect in humans. Emulsifiers are used most extensively in processed and ultra-processed foods. Unprocessed foods do not contain emulsifiers. Once again, the jury is out on whether emulsifiers have adverse effects in humans, but they might have an effect on the gut microbiome and promote inflammation and they might not. Kennedy is opposed to all emulsifiers in food. This is not exactly a nuanced perspective, as is the case with all his recommendations and obsessions.

Other Food Additives

There are hundreds of substances added to foods. Here is a link to an FDA list of all substances added to foods that are approved by the FDA or are GRAS (generally recognized as safe): Substances Added to Food. This list is 80 pages long! I have to say that I agree with Kennedy on this one. Already, all of these additives have to be listed on the contents label. If there are more than three things on the contents label that you don’t recognize, leave it on the shelf!

Seed Oils

Kennedy (who is a lawyer, not a health expert, by the way) parrots many so called “natural” food advocates who say that seed oils have toxic by products and the wrong ration of omega 6 to omega 3 fatty acids. They maintain that seed oils cause inflammation and thus increase the risk of heart disease and other conditions like obesity and diabetes. The evidence does not support these claims.

What are seed oils anyway?

  • Canola (rapeseed) oil
  • Corn oil
  • Cottonseed oil
  • Soybean oil
  • Sunflower oil
  • Safflower oil
  • Grapeseed oil
  • Rice Bran oil

All of these are polyunsaturated (as opposed to saturated oils like animal fats, palm oil and coconut oil , which are not good for you in more than moderate amounts). They are more refined than cold pressed oils and a chemical process is used in the refining process. These chemicals, including hexane are volatile and completely evaporate during the refining process. There are no toxic by products in refined seed oils.

Health effects of seed oils – The evidence

Seed oils contain linoleic acid which is an omega 6 fatty acid. Multiple studies show that linoleic acid intake decrease the risk of heart disease and decreases , not increases inflammation. The best way to use these or any oil as a beneficial part of a healthy diet is stir frying vegetables, oven roasting fish, or crafting homemade salad dressings.

The correct ration of omega 6 to omega 3 fatty acids is not clear. To get both eat omega 3 fatty acids which are found in high amounts in walnuts and fatty fish. A good summary of the evidence on the good health effects of seed oils can be found on this Massachusetts General website: Seed Oils: Facts and Myths.

Beef Tallow

Kennedy thinks that using beef tallow for frying is healthier than seed oils. While beef tallow does make for delicious french fries, it is 100% saturated fat. Saturated fat can be healthy as a small part of your total fat intake, but eating exclusively animal fat vs unsaturated fat markedly increases the risk of heart disease, obesity and diabetes. Multiple studies over the years have confirmed increased risk from eating exclusively or large quantities of saturated fats. Kennedy has a video of him frying a whole turkey in beef tallow while saying that this is cooking the MAHA way. Here is a link to that video. In my opinion this is the height of irresponsibility.

Water Fluoridation

Kennedy cites studies that show decreased IQ in children who are exposed to fluoridated water. I have a previous post about the safety of water fluoridation. See this link. The bottom line is that these studies were done in countries and locales that had very high natural fluoride levels. There was no effect in these studies on the very low fluoride levels that are used in water supplies to prevent cavities in children. Banning water fluoridation will lead to excess tooth decay in the most vulnerable children.

Limiting foods that can be purchased with SNAP benefits

SNAP stands for Supplemental Food Assistance Program. It used to be called the food stamp program. Benefits are applied to a card that can be used like a credit card to purchase food. As of now households whose gross income is 130% or less of the federal poverty and whose net income is below the federal poverty level are eligible for SNAP benefits. The amount is determined by the number of people in the household. The federal government pays all of the benefits and 50% the administrative costs. The state pays the other half of the administrative costs. The Big Beautiful Bill Act will make substantial cuts to the SNAP program. More about that later.

People can use their SNAP benefits to purchase food, but not alcohol or cigarettes. Texas and Louisiana have just passed laws that also prevent using SNAP benefits to purchase soft drinks or candy. Kennedy has praised these new state laws. While it is true that soft drinks and candy are not healthy foods, excluding these from SNAP benefits is just a way to make lawmakers feel virtuous about limiting the food choices poor people make. It is not going to improve their nutrition because like non-SNAP households foods households buy on SNAP benefits tend to be ultra-processed foods. Healthy unprocessed foods are more expensive and require time to prepare and cook as well as requiring working appliances and cooking equipment. Families at or below the poverty level, who are often renting sub-standard housing are unlikely be able to afford to purchase or to have the time, and equipment to prepare and cook unprocessed foods. Non-SNAP households don’t do much better. See this link from the USDA: Foods typically purchased by SNAP households .One more MAHA recommendation that will likely not improve health!

What makes this even worse are the cuts to the SNAP program in the Big Beautiful Bill Act. Here is a summary of the cuts and when they will kick in:

  • Shifting SNAP costs to states by:
    • Requiring states to pay a portion of SNAP benefits for the first time in program history, up to 15%, based on their payment error rates, beginning in October 2027. Final negotiations in the Senate resulted in a temporary implementation delay for up to two years for states with high error rates. 
    • Increasing the state’s share of administrative costs from 50% to 75%. 
       
  • Restricting future adjustments to the Thrifty Food Plan, which will include cuts to SNAP benefits as well as benefit levels for The Emergency Food Assistance Program (TEFAP), SUN Bucks/Summer EBT benefits, and the Nutrition Assistance Program block-grant to Puerto Rico. 
     
  • Increasing the number of individuals subject to time limits on their SNAP benefits, including, for the first time ever, parents of school-aged children over 14 and older adults age 55 through age 64 by expanding work requirements and restricting waivers. 
     
  • Adds a time limit on benefits for veterans, currently homeless individuals and former foster care youth.
  • Eliminating funding for the SNAP Nutrition Education program. 

SNAP is (or was) the most effective hunger relief program in the U.S.

All of the above information on the changes to SNAP benefits comes from the Harvesters Community Food Network .

Vaccines

With no evidence whatever, the MAHA report calls current childhood vaccination schedules “overmedication.” It emphasizes exceedingly rare adverse effects of vaccines and promises to do “randomized trials” of current vaccine schedules. Randomized trials are routinely done before new vaccines are approved and repeating them will be inordinately expensive and delay vaccine approval. The result of this MAHA policy will mean that we will see serious childhood diseases again, some of which will result in hospitalization and some totally avoidable childhood deaths. We have already seen a resurgence of measles cases in 40 states. See my previous post about Vaccine risks in perspective.

Bottom Line

Kennedy has legitimate concerns about the unhealthy ultra-processed foods that most Americans eat. The concerns about food additives are also reasonable but overblown. These legitimate concerns are mixed in with conspiracy theories about toxic byproducts in seed oils, health benefits of beef tallow, and vaccines as a cause of autism. He completely ignores the fact that most poor people cannot afford to buy, prepare or cook healthy unprocessed foods. He is overall a danger to public health.

Trump Administration Assault on Health Care and Research

The Trump administration along with its rubber stamp republican controlled congress is conducting an unprecedented assault on US health infrastructure and on medical research. In this post I will write about the details of that assault and the current and likely future effects on people in the US and around the world.

HIV Funding Cuts

Funding has been cut for current studies on HIV vaccines being carried out by Duke University, The Scripps Research Institute and Moderna’s clinical trials. These vaccines showed great promise for preventing HIV infection.

The administration has eliminated the CDC HIV prevention division

Funding for the Presidents Emergency Plan for AIDS Relief has been eliminated. This program, begun in 2003 during the George Bush administration, has delivered lifesaving treatment to 25 million people in 54 countries and had previously bipartisan support. Without this funding, thousands of people around the world, especially in African countries will die. Children born with HIV are especially vulnerable.

Center for Disease Control cuts

The CDC has historically held a strong reputation as a global leader in public health. It has been considered the “gold standard” for national health agencies. In April of this year 2400 CDC employees’ jobs were terminated, shuttering whole programs at the agency. About 460 of those employees have been rehired. The Trump administration 2026 proposed budget cuts CDC funding by 50%. Much of CDC funding goes to state health departments, so state health departments will struggle and public health programs like TB treatment, and STD treatment will be understaffed if not eliminated entirely.

Vaccines

Robert F Kennedy Jr was appointed by Trump as head of HHS. He has a long history of conspiracy theories about vaccines. He recently fired all 17 members of the CDC immunization advisory panel and appointed 8 new members, many of whom have been critical of mRNA vaccines as well as other vaccines. Vaccines recommended by the panel have to be covered by insurance. It seems likely that rare side effects of vaccines will be emphasized and that vaccination rates will continue to fall in the US. Prepare yourself for the return of measles, pertussis (whooping cough), and maybe even polio.

Cuts to Medicaid

It is clear that Federal Medicaid funding will decrease substantially, but we won’t know how much until a final budget is worked out between the House and Senate. The Senate version cuts Medicaid even more than the House version. Medicaid cuts will not only affect the health of Medicaid recipients but will have downstream severe effects on the entire US healthcare system. This will include hospitals, physicians, federally qualified health centers, certified nursing facilities, and even insured persons (because premiums will increase). There is an excellent viewpoint piece in JAMA detailing all the damage to US medical care caused by substantial cuts in Medicaid spending. Here is a link to that article. It is worth reading.

Effects of Medicaid Cuts on the Medical Care Ecosystem.

Medicaid Work Requirements

The vast majority of Medicaid recipients who are able to work are working.  in 2023, nearly two-thirds of adults ages 19-64 covered by Medicaid were working and nearly three in ten were not working because of caregiving responsibilities, illness or disability, or due to school attendance, reasons that counted as qualifying exemptions from the work requirements under previous policies (Understanding the Intersection of Medicaid and Work: An Update). Arkansas is the only state that has previously tried work requirements for Medicaid recipients. The documentation requirements were such that over 18,000 people lost their Medicaid insurance, despite the fact that the vast majority of them were already working. If Congress passes Medicaid work requirements, millions of people will lose Medicaid. That means more emergency room care, more untreated chronic illness and more deaths.

Reduced Subsidies for Affordable Health Care Insurance Marketplace

The premium tax credits for the ACA insurance marketplace are set to expire in 2025. The House budget bill does not extend those tax credits. Without those tax credits millions of people will lose their insurance because they will not be able to afford the increased cost.

Cuts to Research Funding

National Institutes of Health (NIH)

The Current Trump administration budget includes a 40% cut in funding for NIH! This is completely unprecedented. If that level of budget cut happens, the NIH will be unable to award any new research grants for at least 3 years!

Importance of NIH Funded Research on Health

NIH funded research has resulted in numerous health benefits in the US and the world. These include improvements in chronic disease treatment and prevention, cancer diagnosis and treatment, infant and maternal health, identification and treatment of immune diseases, and a host of other benefits. Here is a link to an NIH website documenting the health benefits of NIH funded research: Improving Health.

Long Term Effects on US Research

The quality of research in the US has long been among the very best in the world. The US has attracted talented researchers from all over the world. The NIH budget cuts along with the cancellation of existing research grants makes the US a much less attractive place for researchers. The Trump administration focus on limiting immigration also makes the US much less attractive to talented researchers from outside the US.

A recent survey of US scientists was carried out by the prestigious science journal Nature. The survey found that 75% of US scientists were considering leaving the US (The Hill).

Recruitment of US scientists by other countries

A number of countries are actively recruiting top US scientists. They are offering not only funding, but also emphasizing academic freedom (Economic Times).

Bottom Line

The cuts to HIV treatment and HIV vaccine research will result in thousands of preventable deaths from HIV. The One Big Beautiful Bill Act (that is the actual name of the budget bill) will result in millions of people losing both Medicaid and ACA insurance. It will decimate medical research as well as severely compromise the US Public Health Service (because of the CDC cuts). The lack of emphasis on vaccines by HHS will likely result in continued lower vaccination rates with return of measles, pertussis, diptheria and polio. All of this will be a health care disaster.

Feel free to share this post. Also write your congressional representative and your senators. It may not help, but it can’t hurt to do what you can to mitigate this disaster in progress.

US Primary Care In Crisis

According to the American Academy of Family Physicians (AAFP) “Primary care is the provision of integrated, accessible health care services by physicians and their health care teams who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

The AAFP defines a primary care physician as “a specialist in family medicine, general internal medicine or general pediatrics who provides definitive care to the undifferentiated patient at the point of first contact, and takes continuing responsibility for providing the patient’s comprehensive care. This care may include chronic, preventive and acute care in both inpatient and outpatient settings. Such physicians are specifically trained to provide comprehensive primary care services through residency or fellowship training in acute and chronic care settings.”

Multiple studies have shown that those U.S. states with higher ratios of primary care physicians to population had better health outcomes, including lower rates of all causes of mortality: mortality from heart disease, cancer, or stroke; infant mortality; low birth weight; and poor self-reported health.

There are currently not enough primary care physicians in the US to provide this kind of primary care, especially in rural areas, and the situation is about to get a lot worse. As of June 30, 2024 The Health Resource Services Administration (HRSA) estimated that 83 million Americans live in areas that do not have adequate access to primary care doctors. HRSA also estimates that as of June 30, 2024 the US had 13,000 less primary care doctors than were needed to care for the US population.

The number of US medical students who match in primary care residencies (family medicine, general pediatrics and general internal medicine) has decreased every year. In 2024, 600 family medicine slots and 250 general pediatric slots went unfilled in the match. Most of these slots were later filled by offers outside the match in a process called SOAP (Supplemental Offer and Acceptance Program). Most internal medicine and about 40% of pediatric residents do fellowships in subspecialties rather than going into primary care. In 2024 only 9% of US medical students chose family medicine residencies. The US is expected to face a shortage of primary care physicians of as much as 55,000 by the year 2032. To close this gap we need to create 600 family medicine residencies over the next 10 years. At this point there is neither the funding nor the faculty to accomplish this goal.

Can Nurse Practitioners Fill the Primary Care Deficit?

Nurse practitioners can be and are already an important part of healthcare teams. They are especially good at managing people with reasonably stable chronic diseases, better than physicians in fact. They are also very good at preventive care. Part of the problem is that only 34% of nurse practitioners go to work in primary care. The rest end up working as part of a specialist team.

Can Nurse Practitioners Practice Independently?

Twenty seven states allow nurse practitioners to practice completely independently. That is they can diagnose, order tests and prescribe medicines including controlled substances without any physician supervision. In these states they function under the auspices of the state boards of nursing, not the state medical boards. Nurse practitioners have substantially less training than primary care physicians. Nurse practitioner programs require 2 years after an undergraduate bachelor of nursing degree. They do not have to do an internship or residency to practice, although a few pursue such extra training.

Primary care physicians, on the other hand, complete 4 years of medical school after an undergraduate degree and then 3 years of a primary care residency.

Seeing undifferentiated patients in primary care requires being able to identify and diagnose patients with serious disease among the many patients with acute illness who will get better anyway. This requires training and experience. My personal feeling is that most nurse practitioners do not have adequate training to independently see undifferentiated primary care patients without some physician supervision. This is also the position of the American Medical Association. On the other hand, if an independent nurse practitioner is the only primary care clinician available in a rural area, that’s a whole lot better than no primary clinician at all.

Reasons for the low percentage of medical students choosing primary care

There are many reasons that such a low percentage of medical students choose primary care residencies.

Student Loans

One major factor is student loan repayment for medical school. The average student loan debt for graduating medical students is over $200,000. Some are as high as $400,000. Specialty salaries are much higher that those for primary care, so medical students who enter these high paying specialties can pay off their student loans reasonably quickly.

Hidden Curriculum

 The hidden curriculum is a socialization process. Wittingly or unwittingly, norms and values transmitted to future physicians often undermine the formal messages of the declared curriculum. The hidden curriculum consists of what is implicitly taught by example day to day, not the explicit teaching of lectures, grand rounds, and seminars. The hidden curriculum in most medical schools denigrates family medicine and glorifies specialization, suggesting that the best and brightest become specialists.

Corporatization of Primary Care

Over 77% of primary care physicians now work for hospitals, health systems, or corporate entities. These new physician employment models often tie salary to volume of care, based on fee-for-service payment models, rather than on quality. Also employment contracts tend to be one-sided, employer-employee models, leaving employed physicians little opportunity or incentive for creativity in defining and improving how they do their job. One unintended consequence of the employed physician model has been less sense of loyalty and connection and more tendency for younger primary care physicians to switch jobs. This increased mobility has the unfortunate effect of disrupting critically important continuity in the doctor-patient relationship around which trust, deeper caring, and improved outcomes are built (The Corporatization of Primary Care: Unintended Consequences).

Lower Income

The average annual income for all primary care physicians in the United States is between $178,207 and $291,000.. The average salary for family physicians was a little less, coming in at $180,000. Although this sounds like a generous income compared to most people in the US, specialists make a lot more. For specialists the annual income varies by specialty. The highest paid specialties are Neurosurgery: averaging $763,908 in 2024,Thoracic surgery: Averaging $720,634 in 2024, Orthopedic surgery: Averaging $654,815 in 2024, Plastic surgery: Averaging $619,812 in 2024, and Anesthesiology: Averaging $494,522 in 2024. Other specialties make somewhat less, but all of them make more than primary care physicians.

Lifestyle

Most employed primary care physicians are required to see 20-25 patients per day, averaging 15 minutes per patient. It is estimated that for each hour a PCP spends with a patient, up to 2 hours of work are generated, which includes writing summary notes and treatment plans in a patient’s electronic medical record (EMR) and communicating test results or other important information to patients and their caregivers. Many PCPs go home at the end of crushingly stressful days, spend an hour or two with their families, and then stay up late to finish all the computerized documentation that their day in clinic has generated.

Possible Solutions

Increase primary care residency slots

The Center for Medicare and Medicaid Services (CMS) funds residency slots for physician residencies, both specialty and primary care. CMS should increase the number of primary care residency slots. If this decreases funding for specialty residency slots, so be it.

Income

Reduce income disparities between primary care physicians and specialists. “To address this income disparity, physician fees can no longer be set by the Relative Value Scale Update Committee, or RUC, the specialist-dominated committee that determines fees for different services. A new advisory committee should be formed. It should be dominated by primary care providers and include patient advocates. The newly constituted advisory committee can begin to equalize pay by raising payments to primary care (and other cognitive specialties), lowering the rate of payment to proceduralists, or both.” No More Lip Service; It’s Time We Fixed Primary Care (Part Two)

Loan Repayment

The government should either cover the cost of medical school or repay student loans for students who commit to do a primary care residency and stay in primary care for at least 10 years after certification. Another option would be for the government (state or federal) to incentivize individual institutions to offer loan forgiveness programs.

Reforming primary care practice

Reforms proposed by the directors of the Lown Institute include direct primary care and something they call a primary care trust. Here is a link to their article in the Health Affairs journal. They explain these concepts much more clearly than I can in this post. Look for the section labeled “Payment And Delivery Models To Improve The Quality Of Primary Care And Reduce Burnout.” No More Lip Service; It’s Time We Fixed Primary Care (Part Two)

Bottom Line

We already have 83 million people in the US who don’t have adequate access to a primary care doctor. Unless we do something drastic, there will be a deficit of 55,000 primary care physicians by 2032. The number of medical students who want to go into primary care has been steadily diminishing. Possible solutions include increasing primary care residency spots, forgiving loans or paying for medical school for students who commit to primary care residencies and practice for 10 years, exposing medical students to primary care doctors as faculty, diminishing the pay gap between primary care physicians and specialists, and reforming primary care to decrease administrative burdens.

Robert F. Kennedy Jr – A Terrible Choice to Head HHS

Robert F. Kennedy Jr has been nominated by Donald Trump to be the Secretary of HHS. If he is confirmed by the Senate he will be secretary of HHS for four years. He plans to “Make America Healthy Again.” It is true that the current American healthcare system is one of the worst in the developed world as far as health outcomes are concerned. But rather than improving that system, RFK Jr’s plan is not only naive, but very dangerous. In this post I’m going to write about the specifics of what he is advocating and has advocated in the past. He can’t “Make America Healthy Again” but he can do a lot of damage.

Views on Infectious Disease

AIDS

RFK Jr believes that HIV does not cause AIDS. He has argued that the initial signals of AIDS, Kaposi’s sarcoma and Pneumocystis carinii pneumonia (PCP), were both strongly linked to amyl nitrite — “poppers” — a popular drug among promiscuous gays. He thinks the wasting symptoms of AIDS were all caused by heavy drug use and lifestyle stressors. He believes that the afflictions that tortured and killed those AIDS patients were, in fact, a result of their drug use and “compulsive homosexual behavior.”

He of course ignores the fact that the AIDS epidemic also affected people with hemophilia (through the blood products they had to use), children who were born to mothers with HIV, and health workers who had accidental needle sticks. At the peak of the epidemic in 2004, before we had any treatment other than AZT, AIDS killed 2.1 million people worldwide.

Lyme Disease

RFK Jr. believes that Lyme disease was created as a bioweapon by the American military in a Long Island laboratory in the 1950s.

West Nile Virus and RSV

Kennedy has said West Nile virus was created at Plum Island and that respiratory syncytial virus was purposely spread from apes to humans so pharmaceutical companies could profit off vaccines.

1918 Influenza Pandemic

Kennedy said at an online campaign event in June 2023. “We can go down a whole list of diseases, and there is good evidence that even the Spanish flu came from vaccine research.”

COVID

In an interview on Fox News, Kennedy said that many lives would have been saved if ivermectin and hydroycholoroquine had been more widely used. Well designed studies on both of these medicines showed they were no better than placebos for treating COVID.

Views on Vaccines

Measles Vaccine

During a November 2019 measles epidemic that killed 80 children in Samoa, Kennedy wrote to the country’s prime minister falsely claiming that the measles vaccine was probably causing the deaths

Vaccines and Autism

Kennedy believes that vaccine, particularly the MMR vaccine causes autism in children. As noted above, numerous very large well designed studies have disproven that any vaccines cause autism.

COVID vaccines

Mr. Kennedy filed a petition with the F.D.A. in May 2021 demanding that officials rescind authorization for the COVID vaccine and refrain from approving any Covid vaccine in the future.

Fluoridation of Water Supplies

Kennedy claims that fluoridation of water leads to decreased IQ scores in children. There is some evidence for this at very high fluoride levels that naturally occur at some places in the world. The level of fluoride added to water supplies in the US is far below this threshold. There is no evidence whatever that flouride added to drinking water has any ill effects. It has been shown to markedly decrease dental cavities in children, however. Kennedy says that fluoride in toothpaste is enough. The children most benefited by flouridation are minority and marginalized populations who do not or cannot brush their teeth regularly.

Chronic Disease

Kennedy wants the NIH to focus on chronic diseases. Of course many of the institutes of NIH already focus on chronic disease and fund research on them. This has been going on for many years. These include:

National Heart, Lung, and Blood Institute (NHLBI): Focuses on research, training, and education to prevent and treat heart, lung, blood, and sleep disorders 

National Institute on Aging (NIA): Focuses on research related to aging 

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK): Focuses on research related to diabetes, digestion, and kidney disease 

Division of Kidney, Urologic, and Hematologic Diseases (KUH):Focuses on research related to kidney disease, urinary tract disorders, and blood disorders 

National Institute of Environmental Health Sciences (NIEHS):Focuses on research related to chronic disease epidemiology 

Fogarty International Center (FIC): Focuses on global health research, including chronic diseases 

National Institute on Minority Health and Health Disparities (NIMHD): Focuses on research related to chronic disease disparities

The fact that Kennedy is not aware of the fact that NIH does a great deal of research on chronic diseases is more evidence of his unfitness for running HHS.

Nutrition

Kennedy wants to take on the big food industry and move people to eat less ultra-processed foods and eat more unprocessed foods. He thinks food additives cause cancer and gender dysphoria and wants additives removed from foods. Although there is zero evidence that food additives cause gender dysphoria, by and large these are laudable goals. How he is going to accomplish this remains unclear. Chronic disease is certainly related to food choice, lifestyle and poverty. We have known this for a long time, but it will take major societal change to make this happen. It certainly will not be in the power of the secretary of HHS to accomplish this.

Plans for firing employees

At an event in Arizona, Kennedy said he’d fire and replace 600 people from the National Institutes of Health. Kennedy also promised to eliminate the department of nutrition at the FDA.

Bottom Line

Robert F. Kennedy Jr. is a conspiracy theorist with no experience in running a large organization like HHS. He is absolutely unqualified for this role and furthermore constitutes a serious risk to the health of the US. I have written a letter to both my senators urging them to vote against his confirmation. I respectfully request that you do the same.

Antibiotics – When You Need Them and When You Don’t

In the era before antibiotics were available one third of all deaths were from infectious disease. The introduction of antibiotics starting with penicillin represented a tremendous advance in the treatment of infectious diseases. We soon learned, however that overuse of antibiotics led quickly to the development of bacteria that became resistant to that antibiotic. Penicillin, for example can only be used for a small number of infectious diseases now including strep infections and syphilis. In this post I will write about both individual and societal harms of overuse of antibiotics and will also discuss conditions for which they should be and should not be used.

Harms of Antibiotics

Bacterial Resistance

Overuse of antibiotics can lead quickly to resistance. Unfortunately, resistance has eventually developed to nearly all currently available antibiotics. Some bacteria, called gram negative bacteria have developed resistance to almost all antibiotics. Antibiotic resistance in the United States kills approximately 23,000 patients a year and incurs over $20 billion in additional medical expenses.

Overuse of antibiotics

The information below comes from an excellent paper from the journal Pharmacy and Therapeutics: The Antibiotic Resistance Crisis.

 in 2010, the last year that we have complete data, 22 doses of antibiotics were prescribed per person in the U.S. In many other countries, antibiotics are unregulated and available over the counter without a prescription. This lack of regulation results in antibiotics that are easily accessible, plentiful, and cheap, which promotes overuse.

Inappropriate Prescribing

Many studies have shown that antibiotic therapy is not necessary in 30% to 50% of cases! Even in intensive care units 30% to 60% of the antibiotics prescribed have been found to be unnecessary, inappropriate, or at inadequate doses.

Extensive Agricultural Use

In both the developed and developing world, antibiotics are widely used as growth supplements in livestock.  About 80% of antibiotics sold in the U.S. are used in animals, to promote growth and to prevent infection. Molecular detection methods have shown that resistant bacteria in farm animals reach consumers through meat products. This happens through the following sequence of events:

1) Antibiotic use in food-producing animals kills or suppresses susceptible bacteria, allowing antibiotic-resistant bacteria to thrive

2) Resistant bacteria are transmitted to humans through the food supply

3) These bacteria can cause infections in humans that are resistant to most antibiotics

Consequences of Antibiotic Resistant Infections

A 2011 national survey of infectious-disease specialists found that more than 60% of the infectious disease doctors had seen a pan-resistant, untreatable bacterial infection within the previous year. Many public health organizations have described the rapid emergence of resistant bacteria as a “crisis” or “nightmare scenario” that could have “catastrophic consequences.”

Antibiotic Effects on Human Microbiome

It is well established that the gut microbiome plays an important role in health.  It prevents disease causing bacterial colonization, regulates gut immunity, provides essential nutrients and metabolites, and is involved in control of energy. A healthy gut microbiome has lots of diversity. Broad‐spectrum antibiotics reduce gut bacterial diversity. While killing the disease causing bacteria of concern antibiotics can also kill beneficial bacteria.

Studies report changes in gut bacterial composition that last for up to 12 weeks after antibiotic treatment has ended with the incomplete restoration of bacterial composition and emergence of antibiotic‐resistant strains.  In one study one short term course of clindamycin (7 days) resulted in significant disturbances in the gut bacterial community that remained for up to 2 years post‐treatment!

When Antibiotics Are Not Necessary

Viral Infections

The vast majority of infections are caused by viruses. Antibiotics do nothing to shorten viral infections or to relieve symptoms. Here are some examples.

Upper respiratory infections

Symptoms are typical cold symptoms, including runny nose, nasal congestion, sore throat and cough. There may or may not be fever. Fever, sometimes high fever is more common in children. Green or brown discharge from the nose is common with viral upper respiratory infections and does not indicate bacterial infection. Viral upper respiratory infections usually last about 10 days, but can persist for several weeks.

Bronchitis

In otherwise healthy people, bronchitis is another example of a viral infection. The only exception to this is people with chronic obstructive lung disease, in which bronchitis may be caused by bacteria. The main symptom of bronchitis is cough, which may be dry or may be productive of sputum. Yellow or green sputum can occur and does not mean that the bronchitis is bacterial. There is usually no fever. Viral bronchitis can last for weeks. RSV virus can cause a severe bronchitis in children and older adults. There is a vaccine for children and adults that prevents RSV virus infections.

Sinusitis

Most sinus infections are viral and antibiotics are not helpful for these. Symptoms can include thick nasal discharge and some discomfort over the maxillary sinuses (underneath the eyes). Occasionally sinusitis can be bacterial and require antibiotics. I will discuss this later under conditions for which antibiotics are appropriate.

GI Viruses

There are other viruses that affect the gastrointestinal system. Symptoms are usually nausea and vomiting and/or diarrhea. Norovirus is the most common one. Staying hydrated is the only treatment for these viruses. Rotavirus affects children, but there is a an oral vaccine for infants that prevents this disease.

Ear Infections (Otitis Media)

Infections behind the ear drum are called otitis media. These occur almost exclusively in children and can be viral or bacterial. We used to treat all inner ear infections in children with antibiotics. We have now learned that most ear infections in children, even the bacterial kind get better without antibiotics. We now use antibiotics only for children with severe ear infections who more commonly have fever and/or severe pain.

When Antibiotics Should Be Used

Most bacterial infections require antibiotics to get better. It is not always possible for you to know whether you have a viral or bacterial infection. If you are concerned that you might have a bacterial infection you need to see your doctor who will decide whether you need antibiotics or not.

Strep Throat

Although many sore throats are viral, sore throat can also be caused by strep (streptococcus). Strep throat does not cause other symptoms like cough and runny nose. It is diagnosed by a rapid strep throat swab which your doctor can do in his/her office.

Bacterial Sinusitis

This usually happens after a viral upper respiratory infection. The most common sequence is that you start to feel better after a week or so and then get worse. Typically pain from bacterial sinusitis is one side, not both sides. The affected sinus becomes very tender to touch. Fever may or may not be present.

Infection in the ear canal (otitis externa)

This kind of infection is different from infections behind the ear. It can be painful and usually there is some pussy discharge from the ear. It usually responds to topical antibiotic ear drops, but when severe can require oral antibiotics

Pneumonia

Pneumonia can be viral, but it is not easy to tell that kind from the more serious bacterial pneumonia. All pneumonias should be treated with antibiotics. Symptoms of pneumonia are fever, sometimes high fever, cough (usually productive) and shortness of breath. A chest x-ray will show fluid in the air sacs in the lungs.

Urinary tract infection

Bladder infections are common, especially in women. The symptoms are frequent urination and pain or burning with urination. Your doctor will send a urine culture to make sure you are on the right antibiotic.

Kidney infections (also called pyelonephritis) are a more serious type of urinary tract infection. Symptoms can include fever, flank pain and feeling very ill. Sometimes kidney infections require getting IV antibiotics in the hospital.

Soft tissue infections (cellulitis)

A scrape or cut on the skin can sometimes get infected. Usually the area around the injury becomes red and painful. This kind of infection usually requires antibiotics. Again, this is a decision your doctor needs to make.

Sepsis

Sometimes a localized infection will spread through the blood stream and affect other organs. This is a medical emergency and requires hospitalization, IV antibiotics and fluids to maintain blood pressure.

Bottom Line

Overuse and inappropriate use of antibiotics has led to bacterial infections that are increasingly resistant to many and sometimes all antibiotics. Antibiotics, even when used appropriately lead to long standing adverse effects on the gut microbiome. The vast majority of infections are viral and do not improve with antibiotics. Bacterial infections do often require antibiotics. Decision about whether antibiotics are appropriate should be made by your doctor. Requesting antibiotics from your doctor can sometimes lead to inappropriate prescribing.

Private Equity and Healthcare – A Match Not Made in Heaven

A recent article in the Washington Post reported on a hospital system, Steward Healthcare, that was started by a private equity firm, Cerberus, in 2010. It was based in Dallas and owned 30 hospitals across the country. It recently filed for bankruptcy, leaving patients to suffer and some to even die.

This is only the tip of an iceberg. Private equity funds have increasingly purchased healthcare organizations. According to the Lown Institute At least 386 hospitals are now owned by private equity firms, comprising 30% of for-profit hospitals in the U.S. In this post I will discuss effects of private equity ownership of hospitals on the quality and cost of care.

Private equity firms are businesses that seek large investors by having a very large minimum investment, so investors usually include both wealthy individuals and large institutional investors like pension funds, insurance companies, endowments, and sovereign wealth funds. Typical large private equity firms are Cerberus, Bain Capital, Apollo Global Management, TPG, KKR and Blackstone. Private equity firms are different from venture capitalists, who provide a cash infusion to small startups and hope they blossom into the next Facebook. Nor are they stock traders making split-second decisions to buy or sell shares in public companies. Rather, private equity funds aim to take control of a business for a relatively short time, restructure it and resell the company at a profit. Investors in private equity firms expect to make a much larger profit than typically provided by the stock market.

Private equity firms claim they are good for healthcare systems because they provide needed capital for investment in better quality care. Let’s look at the data and see if this is true. Remember that the purpose of a private equity fund is to make a large return for its investors. Its purpose is not to improve healthcare delivery.

Cost

A recent review of 55 studies of cost and quality of care in hospitals and nursing homes owned by private equity firms in the British Medical Journal found that costs to patients and insurers were increased in those institutions owned by private equity firms compared to non-equity owned institutions.

Quality of Care

The review in BMJ also found that effects on quality of care in private equity owned institutions was mixed to harmful. A recent study reported in the Journal of the American Medical Association reported higher complication rates in private equity owned hospitals. Here is a quote from the key points in the JAMA article:

“Private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line–associated bloodstream infections. Medicare beneficiaries at private equity hospitals were modestly younger, less likely to have dual eligibility for Medicare and Medicaid, and transferred more to other acute care hospitals relative to controls.“

Financial Engineering

Private equity firms use some money from investors and borrow the rest to purchase hospital systems. That’s why they are known as leveraged buyouts. They then saddle the hospital systems with the debt. In other words, they have very little “skin in the game.” They do well whether the hospital does or not.

Short Term Goals

Private equity firms make most of their profits when they sell the hospital or hospital system, and they look to exit within 5-8 years. Thus they look for ways to cut costs quickly like reducing staff or selling the hospital real estate.

Moral Hazard

Private equity firms can make a big profit and pay big dividends to investors even if the hospital goes bankrupt or struggles to survive and is unable to provide the services they did before. See this report about how this happened to one hospital system: Shell game. This is different from most investments where the success of the investor depends on how well the target company does.

Financialization of Hospitals

Financialization is a pattern in which profits come primarily through financial channels rather than through trade and commodity production. In healthcare that means that profits come from buying and selling hospitals rather than from the provision of medical care. This has happened for non-profit hospitals as well as for profit hospitals. For non-profits financialization has occurred by purchasing smaller hospitals, creating large medical systems that dominate the market. The acceleration of the acquisition and selling of for-profit hospitals by private equity firms started in the mid 1990’s and continues to accelerate.

Nursing Homes

In 2022 private equity firms owned 5% of nursing homes. As the purchasing trend accelerates, that number is almost certainly higher now. Studies show that private equity ownership results in an 11% increase in mortality, a 6% decrease in mobility, an 8% increase in bedsores and a 10% increase in pain. (Owner Incentives and Performance in Healthcare: Private Equity Investment in Nursing Homes)

Bottom Line

The preponderance of evidence shows that Private equity ownership of healthcare institutions results in lower quality and higher cost healthcare. It is only the worst aspect of financialization of healthcare that has occurred in the US. There are things the US could to about this if the political will were there. Here is a list of solutions from the Lown Institute:

  • Joint Liability. Currently PE firms can put all of their debt on the balance sheet of the firm they acquire, letting them off the hook for this debt and making it harder for the acquired company to succeed. “Requiring private equity firms to share in the responsibility of the debt…would prevent them from making huge profits while they are saddling hospitals and nursing homes with debts that ultimately impact worker pay and cut off care to patients,” write Stewart and Baker.
  • Regulate mergers. Private equity acquisitions often go under the radar because the acquisitions are small enough to not be reported to authorities. But the U.S. Federal Trade Commission could be more aggressive in evaluating mergers and buyouts by PE, as they have done recently in Texas, where a PE firm has been buying up numerous anesthesia practices. 
  • Transparency of PE ownership. It can be hard to know when hospitals are bought by a PE firm. The Department of Health and Human Services could require disclosure of PE ownership for hospitals as they have done for nursing homes.
  • Remove tax loopholes. The carried interest loophole allows PE management fees to be taxed at as capital gains, which is a lower rate than corporate income. Closing this loophole would remove a big incentive that makes PE buyouts so attractive for firms.

If it becomes less lucrative for private equity firms to purchase and sell healthcare institutions then they will concentrate their investments elsewhere. That would be good for all of us.