IM Doc pt7

Continuing IM Doc's posts and related comments. Please see the updated link in the topmost IM-Doc related post on this blog to find the current discussion location.

 IM Doc

January 3, 2021 at 11:16 am

Based on what I have been hearing sub rosa –

The Ivermectin therapy actually does help – There are multiple RCTs out of varying quality, none of them I would call really well done enough to trust. Some of these trials are abysmally done. Anecdotally, I have patients who are taking veterinary Ivermectin ( would never recommend) which in many locations can be had over the counter. Anecdotally, they do seem to get better quicker. Ivermectin has been out for decades and has a very good safety profile if used correctly. Anyone on multiple other meds should have their physician look over this. Interestingly, and anecdotally, I have had 3 family clusters in my practice in which all subjects in the cluster began to take Ivermectin immediately when one person became positive. None of the others in any of those 3 clusters became positive. I have had one other family cluster where the initial patient and one other become positive, the other 3 people in that cluster remained negative. I live in a very rural area where Ivermectin is widely available and people are doing this on their own. Being my old-fashioned self, I do feel strongly that this needs to be immediately studied in real trials that are well done and have statistical significance.

Ivermectin is a widely used OTC product used in much of the world for many things. Many people in the 3rd world take it on a regular basis for all kinds of issues. Again, it has a very good safety profile.

It is also very cheap. That is unless and until a pharma god like Shkreli gets hold of it and all of a sudden it is thousands of dollars a dose. I am certain this is already being worked on by multiple pointed heads all over Manhattan.

The problem that gets sticky, and I heard a very good discussion in a conference this past week from a pharma lawyer is that the Emergency Use Authorizations for the vaccines are apparently only legal if there is no other viable therapy available. If indeed the WHO, or any other large well-done trials, show that Ivermectin is a viable therapy, the EUAs would immediately be null and void. The vaccines would then have to be withdrawn and the regular approval process would have to be followed. This is the black and white of what is in the EUA laws. This obviously has never been tested in court – and who knows what will happen if this becomes an issue. There are obviously numerous different takes on this on multiple legal fronts.

 

1. Jeremy GrimmJanuary 3, 2021 at 12:37 pm

   What are your reservations about using veterinary ivermectin and veterinary medications in general?

    
   1. IM DocJanuary 3, 2021 at 1:31 pm

      It is the same molecule – so I am not so concerned about the actual Ivermectin molecule. Based on the type of animal, they are often in different media that may not work so well on humans. Also, the dosing may be different for a cow or horse and again, the amount of medication in the pills is formulated to dissolve in that specific animal intestine. I have never had a problem with veterinary Ivermectin. I have, however, had problems with other medications. It is a tragedy that I have people in rural America who can afford animal meds but not human meds and take the chance. Because this is a real thing in our society, I encourage them to bring them in for me to evaluate for safety. Never in my wildest dreams did I ever see myself doing this – but that is unfortunately the world we live in.

      The safety issues with Ivermectin in humans seem to be concentrated on transplant drugs like tacrolimus and cyclosporin, on HIV drugs, on antifungal drugs and on some types of antibiotics.

      I would point everyone to this website [TR adds: this link no longer works - this may be a different version of it, but I cannot confirm https://www.evms.edu/media/t4_training/EVMS_Critical_Care_COVID-19_Protocol.pdf.] They have been updating this protocol since the beginning. They use evidence based medicine. They are basically the entire Department of Medicine – primary care, critical care, infectious disease – at one of our medical schools – Eastern Virginia. They have been way out over the curve on this epidemic from the beginning. They instantly update this protocol with new findings. In my opinion, they are doing a much better public service than many of our government agencies.

      You can see where they are using Ivermectin – and it is being done more and more by my colleagues all over the world. Because of the very good safety profile, I am very likely to start doing this myself. I would much rather do this in a controlled manner rather than having people use literal horse pills.

ambritJanuary 12, 2021 at 8:01 pm

You have me at a disadvantage sir. I believed that I was following proper usage. Do enlighten me, seriously. Language can be a slippery beastie at the best of times.
Should the placement have been MD before GP?
Your humble and obedient servant;
Simplicius

 

1. IM DocJanuary 12, 2021 at 8:39 pm

   I will try to explain.

   Internal medicine is a specialty in medicine – 3 years of training after medical school. Has changed somewhat over the years – but in general- trained to take care of sicker patients with multiple medical issues. They also see people in the hospital – but even that has been changed in the past 10 years. This 3 year training must be completed by anyone doing any of the subspecialty training programs – cardiology, GI, ID, etc. Dr. House was a general internist as was Dr. Marcus Welby.

   Family practice – is a specialty mainly for outpatient care of all ages including peds. There was a time, especially in rural medicine where they did minor surgery and OB procedures – but that has largely passed us by. They are not as thoroughly trained in very sick care.

   GP – or general practitioners – really have disappeared – and the new graduates that do this now are often a bit shady as far as their training. In general, this means that someone has done JUST an internship – not a full residency to specialize in internal medicine or family practice. This was very common generations ago – but no longer is. The ones that do this here in the USA are either very old, or new grads with problems – usually drug related.

   When people say GP in America – they are usually referring to a PCP – and that is almost always a family practice doc or a general internist.

1. notabankerJanuary 12, 2021 at 7:36 pm

   I saw my PCP last week for this first time in a while. At the end, I asked how he was doing, generally, and he volunteered that he had just taken the first shot. He has no issues with it. I asked him if it was the mRNA version, and he said yes. Further went on to say that “they” had gene sequenced the virus in January 2020 and had developed the vaccine over a weekend.

   Don’t shoot the messenger. I’m not saying this is fact, but it is most certainly a fact that he volunteered this info to me in casual conversation.

    
   1. IM DocJanuary 12, 2021 at 8:42 pm

      This is largely true. He forgot to tell you the part where they discussed this over a few drinks in a bar and started their work on a napkin. I am trying to find the link with this story – but no luck as of yet. If I find it I will post.

       
      1. MichaelmasJanuary 13, 2021 at 12:29 am

         Further went on to say that “they” had gene sequenced the virus in January 2020 and had developed the vaccine over a weekend …I’m not saying this is fact

         Sure it’s fact. Slightly misunderstood in your version ….

         [1] The “they” who sequenced the virus were scientists over in China, who then sent the sequence over the internet so the scientists at Moderna could build the coronavirus in silico, then build a vaccine for it the same way.

         Presumably, a little later Moderna would have synthesized the virus and vaccine in vivo to make sure the real things matched the computer models. Very easily done — it’s not a big virus.

         [2] This sort of thing has been routine biotech for (at least) 15-18 years now.

         That’s why I’m a little sceptical about stories featuring accidental escape of a COV19 ‘gain-of-function’ model from the Wuhan lab, which is supposedly one of the most advanced labs on the planet. It’s possible, I grant, and certainly that sort of thing happened in the 1980s. But biotech capabilities and working methods between then and now have changed utterly.

         [3] As regards the over-the-weekend part, yes — that’s the point about mRNA vaccines. They’re meant to provide a very flexible chassis for any kind of vaccine.

         Moderna’s original business model was that it was going to build cancer vaccines i.e. personalized medicine on an expensive individual basis; a given cancer patient would have their tumor cells sequenced and this would then be the basis for building an individual-specific mRNA vaccine for that cancer.

         So it would have been an obvious thing to apply the technology to COV19

IM DocJanuary 20, 2021 at 2:14 pm

I am not certain what I am doing to make the comments in italics.

I am responding to the link this morning about the Ivermectin study. This was a pilot study. It is basically a very small study to see if there is enough data support to warrant a larger study. In this case, there clearly is.

I have been very reluctant to discuss my Ivermectin experience – but I feel with all the news coming out, I should at least say something.

The NIH did something extraordinary last week by upgrading ivermectin for COVID. Before Friday, it was considered a STRONG AGAINST recommendation. As of Friday, our own NIH has upgraded this medication ivermectin for COVID to neither encourage or discourage. That may not sound like much to a layman – but in medicine that is a huge deal. Ivermectin has now joined the same NIH “neither discourage or encourage” recommendation level as remdesevir, convalescent plasma, and monoclonal antibodies that we have all been hearing about over the past months. This NIH action opened up the use of this already FDA approved drug (for parasitic infections and immune conditions like rosacea) for an off label use for COVID. Physicians around the country should be far less reluctant and far less shamed to use it at this point.

I have to say I was very skeptical of the Ivermectin situation when I first heard about it. After doing a few weeks of research on this situation in November, I began to use it in a very specific group of patients.
If a patient is having any symptoms of COVID or certainly is COVID positive, I immediately get them on this medication. Usually 9-12 mg in a one time dose for 2 weeks. The vast majority have only needed a single dose. I also treat their immediate contacts in their home with the exact same dosing. I am doing no other therapy with this right now.

Before I started doing this, I was admitting to the hospital an average of 2-6 people a week for COVID. I have admitted only a single patient since I started 6-7 weeks ago. I would say the average conversion rate of COVID close contacts before I started this was on the order of 30% or so. I have now had only 4 household contact conversions in the past 6-7 weeks. It has been a very dramatic change. I would make sure everyone understands – the patients still are sick, they are just not sick enough to be placed in a hospital setting. This is not a cure-all. But the potential to unclog our hospitals – and by extension decrease mortality is there for all to see. Big robust studies should begin immediately to test these possible beneficial effects.

I also want everyone to realize my experience up above is anecdotal, a case series, without a control group. It is how we physicians roll in a time of crisis like this.

However, it has encouraged my soul. This may be something that can really help us keep people out of the hospital. This is a no-brainer in my opinion. The risks on this drug are quite minimal. And this may be a godsend for the world until we have better vaccine options and are not living through our current vaccine fiasco.

I would also point out to everyone – look here – That will guide you to your own research regarding world accepted ethics in human research and human medical care as outlined by our forebears in the Declaration of Helsinki. It is my opinion, among many other physicians, that NOT using this drug at this time of crisis in the world is likely a violation of Article 37 of these Helsinki Declarations.

I will have to say, I have not felt this encouraged in a while. I will continue updating all about how this is going.

freebirdJanuary 20, 2021 at 3:50 pm

Mentioned this in the morning links; are there not nations which have been using ivermectin as a therapy with much better results than we have? Cannot a ‘natural’ experiment on say 100 million people substitute for lengthy formal experiments that none of us have time to wait out?

Could we for once in our lives admit perhaps the mighty US is the one behind the curve, and learn from others?

 

1. IM DocJanuary 20, 2021 at 4:41 pm

   In the Western Hemisphere alone – Argentina, Mexico, Belize, Peru and the Dominican Republic all have nationwide or various areas using this drug fairly heavily. I would recommend you look at these areas hospitalization and mortality rates and compare to the rest of the world. Their use of this drug is certainly not the only thing different – but that is why we need to do robust studies to eliminate confounding factors. Argentina, in particular, has been out in front on this entire issue. Much of the work has been done there.

clarky90January 20, 2021 at 4:58 pm

Hi IM Doc

Can you clarify? “Usually 9-12 mg in a one time dose for 2 weeks.” What does two weeks mean, if it is only a one time dose?

Many thanks for your courageous and lifesaving work!

 

1. IM DocJanuary 20, 2021 at 5:47 pm

   Ivermectin is a very fat soluble molecule. So when you take it, it immediately gets deposited into your fat tissue. And then it slowly releases over time. About 2 weeks or so later, in humans, it is gone. So, the dosage is every 2 weeks or so. Some of the inpatient critical care protocols give it a bit more often. I use 9 mg for average sized people, I use 12 mg for obese or really large people. So, I see the patient back frequently that first week. I have had only 2 people out of all that I have done who still have symptoms after 2 weeks, and I dosed them again. Everyone else is done with just that one dose. There are protocols to do prophylaxis with dosing every 2 weeks or so. I am not doing this at all right now because I am not OK with that general idea at least yet – AND more importantly we are already seeing ivermectin shortages here in America. It should be used just for the sick right now.

   One of the other big reasons I am doing this case series is the huge amount of people who have been taking animal ivermectin. I feel this really should be monitored by a doctor and they should be given human formulations. Animal drugs are meant for animal intestines. But the amount of animal ivermectin being taken by humans right now is staggering.

Ronald GrissmanJanuary 20, 2021 at 6:15 pm

You argue that this drug is not evidence based effective in terms as defined by NIH. I know what some docs do in this situation and it tends to fall into 3 categories which I’m not to get into here. Clearly, experience and advanced education beyond an MD makes a difference. Nothing to radical in all that. But, to say “NOT using this drug at this time of crisis in the world is likely a violation of Article 37 of these Helsinki Declarations.” I find extremely problematic. Could I go the my state medical society and make that claim? No. Could I sue a doc for failure to use, as negligence – no. Docs as I was taught need to treat the patient in front on them, considering all the circumstances. I’m not per disagreeing with about what you decide to do or not do. I feel uneasy that as medicine is highly technical matter and those without the training do not understand all the trade offs, one needs to be careful of what one says. I don’t need patients telling me there doctor is in violation of ‘article 37’. Which now I now doubt will hear. The medium often becomes the message

 

1. IM DocJanuary 20, 2021 at 7:09 pm

   I would tell you to please make sure you noticed that I stated IN MY OPINION. Opinions are not hard and fast.

   However, I would also ask you to realize that medical ethics and risk/benefit ratios take on an entirely different tone and intellectual processing in a time of grave crisis. Please note the paper that a commenter above highlighted in their comment. That was about the ebola crisis – but the same issues apply here.

   So not only is there this Ivermectin issue. Because of the nature of this emergency, we have been tasked with exposing the entire world to the enormous risk involved in basically doing a PHASE III clinical trial without the benefit of having any body (IRBs) locally to assess risk to the subjects. This is a brave new world.

   Believe it or not, these are issues that I struggle with daily. The only thing that keeps me going is this is exactly the same kind of thing I was dealing with as a young doctor on the AIDS wards. It is my duty to remember that experience and to make sure my profession remembers the lessons we all learned. I am doing my best to guide my younger colleagues in how to handle crises like this in the most ethical manner possible.

   These ethical frameworks were largely written in the immediate aftermath of WWII and the Nazi crimes against humanity. They were written in a much brighter time than now. The same ideals we as humanity prescribe in the best of times are there to guide us through the worst of times.

   Again – I understand what you are saying, but these are not normal times.

1. 1. MasonJanuary 20, 2021 at 9:36 pm

      Is it the principal of doing the unknown but at the same time making sure it’s low risk, mitigated risk?

      For example, taking vitamin D and C while taking a little zinc. As long as one doesn’t over-dose on the vitamins, there is very very little risk. At the same time, there is an unproven but not impossible risk that lack of vitamin D compromises the immune system and leads to a very severe case.

      I’m just confused at how the powers that be are so resistant to try these measures out. Just take some vitamin supplements!

      I got one physician in the family who was working cases over in the middle of North Carolina. Her worst cases were folks who had a vitamin D deficiency. They actually are a physician couple that worked in the hospital ward, both eventually got covid. They did well but were taking a cocktail of vitamins. I also believe for a period of time they were using hydroxychloroquine. I need to follow up with them.

       
      1. Yves SmithJanuary 20, 2021 at 9:52 pm

         Ivermectin is fat soluble. That does create a concern about dosing, which is one of the big reasons for cautioning people against trying veterinary ivermectin. That is also a potential issue with Vitamin D and zinc but IMHO most of the handwringing regarding Vitamin D is ill informed. 20 minutes of full body exposure to equatorial sun = 20,000 IU. I have never heard of anyone recommending or taking that much orally. Zinc is also fat soluble and the recommended level is 50 mg/day max.

         With water soluble vitamins, the big risks are:

         1. Possibly interfering with meds, so you need to check

         2. Gastric irritation

         3. Overthinning blood (as in reducing ability to clot)

         4. Expensive urine, as in you are just pissing it out

          
2. Yves SmithJanuary 20, 2021 at 9:29 pm

   Your comment is a complete straw man of what IM Doc wrote. And anyone with an operating brain cell knows the Helsinki Declarations are mere guidelines and have even less force in the US than “international law,” as in none.

   I would have ripped your comment out had IM Doc not responded. He has more important things to do that clean up your informational mess and you cherry picking and misrepresenting one tiny part of his comment…to what? To get the rush of a “gotcha”? To try to discredit him? To present you as the smartest guy in the room?

   I am blacklisting you instead.

1. Alan TothJanuary 20, 2021 at 6:46 pm

   But → Among patients with non-severe COVID-19 and no risk factors for severe disease receiving a single 400 mcg/kg dose of ivermectin within 72 h of fever or cough onset there was no difference in the proportion of PCR positives. There was however a marked reduction of self-reported anosmia/hyposmia, a reduction of cough and a tendency to lower viral loads and lower IgG titers which warrants assessment in larger trials.

   And → I also want everyone to realize my experience up above is anecdotal, a case series, without a control group. It is how we physicians roll in a time of crisis like this.

   Thus to say: “physicians, that NOT using this drug at this time of crisis in the world is likely a violation of Article 37 of these Helsinki Declarations.”

   Is without, merit and in fact dangerous. No I’m not kidding.

    
   1. IM DocJanuary 20, 2021 at 7:15 pm

      I would also point you to the numerous randomized controlled trials that have already been done over the world. Some of them not so good – some of them excellent. They all seem to be pointing to the same conclusion. The drug does seem to have an impact on hospitalizations, on death, and on health care workers remaining negative while working with COVID patients.

      We cannot just quote the conclusions of a very small pilot study and think that represents the totality of what has been already done. That certainly would not have made my decision. I do not believe for a minute the NIH would have changed course on this drug had there not been very compelling data otherwise.

       
   2. Yves SmithJanuary 20, 2021 at 9:44 pm

      What I said to Ronald Grissman goes double for you. Cherrypicking, straw manning, bad faith. Trash talking ivermectin as risky is Making Shit Up. It’s an old drug, with decades of use, and the doses discussed here are a bit lower than for its typical application as an antiparasitic. Goodbye.

RE: #COVID19

Variants and chronic infection, a thread:

 

 

Indeed, this particular chronic infection evolved some of the exact same mutations seen in these variant viruses including 484K, 501Y and a 144 deletion. 16/19 pic.twitter.com/BUgESbp1uk

— Trevor Bedford (@trvrb) January 14, 2021

IM DocJanuary 21, 2021 at 10:35 am

In regard to the Dr. Trevor Bedford twitter feeds posted above.

This is truly an amazing thing that has been happening on Twitter and Facebook lately.

Dr. Bedford is truly a world-class researcher at the Fred Hutchinson Center in Seattle. I follow him and multiple dozens like him on Twitter and Facebook. This instant access to real thinking and data has been of great importance. The Twitter platform is not at times the best for this kind of thing. For example, in today’s discussion it is not exactly clear what is meant by “chronic” infections. You can find that out by doing a little digging around – and that is what keeps me on my toes so it is no problem. However, this is ages beyond what we had in the AIDS era and I could not be more pleased.

A big reason why these researchers are having to resort to Twitter and Facebook. Read this piece in The Atlantic. The COVID research has become a tsunami and has overwhelmed our peer review and journal system. They have to put their findings out on Twitter et al because it may take months/years otherwise.

It is dramatic how different this era is than the AIDS crisis – but is also dramatic how much it is the same.

IM DocJanuary 23, 2021 at 11:27 am

As an answer to your comment, I have personally seen multiple patients who clearly have COVID and are COVID positive being started on ZITHROMAX. I have read enough comments about this in the national medical press to know this is a very common practice. It is without any merit at all. There is no evidence that zithromax or any other ANTI-BACTERIAL antibiotic has much effect on COVID one way or the other. There are multiple other anti-virals, and immune modulators that might. Much work in this area remains undone. We are having increasing evidence that IVERMECTIN has COVID effects although the exact pathway remains unknown.

The idea in many providers’ minds seems to be that the patient is sick, likely has pneumonia, and I better cover them with antibacterials just in case. This may actually be harming way more than helping. It is a very unfortunate practice, not just with COVID, that I have spent decades trying to beat out of students.

IM Doc pt8

This is the last of the January 2021 comments. Please see the updated link in the topmost IM-Doc related post on this blog to find the current discussion location..

 First, IM doc's comment is in reference to this post on NC:

Deaths of Despair and the Incidence of Excess Mortality in 2020

Posted on January 29, 2021 by Yves Smith

Yves here. While this paper does a good job of compiling and analyzing data about Covid deaths and excess mortality, and speculating about deaths of despair, I find one of its assumptions to be odd. It sees Covid-related deaths of despair as mainly the result of isolation. In the US, I would hazard that economic desperation is likely a significant factor. Think of the people who had successful or at least viable service businesses: hair stylists, personal trainers, caterers, conference organizers. One friend had a very successful business training and rehabbing pro and Olympic athletes. They’ve gone from pretty to very well situated to frantic about how they will get by.

While Mulligan does mention loss of income in passing in the end, it seems the more devastating but harder to measure damage is loss of livelihood, thinking that your way of earning a living might never come back to anything dimly approaching the old normal. Another catastrophic loss would be the possibility of winding up homeless, particularly for those who’d never faced that risk before.

By Casey Mulligan, Professor of Economics, University of Chicago and former Chief Economist of the White House Council of Economic Advisers. Originally published at VoxEU

The spread of COVID-19 in the US has prompted extraordinary steps by individuals and institutions to limit infections. Some worry that ‘the cure is worse than the disease’ and these measures may lead to an increase in deaths of despair. Using data from the US, this column estimates how many non-COVID-19 excess deaths have occurred during the pandemic. Mortality in 2020 significantly exceeds the total of official COVID-19 deaths and a normal number of deaths from other causes. Certain characteristics suggest the excess are deaths of despair. Social isolation may be part of the mechanism that turns a pandemic into a wave of deaths of despair; further studies are needed to show if that is the case and how.

The spread of COVID-19 in the US has prompted extraordinary, although often untested, steps by individuals and institutions to limit infections. Some have worried that ‘the cure is worse than the disease’. Economists Anne Case and Angus Deaton mocked such worries as a “pet theory about the fatal dangers of quarantine”. They concluded in the summer of 2020 that “a wave of deaths of despair is highly unlikely” because, they said, the duration of a pandemic is measured in months whereas the underlying causes of drug abuse and suicide take many years to accumulate (Case and Deaton 2020). With the extraordinary social distancing continuing and mortality data accumulating, now is a good time to estimate the number of deaths of despair and their incidence.

As a theoretical matter, I am not confident that demand and supply conditions were even approximately constant as the country went into a pandemic recession. Take the demand and supply for non-medical opioid use, which before 2020 accounted for the majority of deaths of despair.1 I acknowledge that the correlation between opioid fatalities and the unemployment rate has been only weakly positive (Council of Economic Advisers February 2020, Ruhm 2019). However, in previous recessions, the income of the unemployed and the nation generally fell.

In this recession, personal income increased record amounts while the majority of the unemployed received more income than they did when they were working (Congressional Budget Office 2020).2 Whereas alcohol and drug abuse can occur in isolation, many normal, non-lethal consumption opportunities disappeared as the population socially distanced. Patients suffering pain may have less access to physical therapy during a pandemic.

On the supply side, social distancing may affect the production of safety.3 A person who overdoses on opioids has a better chance of survival if the overdose event is observed contemporaneously by a person nearby who can administer treatment or call paramedics.4 Socially distanced physicians may be more willing to grant opioid prescriptions over the phone rather than insist on an office visit. Although supply interruptions on the southern border may raise the price of heroin and fentanyl, the market may respond by mixing heroin with more fentanyl and other additives that make each consumption episode more dangerous (Mulligan 2020a, Wan and Long 2020).

Mortality is part of the full price of opioid consumption and therefore a breakdown in safety production may by itself reduce the quantity consumed but nonetheless increase mortality per capita as long as the demand for opioids is price inelastic. I emphasise that these theoretical hypotheses about opioid markets in 2020 are not yet tested empirically. My point is that mortality measurement is needed because the potential for extraordinary changes is real.

The Multiple Cause of Death Files (National Center for Health Statistics 1999–2018) contain information from all death certificates in the US and would be especially valuable for measuring causes of mortality in 2020. However, the public 2020 edition of those files is not expected until early 2022. For the time being, my recent study (Mulligan 2020b) used the 2015–2018 files to project the normal number of 2020 deaths, absent a pandemic.

‘Excess deaths’ are defined to be actual deaths minus projected deaths. Included in the projections, and therefore excluded from excess deaths, are some year-over-year increases in drug overdoses because they had been trending up in recent years, especially among working-age men, as illicit fentanyl diffused across the country.

I measure actual COVID-19 deaths and deaths from all causes from a Centres for Disease Control and Prevention (CDC) file for 2020 that begins in week five (the week beginning 26 January 2020) and aggregates to week, sex, and eleven age groups. To minimise underreporting, I only use the data in this file through week 40 (the week ending 3 October). In separate analyses, I also use medical examiner data from Cook County, Illinois, and San Diego County, California, which indicate deaths handled by those offices through September (Cook) or June 2020 (San Diego) and whether opioids were involved, and 12-month moving sums of drug overdoses reported by CDC (2020) through May 2020.

Mortality in 2020 significantly exceeds what would have occurred if official COVID-19 deaths were combined with a normal number of deaths from other causes. The demographic and time patterns of the non-COVID-19 excess deaths (NCEDs) point to deaths of despair rather than an undercount of COVID-19 deaths. The flow of NCEDs increased steadily from March to June and then plateaued. They were disproportionately experienced by working-age men, including men as young as 15 to 24. The chart below, reproduced from Mulligan (2020b), shows these results for men aged 15–54. To compare the weekly timing of their excess deaths to a weekly measure of economic conditions, Figure 1 also includes continued state unemployment claims scaled by a factor of 25,000, shown together with deaths.

Figure 1 2020 weekly excess deaths by cause (men aged 15–54)

NCEDs are negative for elderly people before March 2020, as they were during the same time of 2019, due to mild flu seasons. Offsetting these negative NCEDs are about 30,000 positive NCEDs for the rest of the year, after accounting for an estimated 17,000 undercount of COVID-19 deaths in March and April.

If deaths of despair were the only causes of death with significant net contributions to NCEDs after February, 30,000 NCEDs would represent at least a 45% increase in deaths of despair from 2018, which itself was high by historical standards. At the same time, I cannot rule out the possibility that other non-COVID-19 causes of death or even a bit of COVID-19 undercounting (beyond my estimates) are contributing to the NCED totals.

One federal and various local measures of mortality from opioid overdose also point to mortality rates during the pandemic that exceed those of late 2019 and early 2020, which themselves exceed the rates for 2017 and 2018. These sources are not precise enough to indicate whether rates of fatal opioid overdose during the pandemic were 10% above the rates from before, 60% above, or somewhere in between.

Presumably, social isolation is part of the mechanism that turns a pandemic into a wave of deaths of despair. However, the results so far do not say how many, if any, come from government stay-at-home orders versus various actions individual households and private businesses have taken to encourage social distancing. The data in this paper do not reveal how many deaths of despair are due to changes in ‘demand’ – such as changes in a person’s income, outlook, or employment situation – versus changes in ‘supply’ – such as the production of safety and a changing composition of dangerous recreational substances.

See original post for references

IM DocJanuary 29, 2021 at 1:39 pm

As an internist with boots on the ground – I cannot express enough gratitude that these kinds of reports are getting out.

As busy as I have been this past year with COVID, the actual patients struggling with anxiety and depression have just dwarved the actual COVID numbers.

I cannot even begin to tell you the heartbreak of being a provider and having 20-40 year old young men in your office crying their eyes out. Lots of job loss, lots of income issues, lots of not being able to pay for things for your kids. All the while being completely unable to find other work or extra work. It is truly a nightmare for these people. And the attitude by so many of the lockdown Karens who seem to have no conception of how this is all going down for these young people has been deeply worrisome to me.
It is really not getting better – if anything slowly getting worse.

I would agree with the article above that loneliness is a problem – this is for the minority – mainly older people and should not be dismissed.

Loneliness is not the big problem however, in my experience. The big problem is the economic despair for our young people and the complete loss of socialization for our teenagers and kids.

And I have no clue what the answer is.

1. Subsequent comments are not related to the information above
2. IM DocJanuary 31, 2021 at 7:41 pm

   I hit the lottery in my medical residency when Dr. Fauci was in our city for a week. This was decades ago. He was on our Infectious Disease rounds during the midst of the AIDS epidemic. An incredible memory. He was a class act all around. Most Americans do not realize – he is to this day one of the lead editors, credited on the cover, of our foundational Internal Medicine Textbook – Harrison’s.

   Has he made mistakes? Absolutely. Have we all? Absolutely. I have watched him all this past year exemplifying for every American the concept of working in an impossible situation. I would add it was not just Trump. I distinctly remember two Congressional hearings when it was obvious he was trying to talk/educate and the Congresspeople were just yelling over him.

IM DocJanuary 31, 2021 at 7:48 pm

I hesitate to post this reference.

Let me explain.

The gentleman that runs that blog is at times a crackpot. But at times he is brilliant. I do not really agree with his politics, but I do read his blog to see what informed people on different sides are thinking.

Surprisingly, he posted this today. To be fair and honest, this piece is highly well-referenced and it corresponds to things I have been hearing from Coronavirus experts in Grand Rounds all year.

This was not written by the owner of that blog, rather, it is some type of guest post which I have to be honest, I have never seen him do before. They clearly know what they are talking about. And it is as good a discussion of “gain of function” research written in non-jargon English I have ever seen.

FWIW, the questions asked at the end have never been successfully answered and are indeed critical to our understanding of this situation.

Comments

Based on what I have been hearing sub rosa –

The Ivermectin therapy actually does help – There are multiple RCTs out of varying quality, none of them I would call really well done enough to trust. Some of these trials are abysmally done. Anecdotally, I have patients who are taking veterinary Ivermectin ( would never recommend) which in many locations can be had over the counter. Anecdotally, they do seem to get better quicker. Ivermectin has been out for decades and has a very good safety profile if used correctly. Anyone on multiple other meds should have their physician look over this. Interestingly, and anecdotally, I have had 3 family clusters in my practice in which all subjects in the cluster began to take Ivermectin immediately when one person became positive. None of the others in any of those 3 clusters became positive. I have had one other family cluster where the initial patient and one other become positive, the other 3 people in that cluster remained negative. I live in a very rural area where Ivermectin is widely available and people are doing this on their own. Being my old-fashioned self, I do feel strongly that this needs to be immediately studied in real trials that are well done and have statistical significance.

Ivermectin is a widely used OTC product used in much of the world for many things. Many people in the 3rd world take it on a regular basis for all kinds of issues. Again, it has a very good safety profile.

It is also very cheap. That is unless and until a pharma god like Shkreli gets hold of it and all of a sudden it is thousands of dollars a dose. I am certain this is already being worked on by multiple pointed heads all over Manhattan.

The problem that gets sticky, and I heard a very good discussion in a conference this past week from a pharma lawyer is that the Emergency Use Authorizations for the vaccines are apparently only legal if there is no other viable therapy available. If indeed the WHO, or any other large well-done trials, show that Ivermectin is a viable therapy, the EUAs would immediately be null and void. The vaccines would then have to be withdrawn and the regular approval process would have to be followed. This is the black and white of what is in the EUA laws. This obviously has never been tested in court – and who knows what will happen if this becomes an issue. There are obviously numerous different takes on this on multiple legal fronts.

Based on what I have been hearing sub rosa –

The Ivermectin therapy actually does help – There are multiple RCTs out of varying quality, none of them I would call really well done enough to trust. Some of these trials are abysmally done. Anecdotally, I have patients who are taking veterinary Ivermectin ( would never recommend) which in many locations can be had over the counter. Anecdotally, they do seem to get better quicker. Ivermectin has been out for decades and has a very good safety profile if used correctly. Anyone on multiple other meds should have their physician look over this. Interestingly, and anecdotally, I have had 3 family clusters in my practice in which all subjects in the cluster began to take Ivermectin immediately when one person became positive. None of the others in any of those 3 clusters became positive. I have had one other family cluster where the initial patient and one other become positive, the other 3 people in that cluster remained negative. I live in a very rural area where Ivermectin is widely available and people are doing this on their own. Being my old-fashioned self, I do feel strongly that this needs to be immediately studied in real trials that are well done and have statistical significance.

Ivermectin is a widely used OTC product used in much of the world for many things. Many people in the 3rd world take it on a regular basis for all kinds of issues. Again, it has a very good safety profile.

It is also very cheap. That is unless and until a pharma god like Shkreli gets hold of it and all of a sudden it is thousands of dollars a dose. I am certain this is already being worked on by multiple pointed heads all over Manhattan.

The problem that gets sticky, and I heard a very good discussion in a conference this past week from a pharma lawyer is that the Emergency Use Authorizations for the vaccines are apparently only legal if there is no other viable therapy available. If indeed the WHO, or any other large well-done trials, show that Ivermectin is a viable therapy, the EUAs would immediately be null and void. The vaccines would then have to be withdrawn and the regular approval process would have to be followed. This is the black and white of what is in the EUA laws. This obviously has never been tested in court – and who knows what will happen if this becomes an issue. There are obviously numerous different takes on this on multiple legal fronts.

It is the same molecule – so I am not so concerned about the actual Ivermectin molecule. Based on the type of animal, they are often in different media that may not work so well on humans. Also, the dosing may be different for a cow or horse and again, the amount of medication in the pills is formulated to dissolve in that specific animal intestine. I have never had a problem with veterinary Ivermectin. I have, however, had problems with other medications. It is a tragedy that I have people in rural America who can afford animal meds but not human meds and take the chance. Because this is a real thing in our society, I encourage them to bring them in for me to evaluate for safety. Never in my wildest dreams did I ever see myself doing this – but that is unfortunately the world we live in.

The safety issues with Ivermectin in humans seem to be concentrated on transplant drugs like tacrolimus and cyclosporin, on HIV drugs, on antifungal drugs and on some types of antibiotics.

I would point everyone to this website [TR adds: this link no longer works - this may be a different version of it, but I cannot confirm https://www.evms.edu/media/t4_training/EVMS_Critical_Care_COVID-19_Protocol.pdf.] They have been updating this protocol since the beginning. They use evidence based medicine. They are basically the entire Department of Medicine – primary care, critical care, infectious disease – at one of our medical schools – Eastern Virginia. They have been way out over the curve on this epidemic from the beginning. They instantly update this protocol with new findings. In my opinion, they are doing a much better public service than many of our government agencies.

You can see where they are using Ivermectin – and it is being done more and more by my colleagues all over the world. Because of the very good safety profile, I am very likely to start doing this myself. I would much rather do this in a controlled manner rather than having people use literal horse pills.

What are your reservations about using veterinary ivermectin and veterinary medications in general?

What are your reservations about using veterinary ivermectin and veterinary medications in general?

It is the same molecule – so I am not so concerned about the actual Ivermectin molecule. Based on the type of animal, they are often in different media that may not work so well on humans. Also, the dosing may be different for a cow or horse and again, the amount of medication in the pills is formulated to dissolve in that specific animal intestine. I have never had a problem with veterinary Ivermectin. I have, however, had problems with other medications. It is a tragedy that I have people in rural America who can afford animal meds but not human meds and take the chance. Because this is a real thing in our society, I encourage them to bring them in for me to evaluate for safety. Never in my wildest dreams did I ever see myself doing this – but that is unfortunately the world we live in.

The safety issues with Ivermectin in humans seem to be concentrated on transplant drugs like tacrolimus and cyclosporin, on HIV drugs, on antifungal drugs and on some types of antibiotics.

I would point everyone to this website [TR adds: this link no longer works - this may be a different version of it, but I cannot confirm https://www.evms.edu/media/t4_training/EVMS_Critical_Care_COVID-19_Protocol.pdf.] They have been updating this protocol since the beginning. They use evidence based medicine. They are basically the entire Department of Medicine – primary care, critical care, infectious disease – at one of our medical schools – Eastern Virginia. They have been way out over the curve on this epidemic from the beginning. They instantly update this protocol with new findings. In my opinion, they are doing a much better public service than many of our government agencies.

You can see where they are using Ivermectin – and it is being done more and more by my colleagues all over the world. Because of the very good safety profile, I am very likely to start doing this myself. I would much rather do this in a controlled manner rather than having people use literal horse pills.

It is the same molecule – so I am not so concerned about the actual Ivermectin molecule. Based on the type of animal, they are often in different media that may not work so well on humans. Also, the dosing may be different for a cow or horse and again, the amount of medication in the pills is formulated to dissolve in that specific animal intestine. I have never had a problem with veterinary Ivermectin. I have, however, had problems with other medications. It is a tragedy that I have people in rural America who can afford animal meds but not human meds and take the chance. Because this is a real thing in our society, I encourage them to bring them in for me to evaluate for safety. Never in my wildest dreams did I ever see myself doing this – but that is unfortunately the world we live in.

The safety issues with Ivermectin in humans seem to be concentrated on transplant drugs like tacrolimus and cyclosporin, on HIV drugs, on antifungal drugs and on some types of antibiotics.

I would point everyone to this website [TR adds: this link no longer works - this may be a different version of it, but I cannot confirm https://www.evms.edu/media/t4_training/EVMS_Critical_Care_COVID-19_Protocol.pdf.] They have been updating this protocol since the beginning. They use evidence based medicine. They are basically the entire Department of Medicine – primary care, critical care, infectious disease – at one of our medical schools – Eastern Virginia. They have been way out over the curve on this epidemic from the beginning. They instantly update this protocol with new findings. In my opinion, they are doing a much better public service than many of our government agencies.

You can see where they are using Ivermectin – and it is being done more and more by my colleagues all over the world. Because of the very good safety profile, I am very likely to start doing this myself. I would much rather do this in a controlled manner rather than having people use literal horse pills.

It is the same molecule – so I am not so concerned about the actual Ivermectin molecule. Based on the type of animal, they are often in different media that may not work so well on humans. Also, the dosing may be different for a cow or horse and again, the amount of medication in the pills is formulated to dissolve in that specific animal intestine. I have never had a problem with veterinary Ivermectin. I have, however, had problems with other medications. It is a tragedy that I have people in rural America who can afford animal meds but not human meds and take the chance. Because this is a real thing in our society, I encourage them to bring them in for me to evaluate for safety. Never in my wildest dreams did I ever see myself doing this – but that is unfortunately the world we live in.

The safety issues with Ivermectin in humans seem to be concentrated on transplant drugs like tacrolimus and cyclosporin, on HIV drugs, on antifungal drugs and on some types of antibiotics.

I would point everyone to this website [TR adds: this link no longer works - this may be a different version of it, but I cannot confirm https://www.evms.edu/media/t4_training/EVMS_Critical_Care_COVID-19_Protocol.pdf.] They have been updating this protocol since the beginning. They use evidence based medicine. They are basically the entire Department of Medicine – primary care, critical care, infectious disease – at one of our medical schools – Eastern Virginia. They have been way out over the curve on this epidemic from the beginning. They instantly update this protocol with new findings. In my opinion, they are doing a much better public service than many of our government agencies.

You can see where they are using Ivermectin – and it is being done more and more by my colleagues all over the world. Because of the very good safety profile, I am very likely to start doing this myself. I would much rather do this in a controlled manner rather than having people use literal horse pills.

You have me at a disadvantage sir. I believed that I was following proper usage. Do enlighten me, seriously. Language can be a slippery beastie at the best of times.
Should the placement have been MD before GP?
Your humble and obedient servant;
Simplicius

You have me at a disadvantage sir. I believed that I was following proper usage. Do enlighten me, seriously. Language can be a slippery beastie at the best of times.
Should the placement have been MD before GP?
Your humble and obedient servant;
Simplicius

I will try to explain.

Internal medicine is a specialty in medicine – 3 years of training after medical school. Has changed somewhat over the years – but in general- trained to take care of sicker patients with multiple medical issues. They also see people in the hospital – but even that has been changed in the past 10 years. This 3 year training must be completed by anyone doing any of the subspecialty training programs – cardiology, GI, ID, etc. Dr. House was a general internist as was Dr. Marcus Welby.

Family practice – is a specialty mainly for outpatient care of all ages including peds. There was a time, especially in rural medicine where they did minor surgery and OB procedures – but that has largely passed us by. They are not as thoroughly trained in very sick care.

GP – or general practitioners – really have disappeared – and the new graduates that do this now are often a bit shady as far as their training. In general, this means that someone has done JUST an internship – not a full residency to specialize in internal medicine or family practice. This was very common generations ago – but no longer is. The ones that do this here in the USA are either very old, or new grads with problems – usually drug related.

When people say GP in America – they are usually referring to a PCP – and that is almost always a family practice doc or a general internist.

I will try to explain.

Internal medicine is a specialty in medicine – 3 years of training after medical school. Has changed somewhat over the years – but in general- trained to take care of sicker patients with multiple medical issues. They also see people in the hospital – but even that has been changed in the past 10 years. This 3 year training must be completed by anyone doing any of the subspecialty training programs – cardiology, GI, ID, etc. Dr. House was a general internist as was Dr. Marcus Welby.

Family practice – is a specialty mainly for outpatient care of all ages including peds. There was a time, especially in rural medicine where they did minor surgery and OB procedures – but that has largely passed us by. They are not as thoroughly trained in very sick care.

GP – or general practitioners – really have disappeared – and the new graduates that do this now are often a bit shady as far as their training. In general, this means that someone has done JUST an internship – not a full residency to specialize in internal medicine or family practice. This was very common generations ago – but no longer is. The ones that do this here in the USA are either very old, or new grads with problems – usually drug related.

When people say GP in America – they are usually referring to a PCP – and that is almost always a family practice doc or a general internist.

I will try to explain.

Internal medicine is a specialty in medicine – 3 years of training after medical school. Has changed somewhat over the years – but in general- trained to take care of sicker patients with multiple medical issues. They also see people in the hospital – but even that has been changed in the past 10 years. This 3 year training must be completed by anyone doing any of the subspecialty training programs – cardiology, GI, ID, etc. Dr. House was a general internist as was Dr. Marcus Welby.

Family practice – is a specialty mainly for outpatient care of all ages including peds. There was a time, especially in rural medicine where they did minor surgery and OB procedures – but that has largely passed us by. They are not as thoroughly trained in very sick care.

GP – or general practitioners – really have disappeared – and the new graduates that do this now are often a bit shady as far as their training. In general, this means that someone has done JUST an internship – not a full residency to specialize in internal medicine or family practice. This was very common generations ago – but no longer is. The ones that do this here in the USA are either very old, or new grads with problems – usually drug related.

When people say GP in America – they are usually referring to a PCP – and that is almost always a family practice doc or a general internist.

Further went on to say that “they” had gene sequenced the virus in January 2020 and had developed the vaccine over a weekend …I’m not saying this is fact

Sure it’s fact. Slightly misunderstood in your version ….

[1] The “they” who sequenced the virus were scientists over in China, who then sent the sequence over the internet so the scientists at Moderna could build the coronavirus in silico, then build a vaccine for it the same way.

Presumably, a little later Moderna would have synthesized the virus and vaccine in vivo to make sure the real things matched the computer models. Very easily done — it’s not a big virus.

[2] This sort of thing has been routine biotech for (at least) 15-18 years now.

That’s why I’m a little sceptical about stories featuring accidental escape of a COV19 ‘gain-of-function’ model from the Wuhan lab, which is supposedly one of the most advanced labs on the planet. It’s possible, I grant, and certainly that sort of thing happened in the 1980s. But biotech capabilities and working methods between then and now have changed utterly.

[3] As regards the over-the-weekend part, yes — that’s the point about mRNA vaccines. They’re meant to provide a very flexible chassis for any kind of vaccine.

Moderna’s original business model was that it was going to build cancer vaccines i.e. personalized medicine on an expensive individual basis; a given cancer patient would have their tumor cells sequenced and this would then be the basis for building an individual-specific mRNA vaccine for that cancer.

So it would have been an obvious thing to apply the technology to COV19

I saw my PCP last week for this first time in a while. At the end, I asked how he was doing, generally, and he volunteered that he had just taken the first shot. He has no issues with it. I asked him if it was the mRNA version, and he said yes. Further went on to say that “they” had gene sequenced the virus in January 2020 and had developed the vaccine over a weekend.

Don’t shoot the messenger. I’m not saying this is fact, but it is most certainly a fact that he volunteered this info to me in casual conversation.

I saw my PCP last week for this first time in a while. At the end, I asked how he was doing, generally, and he volunteered that he had just taken the first shot. He has no issues with it. I asked him if it was the mRNA version, and he said yes. Further went on to say that “they” had gene sequenced the virus in January 2020 and had developed the vaccine over a weekend.

Don’t shoot the messenger. I’m not saying this is fact, but it is most certainly a fact that he volunteered this info to me in casual conversation.

Further went on to say that “they” had gene sequenced the virus in January 2020 and had developed the vaccine over a weekend …I’m not saying this is fact

Sure it’s fact. Slightly misunderstood in your version ….

[1] The “they” who sequenced the virus were scientists over in China, who then sent the sequence over the internet so the scientists at Moderna could build the coronavirus in silico, then build a vaccine for it the same way.

Presumably, a little later Moderna would have synthesized the virus and vaccine in vivo to make sure the real things matched the computer models. Very easily done — it’s not a big virus.

[2] This sort of thing has been routine biotech for (at least) 15-18 years now.

That’s why I’m a little sceptical about stories featuring accidental escape of a COV19 ‘gain-of-function’ model from the Wuhan lab, which is supposedly one of the most advanced labs on the planet. It’s possible, I grant, and certainly that sort of thing happened in the 1980s. But biotech capabilities and working methods between then and now have changed utterly.

[3] As regards the over-the-weekend part, yes — that’s the point about mRNA vaccines. They’re meant to provide a very flexible chassis for any kind of vaccine.

Moderna’s original business model was that it was going to build cancer vaccines i.e. personalized medicine on an expensive individual basis; a given cancer patient would have their tumor cells sequenced and this would then be the basis for building an individual-specific mRNA vaccine for that cancer.

So it would have been an obvious thing to apply the technology to COV19

This is largely true. He forgot to tell you the part where they discussed this over a few drinks in a bar and started their work on a napkin. I am trying to find the link with this story – but no luck as of yet. If I find it I will post.

This is largely true. He forgot to tell you the part where they discussed this over a few drinks in a bar and started their work on a napkin. I am trying to find the link with this story – but no luck as of yet. If I find it I will post.

Further went on to say that “they” had gene sequenced the virus in January 2020 and had developed the vaccine over a weekend …I’m not saying this is fact

Sure it’s fact. Slightly misunderstood in your version ….

[1] The “they” who sequenced the virus were scientists over in China, who then sent the sequence over the internet so the scientists at Moderna could build the coronavirus in silico, then build a vaccine for it the same way.

Presumably, a little later Moderna would have synthesized the virus and vaccine in vivo to make sure the real things matched the computer models. Very easily done — it’s not a big virus.

[2] This sort of thing has been routine biotech for (at least) 15-18 years now.

That’s why I’m a little sceptical about stories featuring accidental escape of a COV19 ‘gain-of-function’ model from the Wuhan lab, which is supposedly one of the most advanced labs on the planet. It’s possible, I grant, and certainly that sort of thing happened in the 1980s. But biotech capabilities and working methods between then and now have changed utterly.

[3] As regards the over-the-weekend part, yes — that’s the point about mRNA vaccines. They’re meant to provide a very flexible chassis for any kind of vaccine.

Moderna’s original business model was that it was going to build cancer vaccines i.e. personalized medicine on an expensive individual basis; a given cancer patient would have their tumor cells sequenced and this would then be the basis for building an individual-specific mRNA vaccine for that cancer.

So it would have been an obvious thing to apply the technology to COV19

Further went on to say that “they” had gene sequenced the virus in January 2020 and had developed the vaccine over a weekend …I’m not saying this is fact

Sure it’s fact. Slightly misunderstood in your version ….

[1] The “they” who sequenced the virus were scientists over in China, who then sent the sequence over the internet so the scientists at Moderna could build the coronavirus in silico, then build a vaccine for it the same way.

Presumably, a little later Moderna would have synthesized the virus and vaccine in vivo to make sure the real things matched the computer models. Very easily done — it’s not a big virus.

[2] This sort of thing has been routine biotech for (at least) 15-18 years now.

That’s why I’m a little sceptical about stories featuring accidental escape of a COV19 ‘gain-of-function’ model from the Wuhan lab, which is supposedly one of the most advanced labs on the planet. It’s possible, I grant, and certainly that sort of thing happened in the 1980s. But biotech capabilities and working methods between then and now have changed utterly.

[3] As regards the over-the-weekend part, yes — that’s the point about mRNA vaccines. They’re meant to provide a very flexible chassis for any kind of vaccine.

Moderna’s original business model was that it was going to build cancer vaccines i.e. personalized medicine on an expensive individual basis; a given cancer patient would have their tumor cells sequenced and this would then be the basis for building an individual-specific mRNA vaccine for that cancer.

So it would have been an obvious thing to apply the technology to COV19

Further went on to say that “they” had gene sequenced the virus in January 2020 and had developed the vaccine over a weekend …I’m not saying this is fact

Sure it’s fact. Slightly misunderstood in your version ….

[1] The “they” who sequenced the virus were scientists over in China, who then sent the sequence over the internet so the scientists at Moderna could build the coronavirus in silico, then build a vaccine for it the same way.

Presumably, a little later Moderna would have synthesized the virus and vaccine in vivo to make sure the real things matched the computer models. Very easily done — it’s not a big virus.

[2] This sort of thing has been routine biotech for (at least) 15-18 years now.

That’s why I’m a little sceptical about stories featuring accidental escape of a COV19 ‘gain-of-function’ model from the Wuhan lab, which is supposedly one of the most advanced labs on the planet. It’s possible, I grant, and certainly that sort of thing happened in the 1980s. But biotech capabilities and working methods between then and now have changed utterly.

[3] As regards the over-the-weekend part, yes — that’s the point about mRNA vaccines. They’re meant to provide a very flexible chassis for any kind of vaccine.

Moderna’s original business model was that it was going to build cancer vaccines i.e. personalized medicine on an expensive individual basis; a given cancer patient would have their tumor cells sequenced and this would then be the basis for building an individual-specific mRNA vaccine for that cancer.

So it would have been an obvious thing to apply the technology to COV19

I am not certain what I am doing to make the comments in italics.

I am responding to the link this morning about the Ivermectin study. This was a pilot study. It is basically a very small study to see if there is enough data support to warrant a larger study. In this case, there clearly is.

I have been very reluctant to discuss my Ivermectin experience – but I feel with all the news coming out, I should at least say something.

The NIH did something extraordinary last week by upgrading ivermectin for COVID. Before Friday, it was considered a STRONG AGAINST recommendation. As of Friday, our own NIH has upgraded this medication ivermectin for COVID to neither encourage or discourage. That may not sound like much to a layman – but in medicine that is a huge deal. Ivermectin has now joined the same NIH “neither discourage or encourage” recommendation level as remdesevir, convalescent plasma, and monoclonal antibodies that we have all been hearing about over the past months. This NIH action opened up the use of this already FDA approved drug (for parasitic infections and immune conditions like rosacea) for an off label use for COVID. Physicians around the country should be far less reluctant and far less shamed to use it at this point.

I have to say I was very skeptical of the Ivermectin situation when I first heard about it. After doing a few weeks of research on this situation in November, I began to use it in a very specific group of patients.
If a patient is having any symptoms of COVID or certainly is COVID positive, I immediately get them on this medication. Usually 9-12 mg in a one time dose for 2 weeks. The vast majority have only needed a single dose. I also treat their immediate contacts in their home with the exact same dosing. I am doing no other therapy with this right now.

Before I started doing this, I was admitting to the hospital an average of 2-6 people a week for COVID. I have admitted only a single patient since I started 6-7 weeks ago. I would say the average conversion rate of COVID close contacts before I started this was on the order of 30% or so. I have now had only 4 household contact conversions in the past 6-7 weeks. It has been a very dramatic change. I would make sure everyone understands – the patients still are sick, they are just not sick enough to be placed in a hospital setting. This is not a cure-all. But the potential to unclog our hospitals – and by extension decrease mortality is there for all to see. Big robust studies should begin immediately to test these possible beneficial effects.

I also want everyone to realize my experience up above is anecdotal, a case series, without a control group. It is how we physicians roll in a time of crisis like this.

However, it has encouraged my soul. This may be something that can really help us keep people out of the hospital. This is a no-brainer in my opinion. The risks on this drug are quite minimal. And this may be a godsend for the world until we have better vaccine options and are not living through our current vaccine fiasco.

I would also point out to everyone – look here – That will guide you to your own research regarding world accepted ethics in human research and human medical care as outlined by our forebears in the Declaration of Helsinki. It is my opinion, among many other physicians, that NOT using this drug at this time of crisis in the world is likely a violation of Article 37 of these Helsinki Declarations.

I will have to say, I have not felt this encouraged in a while. I will continue updating all about how this is going.

Mentioned this in the morning links; are there not nations which have been using ivermectin as a therapy with much better results than we have? Cannot a ‘natural’ experiment on say 100 million people substitute for lengthy formal experiments that none of us have time to wait out?

Could we for once in our lives admit perhaps the mighty US is the one behind the curve, and learn from others?

Mentioned this in the morning links; are there not nations which have been using ivermectin as a therapy with much better results than we have? Cannot a ‘natural’ experiment on say 100 million people substitute for lengthy formal experiments that none of us have time to wait out?

Could we for once in our lives admit perhaps the mighty US is the one behind the curve, and learn from others?

In the Western Hemisphere alone – Argentina, Mexico, Belize, Peru and the Dominican Republic all have nationwide or various areas using this drug fairly heavily. I would recommend you look at these areas hospitalization and mortality rates and compare to the rest of the world. Their use of this drug is certainly not the only thing different – but that is why we need to do robust studies to eliminate confounding factors. Argentina, in particular, has been out in front on this entire issue. Much of the work has been done there.

In the Western Hemisphere alone – Argentina, Mexico, Belize, Peru and the Dominican Republic all have nationwide or various areas using this drug fairly heavily. I would recommend you look at these areas hospitalization and mortality rates and compare to the rest of the world. Their use of this drug is certainly not the only thing different – but that is why we need to do robust studies to eliminate confounding factors. Argentina, in particular, has been out in front on this entire issue. Much of the work has been done there.

In the Western Hemisphere alone – Argentina, Mexico, Belize, Peru and the Dominican Republic all have nationwide or various areas using this drug fairly heavily. I would recommend you look at these areas hospitalization and mortality rates and compare to the rest of the world. Their use of this drug is certainly not the only thing different – but that is why we need to do robust studies to eliminate confounding factors. Argentina, in particular, has been out in front on this entire issue. Much of the work has been done there.

Hi IM Doc

Can you clarify? “Usually 9-12 mg in a one time dose for 2 weeks.” What does two weeks mean, if it is only a one time dose?

Many thanks for your courageous and lifesaving work!

Hi IM Doc

Can you clarify? “Usually 9-12 mg in a one time dose for 2 weeks.” What does two weeks mean, if it is only a one time dose?

Many thanks for your courageous and lifesaving work!

Ivermectin is a very fat soluble molecule. So when you take it, it immediately gets deposited into your fat tissue. And then it slowly releases over time. About 2 weeks or so later, in humans, it is gone. So, the dosage is every 2 weeks or so. Some of the inpatient critical care protocols give it a bit more often. I use 9 mg for average sized people, I use 12 mg for obese or really large people. So, I see the patient back frequently that first week. I have had only 2 people out of all that I have done who still have symptoms after 2 weeks, and I dosed them again. Everyone else is done with just that one dose. There are protocols to do prophylaxis with dosing every 2 weeks or so. I am not doing this at all right now because I am not OK with that general idea at least yet – AND more importantly we are already seeing ivermectin shortages here in America. It should be used just for the sick right now.

One of the other big reasons I am doing this case series is the huge amount of people who have been taking animal ivermectin. I feel this really should be monitored by a doctor and they should be given human formulations. Animal drugs are meant for animal intestines. But the amount of animal ivermectin being taken by humans right now is staggering.

Ivermectin is a very fat soluble molecule. So when you take it, it immediately gets deposited into your fat tissue. And then it slowly releases over time. About 2 weeks or so later, in humans, it is gone. So, the dosage is every 2 weeks or so. Some of the inpatient critical care protocols give it a bit more often. I use 9 mg for average sized people, I use 12 mg for obese or really large people. So, I see the patient back frequently that first week. I have had only 2 people out of all that I have done who still have symptoms after 2 weeks, and I dosed them again. Everyone else is done with just that one dose. There are protocols to do prophylaxis with dosing every 2 weeks or so. I am not doing this at all right now because I am not OK with that general idea at least yet – AND more importantly we are already seeing ivermectin shortages here in America. It should be used just for the sick right now.

One of the other big reasons I am doing this case series is the huge amount of people who have been taking animal ivermectin. I feel this really should be monitored by a doctor and they should be given human formulations. Animal drugs are meant for animal intestines. But the amount of animal ivermectin being taken by humans right now is staggering.

Ivermectin is a very fat soluble molecule. So when you take it, it immediately gets deposited into your fat tissue. And then it slowly releases over time. About 2 weeks or so later, in humans, it is gone. So, the dosage is every 2 weeks or so. Some of the inpatient critical care protocols give it a bit more often. I use 9 mg for average sized people, I use 12 mg for obese or really large people. So, I see the patient back frequently that first week. I have had only 2 people out of all that I have done who still have symptoms after 2 weeks, and I dosed them again. Everyone else is done with just that one dose. There are protocols to do prophylaxis with dosing every 2 weeks or so. I am not doing this at all right now because I am not OK with that general idea at least yet – AND more importantly we are already seeing ivermectin shortages here in America. It should be used just for the sick right now.

One of the other big reasons I am doing this case series is the huge amount of people who have been taking animal ivermectin. I feel this really should be monitored by a doctor and they should be given human formulations. Animal drugs are meant for animal intestines. But the amount of animal ivermectin being taken by humans right now is staggering.

You argue that this drug is not evidence based effective in terms as defined by NIH. I know what some docs do in this situation and it tends to fall into 3 categories which I’m not to get into here. Clearly, experience and advanced education beyond an MD makes a difference. Nothing to radical in all that. But, to say “NOT using this drug at this time of crisis in the world is likely a violation of Article 37 of these Helsinki Declarations.” I find extremely problematic. Could I go the my state medical society and make that claim? No. Could I sue a doc for failure to use, as negligence – no. Docs as I was taught need to treat the patient in front on them, considering all the circumstances. I’m not per disagreeing with about what you decide to do or not do. I feel uneasy that as medicine is highly technical matter and those without the training do not understand all the trade offs, one needs to be careful of what one says. I don’t need patients telling me there doctor is in violation of ‘article 37’. Which now I now doubt will hear. The medium often becomes the message

You argue that this drug is not evidence based effective in terms as defined by NIH. I know what some docs do in this situation and it tends to fall into 3 categories which I’m not to get into here. Clearly, experience and advanced education beyond an MD makes a difference. Nothing to radical in all that. But, to say “NOT using this drug at this time of crisis in the world is likely a violation of Article 37 of these Helsinki Declarations.” I find extremely problematic. Could I go the my state medical society and make that claim? No. Could I sue a doc for failure to use, as negligence – no. Docs as I was taught need to treat the patient in front on them, considering all the circumstances. I’m not per disagreeing with about what you decide to do or not do. I feel uneasy that as medicine is highly technical matter and those without the training do not understand all the trade offs, one needs to be careful of what one says. I don’t need patients telling me there doctor is in violation of ‘article 37’. Which now I now doubt will hear. The medium often becomes the message

I would tell you to please make sure you noticed that I stated IN MY OPINION. Opinions are not hard and fast.

However, I would also ask you to realize that medical ethics and risk/benefit ratios take on an entirely different tone and intellectual processing in a time of grave crisis. Please note the paper that a commenter above highlighted in their comment. That was about the ebola crisis – but the same issues apply here.

So not only is there this Ivermectin issue. Because of the nature of this emergency, we have been tasked with exposing the entire world to the enormous risk involved in basically doing a PHASE III clinical trial without the benefit of having any body (IRBs) locally to assess risk to the subjects. This is a brave new world.

Believe it or not, these are issues that I struggle with daily. The only thing that keeps me going is this is exactly the same kind of thing I was dealing with as a young doctor on the AIDS wards. It is my duty to remember that experience and to make sure my profession remembers the lessons we all learned. I am doing my best to guide my younger colleagues in how to handle crises like this in the most ethical manner possible.

These ethical frameworks were largely written in the immediate aftermath of WWII and the Nazi crimes against humanity. They were written in a much brighter time than now. The same ideals we as humanity prescribe in the best of times are there to guide us through the worst of times.

Again – I understand what you are saying, but these are not normal times.

I would tell you to please make sure you noticed that I stated IN MY OPINION. Opinions are not hard and fast.

However, I would also ask you to realize that medical ethics and risk/benefit ratios take on an entirely different tone and intellectual processing in a time of grave crisis. Please note the paper that a commenter above highlighted in their comment. That was about the ebola crisis – but the same issues apply here.

So not only is there this Ivermectin issue. Because of the nature of this emergency, we have been tasked with exposing the entire world to the enormous risk involved in basically doing a PHASE III clinical trial without the benefit of having any body (IRBs) locally to assess risk to the subjects. This is a brave new world.

Believe it or not, these are issues that I struggle with daily. The only thing that keeps me going is this is exactly the same kind of thing I was dealing with as a young doctor on the AIDS wards. It is my duty to remember that experience and to make sure my profession remembers the lessons we all learned. I am doing my best to guide my younger colleagues in how to handle crises like this in the most ethical manner possible.

These ethical frameworks were largely written in the immediate aftermath of WWII and the Nazi crimes against humanity. They were written in a much brighter time than now. The same ideals we as humanity prescribe in the best of times are there to guide us through the worst of times.

Again – I understand what you are saying, but these are not normal times.

I would tell you to please make sure you noticed that I stated IN MY OPINION. Opinions are not hard and fast.

However, I would also ask you to realize that medical ethics and risk/benefit ratios take on an entirely different tone and intellectual processing in a time of grave crisis. Please note the paper that a commenter above highlighted in their comment. That was about the ebola crisis – but the same issues apply here.

So not only is there this Ivermectin issue. Because of the nature of this emergency, we have been tasked with exposing the entire world to the enormous risk involved in basically doing a PHASE III clinical trial without the benefit of having any body (IRBs) locally to assess risk to the subjects. This is a brave new world.

Believe it or not, these are issues that I struggle with daily. The only thing that keeps me going is this is exactly the same kind of thing I was dealing with as a young doctor on the AIDS wards. It is my duty to remember that experience and to make sure my profession remembers the lessons we all learned. I am doing my best to guide my younger colleagues in how to handle crises like this in the most ethical manner possible.

These ethical frameworks were largely written in the immediate aftermath of WWII and the Nazi crimes against humanity. They were written in a much brighter time than now. The same ideals we as humanity prescribe in the best of times are there to guide us through the worst of times.

Again – I understand what you are saying, but these are not normal times.

Ivermectin is fat soluble. That does create a concern about dosing, which is one of the big reasons for cautioning people against trying veterinary ivermectin. That is also a potential issue with Vitamin D and zinc but IMHO most of the handwringing regarding Vitamin D is ill informed. 20 minutes of full body exposure to equatorial sun = 20,000 IU. I have never heard of anyone recommending or taking that much orally. Zinc is also fat soluble and the recommended level is 50 mg/day max.

With water soluble vitamins, the big risks are:

1. Possibly interfering with meds, so you need to check

2. Gastric irritation

3. Overthinning blood (as in reducing ability to clot)

4. Expensive urine, as in you are just pissing it out

Ivermectin is fat soluble. That does create a concern about dosing, which is one of the big reasons for cautioning people against trying veterinary ivermectin. That is also a potential issue with Vitamin D and zinc but IMHO most of the handwringing regarding Vitamin D is ill informed. 20 minutes of full body exposure to equatorial sun = 20,000 IU. I have never heard of anyone recommending or taking that much orally. Zinc is also fat soluble and the recommended level is 50 mg/day max.

With water soluble vitamins, the big risks are:

1. Possibly interfering with meds, so you need to check

2. Gastric irritation

3. Overthinning blood (as in reducing ability to clot)

4. Expensive urine, as in you are just pissing it out

Is it the principal of doing the unknown but at the same time making sure it’s low risk, mitigated risk?

For example, taking vitamin D and C while taking a little zinc. As long as one doesn’t over-dose on the vitamins, there is very very little risk. At the same time, there is an unproven but not impossible risk that lack of vitamin D compromises the immune system and leads to a very severe case.

I’m just confused at how the powers that be are so resistant to try these measures out. Just take some vitamin supplements!

I got one physician in the family who was working cases over in the middle of North Carolina. Her worst cases were folks who had a vitamin D deficiency. They actually are a physician couple that worked in the hospital ward, both eventually got covid. They did well but were taking a cocktail of vitamins. I also believe for a period of time they were using hydroxychloroquine. I need to follow up with them.

Is it the principal of doing the unknown but at the same time making sure it’s low risk, mitigated risk?

For example, taking vitamin D and C while taking a little zinc. As long as one doesn’t over-dose on the vitamins, there is very very little risk. At the same time, there is an unproven but not impossible risk that lack of vitamin D compromises the immune system and leads to a very severe case.

I’m just confused at how the powers that be are so resistant to try these measures out. Just take some vitamin supplements!

I got one physician in the family who was working cases over in the middle of North Carolina. Her worst cases were folks who had a vitamin D deficiency. They actually are a physician couple that worked in the hospital ward, both eventually got covid. They did well but were taking a cocktail of vitamins. I also believe for a period of time they were using hydroxychloroquine. I need to follow up with them.

Ivermectin is fat soluble. That does create a concern about dosing, which is one of the big reasons for cautioning people against trying veterinary ivermectin. That is also a potential issue with Vitamin D and zinc but IMHO most of the handwringing regarding Vitamin D is ill informed. 20 minutes of full body exposure to equatorial sun = 20,000 IU. I have never heard of anyone recommending or taking that much orally. Zinc is also fat soluble and the recommended level is 50 mg/day max.

With water soluble vitamins, the big risks are:

1. Possibly interfering with meds, so you need to check

2. Gastric irritation

3. Overthinning blood (as in reducing ability to clot)

4. Expensive urine, as in you are just pissing it out

Ivermectin is fat soluble. That does create a concern about dosing, which is one of the big reasons for cautioning people against trying veterinary ivermectin. That is also a potential issue with Vitamin D and zinc but IMHO most of the handwringing regarding Vitamin D is ill informed. 20 minutes of full body exposure to equatorial sun = 20,000 IU. I have never heard of anyone recommending or taking that much orally. Zinc is also fat soluble and the recommended level is 50 mg/day max.

With water soluble vitamins, the big risks are:

1. Possibly interfering with meds, so you need to check

2. Gastric irritation

3. Overthinning blood (as in reducing ability to clot)

4. Expensive urine, as in you are just pissing it out

Ivermectin is fat soluble. That does create a concern about dosing, which is one of the big reasons for cautioning people against trying veterinary ivermectin. That is also a potential issue with Vitamin D and zinc but IMHO most of the handwringing regarding Vitamin D is ill informed. 20 minutes of full body exposure to equatorial sun = 20,000 IU. I have never heard of anyone recommending or taking that much orally. Zinc is also fat soluble and the recommended level is 50 mg/day max.

With water soluble vitamins, the big risks are:

1. Possibly interfering with meds, so you need to check

2. Gastric irritation

3. Overthinning blood (as in reducing ability to clot)

4. Expensive urine, as in you are just pissing it out

Your comment is a complete straw man of what IM Doc wrote. And anyone with an operating brain cell knows the Helsinki Declarations are mere guidelines and have even less force in the US than “international law,” as in none.

I would have ripped your comment out had IM Doc not responded. He has more important things to do that clean up your informational mess and you cherry picking and misrepresenting one tiny part of his comment…to what? To get the rush of a “gotcha”? To try to discredit him? To present you as the smartest guy in the room?

I am blacklisting you instead.

Your comment is a complete straw man of what IM Doc wrote. And anyone with an operating brain cell knows the Helsinki Declarations are mere guidelines and have even less force in the US than “international law,” as in none.

I would have ripped your comment out had IM Doc not responded. He has more important things to do that clean up your informational mess and you cherry picking and misrepresenting one tiny part of his comment…to what? To get the rush of a “gotcha”? To try to discredit him? To present you as the smartest guy in the room?

I am blacklisting you instead.

Your comment is a complete straw man of what IM Doc wrote. And anyone with an operating brain cell knows the Helsinki Declarations are mere guidelines and have even less force in the US than “international law,” as in none.

I would have ripped your comment out had IM Doc not responded. He has more important things to do that clean up your informational mess and you cherry picking and misrepresenting one tiny part of his comment…to what? To get the rush of a “gotcha”? To try to discredit him? To present you as the smartest guy in the room?

I am blacklisting you instead.

What I said to Ronald Grissman goes double for you. Cherrypicking, straw manning, bad faith. Trash talking ivermectin as risky is Making Shit Up. It’s an old drug, with decades of use, and the doses discussed here are a bit lower than for its typical application as an antiparasitic. Goodbye.

But → Among patients with non-severe COVID-19 and no risk factors for severe disease receiving a single 400 mcg/kg dose of ivermectin within 72 h of fever or cough onset there was no difference in the proportion of PCR positives. There was however a marked reduction of self-reported anosmia/hyposmia, a reduction of cough and a tendency to lower viral loads and lower IgG titers which warrants assessment in larger trials.

And → I also want everyone to realize my experience up above is anecdotal, a case series, without a control group. It is how we physicians roll in a time of crisis like this.

Thus to say: “physicians, that NOT using this drug at this time of crisis in the world is likely a violation of Article 37 of these Helsinki Declarations.”

Is without, merit and in fact dangerous. No I’m not kidding.

But → Among patients with non-severe COVID-19 and no risk factors for severe disease receiving a single 400 mcg/kg dose of ivermectin within 72 h of fever or cough onset there was no difference in the proportion of PCR positives. There was however a marked reduction of self-reported anosmia/hyposmia, a reduction of cough and a tendency to lower viral loads and lower IgG titers which warrants assessment in larger trials.

And → I also want everyone to realize my experience up above is anecdotal, a case series, without a control group. It is how we physicians roll in a time of crisis like this.

Thus to say: “physicians, that NOT using this drug at this time of crisis in the world is likely a violation of Article 37 of these Helsinki Declarations.”

Is without, merit and in fact dangerous. No I’m not kidding.

I would also point you to the numerous randomized controlled trials that have already been done over the world. Some of them not so good – some of them excellent. They all seem to be pointing to the same conclusion. The drug does seem to have an impact on hospitalizations, on death, and on health care workers remaining negative while working with COVID patients.

We cannot just quote the conclusions of a very small pilot study and think that represents the totality of what has been already done. That certainly would not have made my decision. I do not believe for a minute the NIH would have changed course on this drug had there not been very compelling data otherwise.

I would also point you to the numerous randomized controlled trials that have already been done over the world. Some of them not so good – some of them excellent. They all seem to be pointing to the same conclusion. The drug does seem to have an impact on hospitalizations, on death, and on health care workers remaining negative while working with COVID patients.

We cannot just quote the conclusions of a very small pilot study and think that represents the totality of what has been already done. That certainly would not have made my decision. I do not believe for a minute the NIH would have changed course on this drug had there not been very compelling data otherwise.

I would also point you to the numerous randomized controlled trials that have already been done over the world. Some of them not so good – some of them excellent. They all seem to be pointing to the same conclusion. The drug does seem to have an impact on hospitalizations, on death, and on health care workers remaining negative while working with COVID patients.

We cannot just quote the conclusions of a very small pilot study and think that represents the totality of what has been already done. That certainly would not have made my decision. I do not believe for a minute the NIH would have changed course on this drug had there not been very compelling data otherwise.

What I said to Ronald Grissman goes double for you. Cherrypicking, straw manning, bad faith. Trash talking ivermectin as risky is Making Shit Up. It’s an old drug, with decades of use, and the doses discussed here are a bit lower than for its typical application as an antiparasitic. Goodbye.

What I said to Ronald Grissman goes double for you. Cherrypicking, straw manning, bad faith. Trash talking ivermectin as risky is Making Shit Up. It’s an old drug, with decades of use, and the doses discussed here are a bit lower than for its typical application as an antiparasitic. Goodbye.

What I said to Ronald Grissman goes double for you. Cherrypicking, straw manning, bad faith. Trash talking ivermectin as risky is Making Shit Up. It’s an old drug, with decades of use, and the doses discussed here are a bit lower than for its typical application as an antiparasitic. Goodbye.

In regard to the Dr. Trevor Bedford twitter feeds posted above.

This is truly an amazing thing that has been happening on Twitter and Facebook lately.

Dr. Bedford is truly a world-class researcher at the Fred Hutchinson Center in Seattle. I follow him and multiple dozens like him on Twitter and Facebook. This instant access to real thinking and data has been of great importance. The Twitter platform is not at times the best for this kind of thing. For example, in today’s discussion it is not exactly clear what is meant by “chronic” infections. You can find that out by doing a little digging around – and that is what keeps me on my toes so it is no problem. However, this is ages beyond what we had in the AIDS era and I could not be more pleased.

A big reason why these researchers are having to resort to Twitter and Facebook. Read this piece in The Atlantic. The COVID research has become a tsunami and has overwhelmed our peer review and journal system. They have to put their findings out on Twitter et al because it may take months/years otherwise.

It is dramatic how different this era is than the AIDS crisis – but is also dramatic how much it is the same.

As an answer to your comment, I have personally seen multiple patients who clearly have COVID and are COVID positive being started on ZITHROMAX. I have read enough comments about this in the national medical press to know this is a very common practice. It is without any merit at all. There is no evidence that zithromax or any other ANTI-BACTERIAL antibiotic has much effect on COVID one way or the other. There are multiple other anti-virals, and immune modulators that might. Much work in this area remains undone. We are having increasing evidence that IVERMECTIN has COVID effects although the exact pathway remains unknown.

The idea in many providers’ minds seems to be that the patient is sick, likely has pneumonia, and I better cover them with antibacterials just in case. This may actually be harming way more than helping. It is a very unfortunate practice, not just with COVID, that I have spent decades trying to beat out of students.

As an internist with boots on the ground – I cannot express enough gratitude that these kinds of reports are getting out.

As busy as I have been this past year with COVID, the actual patients struggling with anxiety and depression have just dwarved the actual COVID numbers.

I cannot even begin to tell you the heartbreak of being a provider and having 20-40 year old young men in your office crying their eyes out. Lots of job loss, lots of income issues, lots of not being able to pay for things for your kids. All the while being completely unable to find other work or extra work. It is truly a nightmare for these people. And the attitude by so many of the lockdown Karens who seem to have no conception of how this is all going down for these young people has been deeply worrisome to me.
It is really not getting better – if anything slowly getting worse.

I would agree with the article above that loneliness is a problem – this is for the minority – mainly older people and should not be dismissed.

Loneliness is not the big problem however, in my experience. The big problem is the economic despair for our young people and the complete loss of socialization for our teenagers and kids.

And I have no clue what the answer is.

I hit the lottery in my medical residency when Dr. Fauci was in our city for a week. This was decades ago. He was on our Infectious Disease rounds during the midst of the AIDS epidemic. An incredible memory. He was a class act all around. Most Americans do not realize – he is to this day one of the lead editors, credited on the cover, of our foundational Internal Medicine Textbook – Harrison’s.

Has he made mistakes? Absolutely. Have we all? Absolutely. I have watched him all this past year exemplifying for every American the concept of working in an impossible situation. I would add it was not just Trump. I distinctly remember two Congressional hearings when it was obvious he was trying to talk/educate and the Congresspeople were just yelling over him.

I hit the lottery in my medical residency when Dr. Fauci was in our city for a week. This was decades ago. He was on our Infectious Disease rounds during the midst of the AIDS epidemic. An incredible memory. He was a class act all around. Most Americans do not realize – he is to this day one of the lead editors, credited on the cover, of our foundational Internal Medicine Textbook – Harrison’s.

Has he made mistakes? Absolutely. Have we all? Absolutely. I have watched him all this past year exemplifying for every American the concept of working in an impossible situation. I would add it was not just Trump. I distinctly remember two Congressional hearings when it was obvious he was trying to talk/educate and the Congresspeople were just yelling over him.

I hit the lottery in my medical residency when Dr. Fauci was in our city for a week. This was decades ago. He was on our Infectious Disease rounds during the midst of the AIDS epidemic. An incredible memory. He was a class act all around. Most Americans do not realize – he is to this day one of the lead editors, credited on the cover, of our foundational Internal Medicine Textbook – Harrison’s.

Has he made mistakes? Absolutely. Have we all? Absolutely. I have watched him all this past year exemplifying for every American the concept of working in an impossible situation. I would add it was not just Trump. I distinctly remember two Congressional hearings when it was obvious he was trying to talk/educate and the Congresspeople were just yelling over him.

I hesitate to post this reference.

Let me explain.

The gentleman that runs that blog is at times a crackpot. But at times he is brilliant. I do not really agree with his politics, but I do read his blog to see what informed people on different sides are thinking.

Surprisingly, he posted this today. To be fair and honest, this piece is highly well-referenced and it corresponds to things I have been hearing from Coronavirus experts in Grand Rounds all year.

This was not written by the owner of that blog, rather, it is some type of guest post which I have to be honest, I have never seen him do before. They clearly know what they are talking about. And it is as good a discussion of “gain of function” research written in non-jargon English I have ever seen.

FWIW, the questions asked at the end have never been successfully answered and are indeed critical to our understanding of this situation.