Is it ethical to get a booster shot when so many people in the world can't even access their first dose?

The same week that Rochelle Walensky, the director of the Centers for Disease Control and Prevention, gave the green light to booster shots for Pfizer vaccine recipients over age 65, the World Health Organization reported that only 2.2% of people in the world’s low-income countries had received even one dose of a Covid vaccine.

That means millions of Americans will receive a third vaccine dose while billions around the world have not had their first.

That stark contrast of U.S. haves and global have-nots prompted one of my clinic patients to ask me, “Is it immoral for me to get a booster?”

My response is in my new article at Boston Globe’s STAT news: https://www.statnews.com/2021/10/15/feeling-guilty-about-getting-covid-booster-shot-do-this/

Scientific transparency - like vaccines - has short-term side effects but they are worth the massive long-term benefits

I recently met hundreds of COVID-19 vaccines at the door of Vermont's large public vaccination drive, shepherding each one to meet the nurses who would perform the vaccination.

I screened each for symptoms of active disease, commented on the lovely spring weather, and asked if they had any concerns.

One nattily dressed Black woman in her mid-forties admitted she was nervous as we walked toward her chair.

"I hate needles," she said, visibly shaking. "Are these vaccines safe?"

We paused. I listened. I said I was glad she had come. I reassured her that I believe, as a physician, that COVID-19 vaccination will make her much safer than she was before.

In Europe, recent reports of extremely rare clotting complications of the AstraZeneca vaccine made European vaccine recipients markedly more nervousabout vaccine safety. Many public health authorities worried public safety fears could hurt efforts to vaccinate past a fourth wave of COVID-19 deaths.

I think it’s worth it, though, ,to be transparent. Like vaccines, scientific transparency has real short-term side effects but they are well-worth the mammoth long-term benefits.

To read more, check out my new post about how scientific transparency, like vaccines, has short-term side effects up at MedPage TODAY.

The Bottom of the Health Care Rationing Iceberg

A stink filled the room as my patient eased coal-black toes out of his shoes. After spending winter nights in a tattered sleeping bag behind a local grocery store, he had developed frostbite and then gangrene.

In the hospital, we gave him intravenous antibiotics and debrided the dead tissue from his toes. Soon he felt better. He was enjoying regular meals and the kind at- tention of his nurses. Each day, a new crayon portrait of his life on the street went up on the walls, scary scenes depicted in bright colors and childlike simplicity.

When the hospitalist said he was getting ready to discharge him, the patient’s nurse shook her head and crossed her arms. “How is he supposed to heal if he goes right back out to the streets?” she asked.

She wasn’t wrong. More than one in four discharged homeless patients is readmitted within 30 days, according to a recent study by a team from the Boston Health Care for the Homeless Program.

The hospitalist noted that the patient would have been dis- charged much earlier if he hadn’t been homeless. “But is hospitalization really the cure for home- lessness?”he asked, as he ran a finger down a list of emergency department patients waiting for a hospital bed. “Don’t we owe them something, too?”

There it is, I thought: the bottom of the health care rationing iceberg.

To read more, including about the contrast between our careful efforts to allocate mechanical ventilators amid the COVID-19 pandemic and the haphazard way we leave the homeless and others out of health care resource allocation on ordinary days, check out my new essay up at The New England Journal of Medicine.

Cutting corners on a coronavirus vaccine could cost lives

In the desperation to save lives in the coronavirus pandemic, we have already begun to relax scientific standards in the hope of finding a treatment without waiting to prove that it works.

Bioethicists have proposed risky human-challenge trials — which expose volunteers to the virus — to speed coronavirus vaccine development, and the Trump administration has already let one vaccine maker skip the usual requirement for animal safety trials before injecting an unproven vaccine into the arms of human volunteers.

The World Health Organization has funded a trial of new drug therapies that shockingly has no placebo-control arm.

And, of course, the experimental and potentially dangerous use of hydroxychloroquine in Covid-19 patients already boasts the presidential seal of approval and has become commonplace in American hospitals.

The next scientific corner to cut is clear.

Influential authors from the Coalition for Epidemic Preparedness Innovations recently wrote in The New England Journal of Medicine that “in a high-mortality situation, populations may not accept randomized, controlled trials with placebo groups.” While placebo-controlled multivaccine trials may be one solution, they wrote, another would be to skip the placebo.

This wouldn’t be the first time doctors took a chance on an unproven vaccine on a mammoth scale.

Read more in my new article at The New York Times.

Life in the time of COVID

A few days ago I held the COVID-19 “pager” for my hospital. I couldn’t keep up. For every call I answered, 3 more showed up. In my 21 years as a physician there have been quick emergencies during which I couldn’t keep up with calls. But nothing close to this.

As our hospital, which serves over a million people in Vermont and surrounding states, gets reads for COVID-19 to hit hard, I’ve worked incredible hard, and been inspired every day. The way our hospital and our entire health network works has been entirely changed. Whole hospital floors retooled. Thousands of elective surgeries cancelled. Buildings commandeered. Entire clinical processes and teams fully made a new over and again.

I direct our ethics program, and a cascade of questions have kept me busy. If we run out of hospital beds or PPE or mechanical ventilator, how should we apportion them wisely? Should we resuscitate someone with COVID-19 even if it could infect their caregivers and the next patients those caregivers see? Should we save the lives of children over older adults? Is it ethical to consider disability in resource allocation schemes?

Even as we address hard ethical and scientific questions, one of the biggest challenges of the COVID-19 epidemic has been getting trustable information out to the general public. Questions abound, from should I stay home (yes), to should I get tested (not if you are stable), to should I take hydroxychloroquine (probably not) . Oh, yeah, and is the grocery store totally safe? (No, but nowhere is).

Here is one example of a PSA put out through the magic of our hardworking communications team. I hope you like it. More to follow, and today I’m going to try my first Facebook live Q&A about the novel coronavirus to see if that is helpful.

Will New Hampshire open safe sites for people who inject drugs?

New Hampshire is still in the throes of one of the worst opioid epidemics in the country. Deaths are mounting, and mostly in young people.

As hospitals around the nation and our fair state scale up to provide medication assisted therapy and other evidence-based ways to help, safe injection sites remain controversial.

Based on data from Vancouver's Insite program showing lower public drug use, less needle sharing, and prevention of infectious diseases like HIV, I think it's time for us to get over our hangups and act to save lives.

It was fun and illuminating to talk with Laura Knoy's and guests on NHPR's Exchange. For a stream of the hour-long show, click here. 

Did I make a professionalism mountain out of a medical education molehill?

Every March I run the last required course at Dartmouth's Geisel School of Medicine. It’s a three-week-long, 47-hour sprint – a sort of boot camp for professional formation. Midway through the usual mechanics of instruction, I got an email that felt routine at first - but then it felt like an opportunity to talk with a student about professionalism.

Click here to read it, over at Reflective MedEd. What do you think? Did I make a professionalism mountain out of a logistical molehill? How do you try to support your students’ professional formation?

Go ahead, hit "record" in the doctor's office

The elderly woman’s right knee was bright red and twice its normal size. Her doctor explained that her prosthetic knee joint was infected and would have to be removed — antibiotics alone couldn’t cure her.

Her doctor (T.L.) began discussing treatment options, but the patient stopped him. “Do you mind if I record you?” she said, picking up her cellphone.

Surprised, the doctor leaned back in his chair.

This simple request can elicit starkly different reactions from patients and clinicians.

To learn more, check out my new article (with co-author Glyn Elwyn) at STAT.

World AIDS Day 2016

As World AIDS Day approaches on Thursday, there is so much to be thankful for, and so much work yet undone.

People with HIV on effective treatment live as long as those without HIV, and almost never transmit HIV to their seronegative partners. Pre-exposure prophylaxis (PrEP) is safe and it works, and through it and other means of prevention we are slowing the epidemic, bit by bit. This fall a new vaccine aiming to build on the RV144 success story began testing in South Africa.

Despite those massive successes, 2 million more people are newly infected with HIV every year. Less than half of the world's HIV-positive population can access HIV therapy. In the United States, only 30 percent of people with HIV achieve the goal of full virological suppression on medications. A substantial fraction of people living with HIV don't know they are infected, and stigma is still a problem for people with HIV.

HIV is the defining health threat of our day. We have made real progress, but we cannot be complacent. It was a honor to discuss these issues and more for NHPR's Exchange radio show.

Opioid contracts can backfire on patients

The US Senate recently passed legislation designed to address the nation’s opioid addiction epidemic, and President Obama is expected to sign it into law. Among other things, the bill promotes the use of opioid contracts. These are written agreements between doctors and patients about the conditions for prescribing opioids long term for chronic pain.

This is great news. It could also harm patients. My patient, Cindy was a perfect example.

To hear what happened, read my new article at The Boston Globe's new publication STAT.