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/

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.

A harder death for people with intellectual disabilities

Several weeks after my patient was admitted to the intensive care unit for pneumonia and other problems, a clear plastic tube sprouted up from the mechanical ventilator, onto his pillow and down into his trachea. He showed few signs of improvement. In fact, the weeks on his back in an I.C.U. bed were making my 59-year-old patient more and more debilitated.

Still worse, a law meant to protect him was probably making him suffer more.

When the prognosis looks this bad, clinicians typically ask the patient what kind of care they want. Should we push for a miracle or focus on comfort? When patients cannot speak for themselves, we ask the same questions of a loved one or a legal guardian. This helps us avoid giving unwanted care that isn’t likely to heal the patient.

This patient was different. Because he was born with a severe intellectual disability, the law made it much harder for him to avoid unwanted care.

To learn more, including what happened, read my new post here at The New York Times.

Let Opioid Users Inject in Hospitals

It is a new world in health care as America grapples with an epidemic of opioid drug abuse. The Centers for Disease Control and Prevention reported that opioid overdoses killed over 28,000 people nationwide in 2014, more than ever before.

From heart-valve infections to drug overdoses, the casualties of this epidemic wash up in our hospitals. It has changed my hospital service significantly. Almost every day, we try to save a young person dying from infectious complications of injection drug use.

Addicted patients usually bond with their providers over the shared goal of healing. Yet these interactions, which often bridge divides of class, culture and personal psychology, can break down. When addicted patients inject drugs in the hospital, doctors and nurses can find themselves cast in the role of disciplinarians, even jailers.

Confining patients to their rooms, restricting their activities and posting guards is expensive. It may also compromise a patient’s well-being: Ambivalent providers may visit less often, educate patients less avidly and spend less time devising the best treatments.

The worst effect of confining addicted patients in the hospital may be the damage to the patient-provider bond. 

To read more, including my proposal to let opioid users inject in the hospital, check out my new op-ed at The New York Times. 

Also, check out my new 8-minute radio spot about the topic at for Word of Mouth by Virginia Prescott at NHPR. It was also a trip to appear on Sirius XM's widely-syndicated Michael Smerconish show, although a recording has not been archived. The controversy the post created was nicely covered in Concord's Union Leader.

Will legislators defuse the ticking time bomb of dirty needle use?

For years, Indiana had slowly dismantled its public health system, and needle exchange programs lacked both funding and legal safeguards. Then an HIV outbreak exploded into public view, and Republican Governor Mike Pence had to do some fancy footwork to undo the damage done. He allowed needle exchange programs to operate and provided some long overdue prevention funding. In the meantime, dozens of young Indianans were infected with hepatitis C and HIV. It was a sad case of politics overturning science and common sense.

Now, New Hampshire and other states are in the same boat: politically-minded legislators bloviate about punitive anti-drug stances while the opiate epidemic rages. Complications of injection drug use are on the rise, and it's only a matter of time before a new HIV outbreak comes to town. Needle exchange programs, proven over and again to prevent infections and thus to save lives, languish in the legal shadows.

Fortunately, new legislation is being considered to change help catch New Hampshire up to the 21st Century, and maybe save some lives in the process. I was proud to be quoted here about this overdue change.

New science shows how loneliness makes older people frail

Every Monday during the summer, some of the residents of Lyme, New Hampshire, gather up fruits and vegetables from their gardens to donate to Veggie Cares, a program that distributes local food to people living alone. Volunteers collect, sort, and package the produce, then head out in separate directions to deliver the food to some Lyme's most vulnerable, isolated residents.

While the stated goal of the program is to provide people with healthy food, Veggie Cares volunteers also deliver companionship. Visits are often more than a quick drop-off—they may involve a shared cup of tea, an offer to replace burned-out light bulbs, or a chance to check in on sick or elderly neighbors.

Nine million elderly people currently suffer from food insecurity in the United States, and the produce provided by Veggie Cares is one way to safeguard the health of Lyme residents who may be at risk. But recent research supports the idea that the companionship the volunteers provide may be physically nourishing in its own way.

Read more in my new article (with the lovely and talented Jessica Lahey) over at The Atlantic. 

Is the new Ebola vaccine too good to be true?

Ebola is on the run: the number of cases dipped below ten a week recently, and a few days ago investigators announced in the prestigious journal The Lancet that a new Ebola vaccine was “100% effective.”

In response, global health authorities are starting to sound a little giddy. “We believe that the world is on the verge of an efficacious Ebola vaccine,” said Marie Paule Kieny, the World Health Organization’s assistant director-general for health systems and innovation (and a senior author on the paper). “It could be a game changer.”

She’s right: this is wonderful news, and a great testament to human ingenuity. A genetically engineered hybrid of the benign vesicular stomatitis virus and the Zaire strain of Ebola, together called rVSV-ZEBOV, was tested in a multi-site clinical trial conducted amid a massive aid response in Guinea, one of the poorest countries in Africa. The scientific and logistical acrobatics required to pull this off boggle the mind.

Yet, for three reasons, we cannot know if the vaccine really worked, or how well. 

To read more, check out my new post over at The Conversation.

New challenges of an aging epidemic

The AIDS activist Larry Kramer once said,

AIDS was allowed to happen. It is a plague that need not have happened. It is a plague that could have been contained from the very beginning.

The past 10 years we have witnessed innumerable incredible advances in HIV science and HIV treatment, but Mr. Kramer's words still ring true. We could have done more to stop it, and we still leave a lot of the work left undone.

This is particularly poignant since new challenges have now joined the old scourges of poverty and stigma and the wily habits of a historically pernicious virus. 

These new challenges include what one of my patients called the "Peter Pan Syndrome" and an uptick in injection drug use in many areas of the United States. The Peter Pan Syndrome is when patients told they did not have long to live at the beginning of the HIV epidemic now grapple with the accelerated effects of aging, a phase of life they never thought they would face. Additional challenges include complacency in youth who didn't grow up losing friends from HIV, and donor fatigue, and the short-term thinking of budget-conscious legislators who cut funding to HIV prevention programs that save lives.

These and other modern realities of the 2015 HIV epidemic are on full display in a new article in the Concord Monitor in which I was proud to be quoted, including:

The most pernicious myth in the HIV epidemic today is that people infected with HIV contracted the virus because they are somehow different – that in some way people with HIV deserved to get infected. This is hard-hearted and ill-informed, but I understand how the finger-pointing can be a defense mechanism against fear. The truth is, we are all vulnerable to this wily virus, and the only way we will win against HIV is to band together in compassion.

Twenty years from now will we look back and say we learned from our early mistakes, or will we rue the mistakes we made again and again?