BUHealth: New KFF/Urban Institute project on medical debt

I do not forward a lot of other people’s news reports, but this one from the Kaiser Family Foundation (KFF) on medical dept is worth pondering. Here is a summary quote:

“more than 100 million people in the US – including 41% of adults – are now beset by health care debt”

Noam Levey’s email broadcasts are always insightful. Full KFF report on line is only about 20 minute read.

Readers from Europe can appropriately chuckle and sigh about our lousy insurance system.

Remarkably, US bankruptcies and credit card debt went DOWN during the pandemic but are now soaring. Total consumer debt is approaching $16 trillion. From a report in 2021: “8 in 10 Americans have some form of consumer debt, and the average debt in America is $38,000 not including mortgage debt.”

From: Noam Levey <NoamL@kff.org>
Sent: Thursday, June 16, 2022 6:19 AM
To: Noam Levey <NoamL@kff.org>
Subject: New project on medical debt

Good day,

It’s been a little while since I’ve written, but I wanted to alert you to a new project we’re launching this morning with NPR and CBS News called Diagnosis: Debt, which examines America’s medical debt crisis.

The first installment in our series, which draws on a new KFF poll conducted for the project and original Urban Institute research, reveals that more than 100 million people in the US – including 41% of adults – are now beset by health care debt, a number significantly larger than is generally realized. Today’s story looks at the awesome scale of this problem and how it is upending countless lives across the country. Accompanying today’s launch is a feature profiling a group of Americans burdened by medical debt, including a mother of twins in Chicago forced to work double shifts and borrow from family, a retired Virginia couple driven into bankruptcy and a medical student in Texas harassed for years by debt collectors for a $131 exam she was given after being sexual assaulted.

You can find the project here: https://khn.org/news/article/diagnosis-debt-investigation-100-million-americans-hidden-medical-debt/

Future stories in the series will explore the burden of medical debt on people with cancer, how this debt is deepening racial disparities and how a burgeoning credit industry is feeding off patients’ inability to pay their bills. I hope you find this first installment interesting, and if so, you’ll consider sharing it with others. And I hope you’ll follow this ongoing project as we publish additional stories throughout the year examining this uniquely American affliction. Thanks, as always, for reading.

All best,


Noam N. Levey  /  Senior Correspondent

Kaiser Health News  /  Washington, DC

nlevey@kff.org / @NoamLevey / +1 202 247 0811

Kaiser Health News (KHN) is the newsroom at KFF (the Kaiser Family Foundation), producing in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of KFF’s three major operating programs. KFF is an endowed non-profit organization providing information on health issues to the nation.

Stay connected with:

khn.org / email / twitter / facebook

kff.org / email / twitter / facebook

Randall P. Ellis, Ph.D. (he/him/his)
Professor, Department of Economics, Boston University
ellisrp@bu.edu    +1 617-353-2741       http://blogs.bu.edu/ellisrp/

Vaccinate, avoid unneeded risks, love the outdoors, be optimistic, work for positive change.

January 6 hearings on the US Capitol Insurrection

Dear friends, family, and colleagues,

I cannot resist sharing some thoughts and links on last night’s Jan 6 hearings.

The January 6 public hearings at the US capital last night are a momentous event that I encourage you to watch.

We should all want to figure out how to avoid such violence in the future.

Several new facts emerged which are central to understanding Donald Trump’s guilt in causing the insurrection.

Trump’s Attorney General William Barr repeatedly told the president in November 2020 that there was no evidence of voting fraud and that his efforts to overcome the election were bullshit. Barr then resigned.

Ivanka Trump stated in her testimony that she respected William Barr and accepted what he was saying about the election.

Vice president Mike Pence repeatedly called to try to get additional police and military support that day, but the president did not.

The Proud Boys and Oathkeepers, numbering in the hundreds at the insurrection, were already on their way to the Capital at 10:00 am well before Trump gave his empowering speeches to the crowds at the White House, confirming that it had to have been preplanned.

Donald Trump and his inner circle met in December 2020 secretly, without their lawyers present, to plot the insurrection, and immediately began promoting the January 6 rally with “Will be wild” tweets.

Here are three different summaries (NYTimes, NPR, and Wall Street Journal) if you don’t have time to watch the two hours of hearings themselves, which are posted online here.



https://www.wsj.com/livecoverage/jan-6-hearings-news-live  (Requires a subscription to read the full article.)

The magnitude of the attack and the violence was much greater than the previously released videos have shown.

This 11:37 video was shown at the hearing. It is remarkable how restrained the capital police were throughout the attack.

Watch: Jan. 6 Committee Plays Never-Before-Seen Video of Capitol Attack

Capitol Police officer Caroline Edwards was a hero and remarkable spokesperson for humanity at the hearing.

For an informative and humorous comic overview, Stephen Colbert’s 11 minute live monologue is also worth a watch.


Favorite blogs about COVID-19

I have not talked or written about COVID-19 much recently, although it is still clearly a very big topic.


The following links, many of which some of you may have already shared, provide a useful background about COVID-19.


From BU SPH, on 2021-12-2 where a BU infectious disease expert talks about the new Omicron variant. (2 minutes)



From Yale School of Medicine, the best Youtube video explaining the biology of how COVID works. 8 minutes. COVID 19 an illustrated scientific summary. Well worth if if you have ever taken a biology class.


Video showing how the Pfizer COVID-19 vaccine is manufactured, tested and distributed, showing the complexity of massively increasing the scale of production. Sadly the NYT took down the audio for nonsubscribers… Pfizer vaccine production is now at the rate of 2.5 billion doses per year.



Ellis Blog 2021-1-1 and JAMA article 2021-3-17 comparing the effectiveness of the US three approved various vaccine types.


2021-3-19 Ellis blog Risk of dying from an allergic reaction from receiving a Pfizer or Moderna vaccine for COVID-19 is lower than the risk of being hit and dying from lightning, JAMA study shows.



2020-5-7 Obesity is the hidden explanation for why COVID-19 is so much worse in the US than in many other countries.


2021-3-2 Yes, even rich white people in the US get bad health care. JAMA study


2021-3-14 Ellis blog Humor about a masked dog



Randomized control trial using masks.

Economists and perhaps others will benefit from seeing the results of this large-scale randomized controlled trial on wearing masks, in Bangledesh, which studied N=342,126 adults with three study arms: cluster randomized Villages and households with no intervention, with free cloth masks, and with free surgical masks. Participants also received information and local  reminders.


Here is the Yale research paper by economist Jason Abaluck et al describing the experiment.

The Impact of Community Masking on COVID-19: A Cluster Randomized Trial in Bangladesh. https://elischolar.library.yale.edu/cowles-discussion-paper-series/2642/

August, 2021


Here is a popular summary in the Atlantic from September 4, 2021



The study shows the superiority of surgical masks over cloth masks, and the both sets of masks achieved a roughly ten percent reduction in symptomatic seroprevalence. This is less than perfect, but the study interventions were only able to increase the wearing of masks from 13% to 42% and raise social distancing from 24% to 29%. Recall that the study was done in Bangladesh.

Three sources on COVID-19

This BUHealth blog contains clips on practical advice about COVID-19 from a Harvard School of Public Health email, links to the The Vaccine Confidence Project, and an except from the CDC advisory on pregnancy and COVID-19

From: Harvard Executive Director Mark Dorgan <oer_info@hsph.harvard.edu>

While globally new cases are trending downward, the virus continues to spread. Half the world’s population still has not had a single shot, many people remain extremely vulnerable, and we continue to learn about the best ways to protect ourselves. For those who have access, medical masks far surpass cloth masks, mRNA vaccines (Pfizer and Moderna) are proving most effective, and rapid tests can help make real-time decisions. In all cases, any protection is better than none.

Bill Hanage, associate professor of epidemiology, said in a recent interview, “You cannot tell where the virus is, or if somebody is infected with it, unless you test for it. Once testing becomes available, you suddenly turn on the lights and you see that there’s a huge problem. And by that stage, it’s a little bit too late to be able to control that problem.” Pardis Sabeti, professor of immunology and infectious diseases, added, “To do it right in the future, whenever a new viral threat emerges, we have to position...clinical labs to be able to set up testing right away.”

Michael Mina, assistant professor of epidemiology, advocates for at-home tests over PCR tests to help stem spread. “If you want to keep businesses running, or to be able to host a safe dinner at home, don’t ask people to get a PCR test two days before. Ask them to use a rapid test within two hours of coming over.” If it’s negative, he said, “It’s extremely unlikely that person is infectious and a risk to other people. It’s an extraordinarily effective way to keep dinner, concerts, workplaces, and schools safe. Will it keep them 100% safe? No, but it will likely be 100% effective in stopping super spreaders from entering gatherings.”

Regarding vaccines, Sarah Fortune, John LaPorte Given Professor of Immunology and Infectious Diseases and chair of the Department of Immunology and Infectious Diseases, explained in a We’re Better Off podcast that mRNA vaccines were not rushed despite the quick rollout. “There were decades of work involved in mRNA vaccine platforms, and in fact, in testing different kinds of vaccines for different coronaviruses. When SARS-CoV-2 first appeared at the end of 2019, actually we had a huge foundational knowledge that accelerated that vaccine development.”


RE: The main battles being fought in developed countries like the US is over the acceptance of science and acceptance of the key importance of the social determinant of health. I highly recommend the series of articles in The Vaccine Confidence Project from the London School of Hygiene and Tropical Medicine. Here is the direct link.



This September 29, 2021 posting on the CDC website has the new recommendations for related to pregnancy, which is a big change.

CDC Statement on Pregnancy Health Advisory


Here are the key paragraphs from this report.

“Today, CDC issued an urgent health advisory to increase COVID-19 vaccination among people who are pregnant, recently pregnant (including those who are lactating), who are trying to become pregnant now, or who might become pregnant in the future to prevent serious illness, deaths, and adverse pregnancy outcomes.”

“Through September 27th, there were more than 125,000 confirmed cases of COVID-19 in pregnant people including more than 22,000 hospitalized and 161 deaths; of which, 22 deaths occurred in the month of August alone. Cases of COVID-19 in symptomatic, pregnant people have a two-fold risk of admission into intensive care and a 70 percent increased risk of death. Pregnant people with COVID-19 are at increased risk of adverse pregnancy outcomes that could include preterm birth, stillbirth, and admission into the ICU of a newborn also infected with COVID-19.”

RE: If you trust your obstetrician’s advice to have your baby in a hospital, then you should also trust their advice to get a COVID-19 vaccine, regardless of what stage of pregnancy you are in: before, during, or after.


Hourly weather forecasts for US

I rely upon my cell phone for hourly forecasts of rain and weather, but have not known how to get hourly forecasts more than 24 hours into the future. Yesterday a friend sent me the following National Weather Service link that forecasts hourly weather up to six days ahead.  Of course, it loses precision, but still, sometimes you need to make decisions far into the future. All the usual radar maps and other information are on nearby clicks.  All free and thanks to NOAA. Enjoy.


Alas, it only does forecasts for the US.

The unsurprising tragedies of the Afghanistan war

As we ponder the tragedies of the US withdrawal from Afghanistan, it is important to also remember the costs of our continuing. An excerpt from the Boston Globe is pasted in below.

The bottom line is that the wars in Afghanistan and Iraq will have cost the US at least $4 trillion dollars (excluding interest costs) which is 4 million million dollars. Given that the US has only 132 million households, this spending averages to over $30,000 per household, all paid for by debt we will eventually have to pay off (unlike previous wars, taxes were not increased).

$4 trillion could have instead been invested in free public university tuition, free health care for all children, reducing climate change, or the $4 trillion infrastructure bill that President Biden is asking for.

I commend President Biden for actually doing what presidents Bush, Obama and Trump all said they wanted to do but did not.

Joy and I have been listening to the audiobook "The Father of All Things: A Marine, His Son and the Legacy of Vietnam" which covers the fall of Saigon in Vietnam and subsequent events. There should be no surprise that the events in Kabul are the consequence of war. Even the speedy fall of the government.

The Father of All Things: A Marine, His Son - Amazon.com

https://www.amazon.com › Father-All-Things-Vietnam-...


Below is from The Boston Globe on Tuesday 8/16/2021.

Costs of the Afghanistan war, in lives and dollars

By ELLEN KNICKMEYER The Associated Press, Updated August 16, 2021, 5:00 p.m.




The longest war:

Percentage of US population born since the 2001 attacks plotted by Al Qaeda leaders who were sheltering in Afghanistan: Roughly one out of every four.

The human cost:

American service members killed in Afghanistan through April: 2,448.

US contractors: 3,846.

Afghan national military and police: 66,000.

Other allied service members, including from other NATO member states: 1,144.

Afghan civilians: 47,245.

Taliban and other opposition fighters: 51,191.

Aid workers: 444.

Journalists: 72.

Afghanistan after nearly 20 years of US occupation:

Percentage drop in infant mortality rate since US, Afghan, and other allied forces overthrew the Taliban government, which had sought to restrict women and girls to the home: About 50. (RE note: Statistica still lists the IMR at 5% (“about 46.5 per 1000”) of all live births in 2019. This is still an abysmal rate: 1 in 20 infants are dying.)

Percentage of Afghan teenage girls able to read today: 37%. (RE note: World Bank data show it as roughly doubling since 2011. Still appalling.)

Oversight by congress:

Date Congress authorized US forces to go after culprits in Sept. 11, 2001, attacks: Sept. 18, 2001.

Number of times US lawmakers have voted to declare war in Afghanistan: 0.

Number of times lawmakers on Senate Appropriations defense subcommittee addressed costs of Vietnam War, during that conflict: 42

Number of times lawmakers in same subcommittee have mentioned costs of Afghanistan and Iraq wars, through mid-summer 2021: 5.

Number of times lawmakers on Senate Finance Committee have mentioned costs of Afghanistan and Iraq wars since Sept. 11, 2001, through mid-summer 2021: 1.

Paying for a war on credit, not in cash:

Amount that President Truman temporarily raised top tax rates to pay for Korean War: 92 percent.

Amount that President Johnson temporarily raised top tax rates to pay for Vietnam War: 77 percent.

Amount that President George W. Bush cut tax rates for the wealthiest, rather than raise them, at outset of Afghanistan and Iraq wars: At least 8 percent.

Estimated amount of direct Afghanistan and Iraq war costs that the United States has debt-financed as of 2020: $2 trillion.

Estimated interest costs by 2050: Up to $6.5 trillion.

The wars end. The costs don’t:

Amount Bilmes estimates the United States has committed to pay in health care, disability, burial and other costs for roughly 4 million Afghanistan and Iraq veterans: more than $2 trillion.

Period those costs will peak: after 2048.

Source of the above: Much of the data is from Linda Bilmes of Harvard University’s Kennedy School and from the Brown University Costs of War project. Because the United States between 2003 and 2011 fought the Afghanistan and Iraq wars simultaneously, and many American troops served tours in both wars, some figures as noted cover both post-9/11 US wars.


BUHealth: COVID-19 risks when fully vaccinated and singing outdoors

This blog started as a response to a colleague who was calculating using local community vaccination and positive infection rates, using a 90% effectiveness rate for vaccines, and asking about the risks of singing without a mask outside. He calculated the risk of infection to singers as perhaps 0.15% to 0.31%. Is that reasonable?

Risk of what?

One thing to highlight is that the early effectiveness calculations, and most assertions about the effectiveness of the vaccines being 70-95%, ask whether the vaccines prevented ANY new COVID-19 infections, with or without symptoms, of COVID-19. We now know that if we instead ask whether the vaccines prevent any SERIOUS symptoms (such as a hospitalization or death) of COVID-19 then all three (Pfizer, Moderna, J&J) are well over 99% effective. Here is one link using CDC numbers (red bold text highlights added).

“According to the Centers for Disease Control and Prevention (CDC), 87 million AmericansTrusted Source had received the COVID-19 vaccine as of April 20, 2021. Among vaccinated people, there were 7,157 breakthrough cases, with fewer than 500 hospitalizations and 88 deaths.

Do the math and you can see the cases are about 1/100th of 1 percent of those vaccinated.

“The effectiveness of any vaccine in preventing serious illness is high, and in the case of the COVID-19 vaccines, it’s very high,” Dr. S. Wesley Long, an infectious disease researcher and clinical microbiologist at Houston Methodist in Texas, told Healthline.

“All the data shows that if you’re vaccinated you probably won’t get any symptoms at all, but even if you do, you still probably won’t get full-blown COVID and end up in the hospital,” he said.“


So 87,000,000/7157 = 1/12,000 => a 0.008 percent risk of any detected new COVID-19 infection (presumably found through patients seeking care symptoms or anyone receiving testing), and 87,000,000/588=1/147,000 => a 0.0007 percent or death or hospitalization. So that risk is equivalent to less than one person becoming seriously ill in the city of Newton, where I live. These risks are comparable to the extremely low rates of new infections and hospitalizations found in Israel, the first >1 million population country to achieve over 90% (i.e. universal) vaccination for COVID-19.


Here is how the CDC website summarizes this research.

A small percentage of people fully vaccinated against COVID-19 will still develop COVID-19 illness

COVID-19 vaccines are effective. However, a small percentage of people who are fully vaccinated will still get COVID-19 if they are exposed to the virus that causes it. These are called “vaccine breakthrough cases.” This means that while people who have been vaccinated are much less likely to get sick, it may still happen. Experts continue to study how common these cases are.”


I believe the CDC does not want to make a more precise statement such as “less than 0.1 percent risk”  instead of “a small percentage” because the CDC wants everyone to get vaccinated. Plus these low rates are in an environment where most people are still wearing masks and social distancing. The rate of breakthrough infections will go up if people stop wearing masks and gather in crowds. Still, the extremely low rates of SERIOUS illness among those who get infected will likely hold, even if by stopping mask-wearing we increase the number of people infected.

So the risk of something serious happening now for a normal healthy vaccinated person is truly minuscule, and when you also note that the prevalence of Influenza this year has been knocked down to close to zero, singing or exercising outside and not wearing a mask inside among vaccinated people seem like acceptable risks for most of us.

Overall risk versus risk from one activity

The above calculations are averages for very large populatinos over the entire period since they were vaccinated, a span of at least a month after full vaccination. We also do not know how much of the reduction is due to having fewer people infectious around you versus lower risk of getting any symptoms when exposed to some virus germs. One assumption is that it is symmetric, in which case the probability of both goes down equally, and the prob of symptoms if vaccinated when exposed to an infectious germ becomes (0.00008)^.5 = .009 and the probabilty of being infectious when vaccinated also become (0.00008)^.5 = .009. Note that .009*.p009=.00008, the overall risk conditional on being vaccinated and when around others who partially vaccinated. I will use this .009 rate below. The fact that this rate is not observed to be getting better suggests that the probability of symptoms when exposed is what is improving the most, but this only strengthens the calculations below.

The probabilities for a given activity, such as singing outdoors or eating inside a restaurant once a week is different since these risks are included in the overall risk calculations. It is hard to attach a probability to any one of these activities. Before precautions, health care workers in China working many hours on patients with covid had very high rates of infection, 70% or more. Similarly spouses of infected people can also have high rates, 70%. And certain wedding, banquet dinner, and Biogen conference attendees also  had very high rates of infections 30-50% from single events, conditional on at least one person being highly infectious. So the right calculation is how many people at a given event (e.g., a group of singers singing outdoors)  will be highly infectious and how many will  they infect, even if we assume exposure would be say 50%. Almost no one who is vaccinated at such an event should be highly infectious. Lets use the conservative assumption  that someone in the choir has a breaktrhough infection with certainty, and that they have a 50% chance of infecting a given person. There is still the good news that for a vacinated other singer, the relative risk of a breakaway infection for a healthy person (see above) remains only 0.009.  If we again conservatively assume that 100 percent of the risk from exposure is from this one risky activity, then this 0.009 risk can be assigned to this one risky activity. But we still should assume that there is only a 0.5 probability of infection even if the one assumed person is infectious. So my back of the envelope calculation is that a plausible upper bound on the probability of a vacciated person becoming infected from a moderate risk activity when around a known person in the group who is infectious becomes (.009)*(0.5) = .0045. If instead of being around a person with a known infectious rate of 1, we are around a random person, and the average infection rate is 1.5%, then the risk to a fully vaccinated person would be (average infection rate) * (upper bound on risk from one risky activity) = 0.015*0.0045  = 0.00007 => 1/14,000 an upper bound on risk to a vaccinated person of doing a risky activity around random people. Note that this upper bound calculation is assigning 100% of the risk of infection to time spent singing outdoors in a choiror eating indoors at restaurants, which is likely way above (100times?) the true risk. And the risk will be much lower to the extent that the people participating in the activity have more than the average population level of vaccination. 

A useful test of these calculations is to look at rates of infection of vaccinated medical staff who are treating COVID-19 patients, or of spouses with an infected partner. For them, the risk using this calculation would be on the order of 0.009, almost one percent, which is high. There will be a literature on these topics. I just have not explored it. Please send me the link if you find them.


Unstated in these calculations is that most of the breakthroughs are occurring in people with compromised immune systems. Conditional on getting a detected breakthrough infection, the probability of getting seriously ill is 588/7157=8.2%, and of dying 88/7157=1.1%. These rates are comparable to early rates for random populations before any social distancing or vaccines. This key group remains at high risk even with the COVID-19 vaccine and is worthy of some extra precautions by all of us.

Another important caveat is that these calculations of risk ignore key correlations. The people not getting vaccinated also tend to be people who are reluctant to wear masks, and also more likely to go to bars and large group gatherings where they are at a much higher risk. Predictions using averages will tend to underestimate the true infection rates since these factors compound the risk. And they tell us to avoid these kind of people.

So enjoy Mother’s Day this weekend. If you are fully vaccinated, your risk of infection is very low from normal activities, but your possible exposure to others when not wearing a mask could still endanger them, especially if they are immune compromised. Wear a mask to be sure when around strangers, especially indoors.

Back to research.


BUHealth: Wonderful news about vaccines and alternative strains

This JAMA research letter came out on March 19, 2021, but it is trending #1 on JAMA, and seems worth highlighting since it gives such hopeful news.

The study compared measures capturing rates of antibodies in three sets of patients: 20 people actively infected with COVID-19, 20 people who had recovered from COVID-19 for 32-94 days, and 14 people who had just finished their second vaccine of Moderna dose 14 days earlier (hence arguably at their maximal responsiveness to the vaccine). Note that these antibody tests are measuring antibodies, related to how well the body is prepared to fight off COVID, not for the virus itself. A higher number is better.

Importantly, the study examined not only the original Wuhan strain that was used to test and approve Moderna and other vaccines, but also three variants that reflect recent concerns, including B.1.1.7. The results are wonderfully summarized in the (Figure) shown below.

The figure makes comparisons across the three types of patients and four strains. Focus on the means and confidence intervals.

Across patient samples:

Not all actively infected are yet protected with antibodies, as expected.

Eventually, convalescent people (recovered infectees) show high rates of antibodies with only one sample showing no signs of being protected, as defined by the low gray line.

All of the Moderna vaccinated sample shows high rates of antibody protection. Scientists are tracking changes in these rates over time, but so far they are encouragingly gradual declines.

Across variants:

More encouraging, across the four COVID-19 strains, there were no statistically significant differences in rates of antibody effects among the two naturally infected groups. ( people infected with A1 appear likely to be almost equally protected against the newer variants. There is a small difference in the strength of antibodies within the vaccinated sample, but the difference is still very small relative to the natural rate of antibody protection observed in the convalescent sample. In short, the Moderna vaccine appears remarkably successful against all four strains considered, even if not exactly as effective against the more recent strains.

This is great news!

My own comment is: The similarity of the effectiveness of the various vaccines suggests similar results are likely with the other vaccines.This is not in the article.

As the article concludes,

“Limitations include the small sample size, possible selection bias, lack of clinical outcomes, and how neutralization titers correlate with protection.”


Research Letter

March 19, 2021

Neutralizing Antibodies Against SARS-CoV-2 Variants After Infection and Vaccination

Venkata Viswanadh Edara, PhD1; William H. Hudson, PhD2; Xuping Xie, PhD3; et al Rafi Ahmed, PhD2; Mehul S. Suthar, PhD1

Author Affiliations Article Information

  • 1Emory University Department of Pediatrics, Atlanta, Georgia
  • 2Emory Vaccine Center, Atlanta, Georgia
  • 3University of Texas Medical Branch, Galveston


Neutralizing Antibodies Against SARS-CoV-2 Variants After Infection and Vaccination





Re: BUHealth: I am vaccinated!

Two serious ones, now one on humor.

This Frozen musical take-off on getting a vaccine is well done if you like over-the- top musical singers.

You may not enjoy this one if you are not likely to get a vaccine soon. 9/10


https://youtu.be/U74wUO54Sdg  5:49 minutes


This medley by the same singer from last spring by the same performer. Has a lot of Disney favorites on COVID-19. 8/10


https://www.youtube.com/watch?v=eI47Q_pfqsQ      4:22 minutes
Done for the day. Have a great weekend. Weather is looking  up here in Boston.



BUHealth: Consider donating blood

If you are curious about whether you have already had COVID-19 and would like to find out whether you already have antibodies, it is worth knowing that if you give blood, then the American Red Cross automatically tests donor blood and will tell you if you have COVID-19 antibodies.

20% of American donating blood test positive for COVID-19 antibodies.

CDC estimates that 25% of adults test positive in a random sample.


Covid-19 antibodies present in about 1 in 5 blood donations from unvaccinated people, according to data from the American Red Cross

By John Bonifield and Deidre McPhillips, CNN

Updated 12:01 AM ET, Tue March 16, 2021



Do something good for others while you find out information about yourself.


I searched the American Red Cross website for any mention about COVID-19 and found none. The following is from the Washington Post article two days ago.



“If I’ve had covid-19 or taken a coronavirus vaccine, can I still donate blood?

“Of course — but with stipulations.”

“Although certain blood donation centers may have their own rules, at the Red Cross, donors who have been diagnosed with covid-19, the disease the virus causes; tested positive for the virus; or experienced any recent symptoms can still donate blood, but they must wait at least 14 days. Because some centers require longer deferrals, check with local blood banks.”


BUHealth: Vaccine effectiveness strong against variants and allergic reactions are trivial.

These two accessible, free JAMA Network articles have excellent answers to some common questions. Below are a few selected quotes with key parts in RED.

My notes are in italics, red italics if important. 2 minutes if you just read the red.

Figuring Out Whether COVID-19 Vaccines Protect Against Variants

“How well do the COVID-19 vaccines developed so far protect against these novel coronavirus spinoffs?”

“In Scotland, researchers estimated that Pfizer-BioNTech’s vaccine was up to 85% effective and Oxford-AstraZeneca’s vaccine up to 94% effective in preventing COVID-19–related hospitalizations 28 to 34 days after a single dose—the UK policy is to provide the second dose 12 weeks later.”

“The study, posted February 22 but not peer reviewed, found a 70% reduction in both types of infection [UK and SA] 21 days after participants received their first dose and an 85% reduction a week after receiving their second dose. “Overall, we’re seeing a really strong effect to reducing any infection—asymptomatic and symptomatic,” coauthor Susan Hopkins, MD, PHE strategic response director, said at a press conference. In March, Pfizer and BioNTech announced that non–peer-reviewed data from Israel showed their vaccine was 94% effective against asymptomatic SARS-CoV-2 infection.”

“Fortunately, as the article notes, nearly all vaccines used in humans prevent asymptomatic infection and spread.”

This means that it is most likely that we will not need to keep wearing masks once vaccinated, once the data are in.

“In general, vaccines that are effective in reducing infections do have major impacts on reducing transmission,” said Goodman, director of Georgetown University’s Center on Medical Product Access, Safety and Stewardship. “It is probable that these vaccines will reduce transmission.”

Mounting evidence supports that notion. In a study of UK health care workers immunized with the Pfizer-BioNTech vaccine, participants underwent biweekly polymerase chain reaction testing and twice weekly rapid antigen testing to help investigators determine rates of asymptomatic and symptomatic infections.

Source: JAMA Network Medical News & Perspectives

March 17, 2021

COVID-19 Vaccines vs Variants—Determining How Much Immunity Is Enough

Figuring Out Whether COVID-19 Vaccines Protect Against Variants

There is continuing concern by some people about getting an allergic reaction to receiving a vaccine. This JAMA article addresses this for Pfizer and Moderna.


JAMA Insights

February 12, 2021

Reports of Anaphylaxis After Receipt of mRNA COVID-19 Vaccines in the US—December 14, 2020-January 18, 2021

Tom T. Shimabukuro, MD, MPH, MBA1; Matthew Cole, MPH2; John R. Su, MD, PhD, MPH1



Here is the key result from their study


“During December 14, 2020 through January 18, 2021, a total of 9 943 247 doses of the Pfizer-BioNTech vaccine and 7 581 429 doses of the Moderna vaccine were reported administered in the US”


No deaths from anaphylaxis after vaccination with either product were reported.


“…mRNA COVID-19 vaccines in the US has confirmed that anaphylaxis [allergic reactions]  following vaccination is a rare event, with rates of 4.7 cases/million Pfizer-BioNTech vaccine doses administered and 2.5 cases/million Moderna vaccine doses administered, based on information through January 18, 2021.


Of those with an allergic reaction, 77% of those using Pfizer and 84% of those taking Moderna had a prior reported history of allergies or allergic reactions.


When considered in the context of morbidity and mortality from COVID-19,9 the benefits of vaccination far outweigh the risk of anaphylaxis, which is treatable. Because of the acute, life-threatening nature of anaphylaxis, immediate epinephrine administration is indicated for all cases. CDC guidance on use of mRNA COVID-19 vaccines8 and management of anaphylaxis is available.10 All facilities administering COVID-19 vaccines should have the necessary supplies and trained medical personnel available to manage anaphylaxis.


To put this in perspective the annual chance of getting hit by lighting is about 4  per million in Montana and 0.25 per million in California, and averages 1 per million per year nationwide.


About 1 in ten people if hit by lightning die, versus so far 0 in ten million from getting vaccines.


Get a vaccine if it is offered to you.

BUHealth humor: final entries in the masked dog photo caption contest

Final entries in the masked dog photo caption contest

Masked Sadie 20210314Waiting for the dog vaccine rollout.”

"Wearing a mask is so easy even my dog can do it!"

“Sadie says: Even I wear a mask when not eating!”

“I hate it when I can’t lick and my hair gets all frizzy!”

“How do you like my matching blue accessories?”

“It takes a smart dog to wear a mask!  How smart does that make you?”

”Don't worry. I’m all bark and no cough.”

“I miss Uncle Phil!!!!“

“I've had enough of being walked by the neighbors during lockdowns ... now I deserve this seat!”

“If I should meet thee
After long quarantine
How should I greet thee?
With silence,
With mask.“

“Stop barking about your rights being violated! It’s a mask, not a muzzle!”

“Stinks in here…”

“I really wasn’t barking all that much.  I wish I lived in Texas!”

“I hate it when I can't lick my butt!”

Thanks for all your great entries! Excellent new entries could be added to this posting.

BUHealth: Being less racist makes some of us less comfortable

The New York Times had a very interesting article on March 5 which documented differences in rates of vaccination by race across the 50 US states. Whereas some states (Florida, Iowa, Wisconsin and Connecticut (?!?) have vaccination rates for blacks that are less than half of the state average, in Massachusetts the rate for blacks is about 85% of the state average, reflecting the states recommitment to serving needier minorities in the state.




Screenshot 2021-03-08 105954













This weekend when I was vaccinated, it was not at my convenient Vanguard primary care provider’s office or at Boston University, which would have mostly served people of privilege, but it was instead provided by a neighborhood community health group in the preschool of a housing project in Brighton MA. Less convenient for me, but much better for the nearby residents.

I am proud of MA for its better-than-average performance on racial equity of COVID-19 vaccinations, even though I know it underlies the enormous dissatisfaction of some of my neighbors and friends of privilege who feel they should have been placed at a higher priority. Being less racist makes some of us uncomfortable, and hopefully also puts more pressure on our government to be sure that everyone who wishes to can get a vaccination. All too often, market systems start by satisfying the needs of the wealthy and privileged (think education, health insurance, zoning, public streets over public transport, etc) and then decide it is not worth doing more for the poor and less privileged. In this case, by vaccinating more minorities, we may also be reducing the overall rates of infection, since infection rates have been much higher in minority groups.

Being less racist makes some of us less comfortable, but in the long run, it may make all of us better off.

BUHealth: I am vaccinated!

A wise friend who read my previous BUHealth post comparing different vaccines warned me that it could be interpreted as saying “Wait to get a vaccine until you get the one you like the most.” I do not recommend that. I care too much about my friends. Instead, you should get a vaccine the first time it is offered to you, whatever one it is.  For me, the first offer was yesterday, when a friend alerted me about a small surplus at one community health center. It was Moderna. I had found it hard to sign up via the weblinks. (I am over age 65, which has blanket permission to get a “jab” in the US now.) Look at how happy it made me.













You too could look like this when you get vaccinated.

I did have a little pain in the arm and a low-grade temperature 99.2o F compared to my norm of 97.7 for the first 24 hours. But it ended. And now I can party continue wearing a mask carefully out of solidarity and because of the nasty new strains that are still popping up.


BUHealth: latest research in JAMA on COVID-19 vaccine effectiveness

One JAMA Network article this week and an accompanying editorial about COVID-19 are the first I have seen to carefully present the research about recent SARS-CoV-2 strains/variants, different types of vaccines, effects of one versus two doses, advice for people who were previously infected by SARS-CoV-2, what we know so far about their effectiveness against different strains, and what seems likely in the future. I put links in at the bottom after my summary.

The editorial by Drs. Mascola, Graham, and Fauci provides an accessible overview to brush up on your high-school level biology. It starts with a discussion of the distinction between lineage, variants, and strains: new genetic virus variants are organized into lineages when one variant builds upon another, and when the variants become sufficiently different in behavior from the original SARS-2 virus strain - such as by being more resistant to antibodies, or to vaccines, or more infective or fatal - then they are called a strain. There are dozens of new variants of SARS-2 virus, suggesting it is mutating rapidly.  The UK, South Africa (SA) and Brazil strains are getting a lot of media attention, as they should. There is also a new variant found in southern California which they are trying to figure out its lineage, but it now represents 44 percent of the cases sequenced. Merely by its rapid appearance as the dominant strain in CA, we know it is a virulent strain.

 The article by John Moore (PhD) of Dartmouth was the most relevant to me.

Here are a few quotes from Moore with interpretation in italics.

“Two categories of variants have different implications for vaccine efficacy. …The first category involves variants “…[that]… “spread more rapidly in a population.”

“The second category involves variants that are more concerning, represented by the B.1.351 and P.1 lineages that emerged in South Africa and Brazil, respectively….[that help the viruses resist antibodies created by vaccines or previous infections].

“The combination of a high virus replication rate within an individual (a high viral load) and a suboptimal level of neutralizing antibodies is the exact environment in which resistant viruses are considered likely to emerge and spread.3,4

In other words, people who have had only one dose of a vaccine are more likely to promote new variants since they do not have enough neutralizing antibodies. This motivates the emphasis in the US for two vaccine doses, close together.

“At present, most scientists active in this area are reasonably optimistic that the efficacy of the mRNA vaccines [Moderna and Pfizer] will not be substantially compromised by the B.1.351 and P.1 [SA and Brazil] variants, …”

This is great news if true, but there is little clinical evidence so far..

In order to reduce the creation of new variants, Moore recommends Pfizer, Moderna, and (when approved) Novavax 2 dose vaccines if available, since they give strong antibody protection.

“The Johnson & Johnson 1-dose adenovirus vector vaccine … is less effective than the Moderna, Pfizer, and Novavax 2-dose designs.”

Moore recommends use of Johnson and Johnson one-dose on younger people (aged <40 years) who tend to have naturally lower “viral replication rates” and hence will not give the SARS-COV-2 as much chance to mutate then they get infected.

“All leading vaccine companies are now redesigning their S-protein components to counter new variants, particularly B.1.351 [SA].”

“Another issue with significant implications involves what happens when a mRNA vaccine [Pfizer or Moderna] is given to a person who has recovered from COVID-19. Small-scale studies have shown that a single mRNA vaccine dose rapidly boosts neutralizing antibody titers to very high levels, perhaps rendering the second dose redundant in this special circumstance.10 … A related issue is that the mRNA vaccines appear to trigger strong (although short-lived) adverse effects (such as headaches and mild fever) in people who have previously been infected with COVID-19.”

In light of this, I am planning to get the Pfizer and Moderna rather than J&J, and await further research for the second dose.

Novovax is a huge potential entrant into this vaccine race with its recombinant protein nanoparticle COVID-19 vaccine. It is not yet approved for use in the US, but is hoping for May. It is gearing  up for production at the rate of 2 billion doses per year to be produced in India and Japan. Early clinical results from tests I SA and Brazil are encouraging.

I foresee a long future for vaccines in the world.  

JAMA Viewpoint

March 4, 2021

Approaches for Optimal Use of Different COVID-19 Vaccines: Issues of Viral Variants and Vaccine Efficacy

John PMoore, PhD

Abstract Full Text

free access is active quiz has multimedia online first

JAMA. 2021; doi: 10.1001/jama.2021.3465

This Viewpoint proposes ways to maximize vaccine efficacy and allocation given the rise of coronavirus variants and authorization of a Johnson & Johnson vaccine, including reserving the latter for younger healthier populations, boosting it with a single-dose messenger RNA (mRNA) vaccination, and single mRNA immunization of people with prior documented SARS-CoV-2 infection.


February 11, 2021

SARS-CoV-2 Viral Variants—Tackling a Moving Target

John R. Mascola, MD1; Barney S. Graham, MD, PhD1; Anthony S. Fauci, MD2

Author Affiliations Article Information

JAMA. Published online February 11, 2021. doi:10.1001/jama.2021.2088


Novavax press release Jan 28, 2021 at 4:05 PM EST

Company web site.

Novavax COVID-19 Vaccine Demonstrates 89.3% Efficacy in UK Phase 3 Trial


Yes, even rich white people in the US get bad health care

Despite the abundant evidence2 showing that health care outcomes in the US are much worse than in every other OECD country, I still hear arguments that this is because uninsured, Medicaid, minorities, or low-income people in the US bring down our health outcomes. This myth is repeated3-5, and believed by a majority of Americans. 6 This JAMA study shows that this is not true. Even high-income white people get worse health outcomes than the average result in OECD countries. Time to change to a better health care system!


Key Points

Question  Are the health outcomes of White US citizens living in the 1% and 5% richest counties better than the health outcomes of average residents in other developed countries?

Findings  In this comparative effectiveness study of 6 health outcomes, White US citizens in the 1% and 5% highest-income counties obtained better health outcomes than average US citizens but had worse outcomes for infant and maternal mortality, colon cancer, childhood acute lymphocytic leukemia, and acute myocardial infarction compared with average citizens of other developed countries.

Meaning  For 6 health outcomes, the health outcomes of White US citizens living in the 1% and 5% richest counties are better than those of average US citizens but are not consistently better than those of average residents in many other developed countries, suggesting that in the US, even if everyone achieved the health outcomes of White US citizens living in the 1% and 5% richest counties, health indicators would still lag behind those in many other countries.

JAMA Intern Med. 2021;181(3):339-344. doi:10.1001/jamainternmed.2020.7484

Comparing Health Outcomes of Privileged US Citizens With Those of Average Residents of Other Developed Countries

Ezekiel J. Emanuel, MD, PhD; Emily Gudbranson, BA; Jessica Van Parys, PhD; et al.

December 28, 2020

BUHealth: UK/South African COVID strains are at BU; BU testing looks great; BU plans in-person commencement!

I greatly enjoyed reading about how BU is using its extensive research laboratory resources to test for the presence of the UK and South African variants at BU. This report includes the 70 cases of COVID-19 detected in members of the BU faculty, staff and students during the week of Feb 17-23. Below are a few selected quotes.

Boston University Weekly COVID-19 Report: February 17 to 23

BU has begun sequencing COVID samples for variants; two variants that first emerged in South Africa, UK already detected at BU

Of the positive tests sent to the NEIDL for sequencing since January 25, more than 130 samples have contained enough viral material to allow them to be sequenced.

… thus far, we have detected eight samples containing a COVID variant of concern. Specifically, we have detected two variants of concern: one case of the B.1.351, first detected in South Africa, and seven cases of the B.1.1.7, first detected in the UK. We were not surprised by these results—they confirm what we already suspected, that those two variants have reached our community. “


It was informative to me to learn that BU is not able or allowed to tell people which variant they have if infected.

“For regulatory reasons, BU is not permitted to tell individuals if they have a variant form of COVID-19. The scientists who are doing this study are not even aware of which person the samples they are sequencing came from; they just know the virus sample was collected from someone at BU. “

even if we could tell individuals that they had been infected with a COVID-19 variant, that knowledge wouldn’t change our clinical management of that person’s illness.”

 I am fortunate to be part of BU’s comprehensive testing. It is available daily on the COVID-19 dashboard, with testing results as of two days ago.

I only wish that more people had such excellent testing available. I have not seen any recent estimates of the cost to BU of doing these COVID tests, but an early guess was $12 per test. I think a lot of people would be willing to pay $12 (weekly) or $25 (biweekly) for careful testing, which is the cost per faculty member or undergraduate of BU’s testing program. BU is continuing its hybrid teaching, with students in many classes allowed to choose between in-class and remote zooming.

 Based on these low current testing and vaccination efforts at BU, BU announced this week that it will be holding in-person graduation ceremonies on May 16 (graduates only) as long as the city and state allow it. Link is here and below. Go BU!

In-Person Commencement for BU Class of 2021 Planned for May 16, unless City Requires Virtual Ceremony

Class of 2020 will gather October 2 for virus-delayed ceremony: both will be for graduates only


JAMA Network articles on P4P, Policy Equipoise and Nocebo effects

In these days when pay-for-performance and value-based payment reform have become the centerpiece of US Medicare payment reform, this short and accessible article in JAMA Health Forum (5 minutes) argues that we implement and evaluate reforms using "policy equipoise" rather than the usual foundational belief - that too many economists adhere to - that these policies must work because the models economists use predict they should because of the incentives they create. The paper provides links highlighting that in many cases these reforms have very mixed or no success. Policy equipoise - the acceptance of true uncertainty about whether one policy is better than another in a given situation - should guide randomized designs to generate more convincing evidence about what works. Check out its links for a systematic review of (y)our favorite US payment reform: VPB, P4P, ACO, bundled payments.

It’s Time to Advance Payment Reform Using the Principle of Policy Equipoise

Jonathan A. Staloff, MD, MSc1,2; Amol S. Navathe, MD, PhD3,4; Joshua M. Liao, MD, MSc1,2


I happened upon the above article after reading this one, which is also interesting  (3 minutes).

“Important Conversations” Are Needed to Explain the Nocebo Effect

Anita Slomski, MA

A Momentous Day for Democracy!

Today is a momentous day for the US and for democracy, so I thought I would comment on it. I did not expect to be so happy today.

The Associated Press has not yet called the second of the two Georgia senate elections but I trust the NY Times report (see article below) that Georgia voters will ultimately elect two democratic senators, which will give the democrats the leadership in our Senate to combine with our democratic majority in the House and allow the Biden administration to negotiate key legislation in coming months.

Also momentous will be when our senate and house today vote to affirm the results of our electoral college, and bring to an end the legislative attempted coup still in play that our current president and a disturbing number of anti-democratic Republicans are still pursuing today.

Today has to be viewed as a success for all who believe in popular democracy in which elections are decided by voters and not just by money and voter suppression, for minorities and other lower caste members* whose voice is too often suppressed and ignored, for citizens who want a congress that debates and enacts legislation rather than simply issuing executive orders that undoes legislation, and for those who want to see government leadership on the environment, COVID-19, immigration, trade, education, racial equality, infrastructure, science-based decision-making, and so much more.

It will not be an easy path forward, but at least it looks like we can move off of the backwards path of the past four years. We will see if our new leadership is up to the challenge, and whether there are spillover effects on the rest of the world.

Happy New Year! Stay healthy! Stay active.

*Read or listen to Isabel Wilkerson’s book “CASTE: The Origins of Our Discontent” to better understand why so many Americans continue to support Trumpism.

Revised new mantra:

Mask, distance, vaccinate, go outside, wash, be patient, be upbeat, be skeptical, pray, believe.