Vox: All Posts by Julia Belluzhttps://cdn.vox-cdn.com/community_logos/52517/voxv.png2023-04-18T06:00:00-04:00https://www.vox.com/authors/julia-belluz/rss2023-04-18T06:00:00-04:002023-04-18T06:00:00-04:00The pregnancy risks of Ozempic and Wegovy need more attention
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<img alt="A drawing of a pregnant woman with her hand to her head and a positive pregnancy test stick in a bubble in front of her." src="https://cdn.vox-cdn.com/thumbor/t6-wZB4Vx5jcoHoWeJkV7POiGZs=/240x0:1680x1080/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/72190626/VOX_ozempic_2.0.png" />
<figcaption>Sargam Gupta for Vox</figcaption>
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<p>The drugs are linked to birth defects in animal studies. Why is this information so hard to find?</p> <p id="0IVU2S">After neuroscientist <a href="https://neuroscience.wustl.edu/people/martha-bagnall-phd/">Martha Bagnall</a> read a recent <a href="https://www.newyorker.com/magazine/2023/03/27/will-the-ozempic-era-change-how-we-think-about-being-fat-and-being-thin">New Yorker article</a> about Ozempic — the “<a href="https://www.businessinsider.in/science/health/news/mindy-kaling-sparks-jokes-shes-on-buzzy-drug-ozempic-at-the-oscars-heres-what-shes-said-about-her-weight-loss-/articleshow/98611595.cms">buzzy</a>” “<a href="https://www.telegraph.co.uk/news/2023/03/08/wegovy-millions-could-receive-popular-celebrity-weight-loss/">celebrity weight loss jab</a>” that’s <a href="https://www.vox.com/science-and-health/23584679/ozempic-wegovy-semaglutide-weight-loss-obesity">upending obesity medicine</a> — she emailed a colleague to dish on what she felt were gaps in the discussion about the drug’s effects on the brain. His reply blew her away. </p>
<p id="CyCrhu">“Another aspect that’s not talked about much,” he wrote to her, “is that Ozempic is not recommended for use during pregnancy.” </p>
<p id="ocZUBn">The colleague, an obesity researcher, was referring to studies in rats, rabbits, and monkeys, which were treated with the injectable drug and had higher rates of miscarriage. Their offspring were also born smaller and had more birth defects than would normally be expected. </p>
<p id="j9K9e6">The animal studies are the basis for Food and Drug Administration warnings that both <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/209637lbl.pdf">Ozempic</a> — approved only for diabetes but <a href="https://www.fda.gov/patients/learn-about-expanded-access-and-other-treatment-options/understanding-unapproved-use-approved-drugs-label">used off-label</a> for weight loss — as well as the higher-dose obesity formulation, <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/215256s005lbl.pdf">Wegovy</a>, should be discontinued at least two months prior to pregnancy. The agency has also required the drugmaker, Novo Nordisk,<strong> </strong>to organize <a href="https://urldefense.proofpoint.com/v2/url?u=https-3A__www.accessdata.fda.gov_drugsatfda-5Fdocs_appletter_2021_215256Orig1s000ltr.pdf&d=DwMFaQ&c=7MSjEE-cVgLCRHxk1P5PWg&r=WlXLOx96MMAbd81Y4Kks7Q&m=nHNeCmmL0a-p74vf8bE9OgJ9E4FRy4JKBa_vvFp6q6yletOwtXhJpKXZDGaLNTla&s=Nq3hsBIqay6LlUtq_71YTx1rjVHsbgL4FgAfse0onjw&e=">follow-up studies</a> that investigate health outcomes in people exposed to Wegovy during pregnancy. </p>
<aside id="xjctfj"><div data-anthem-component="readmore" data-anthem-component-data='{"stories":[{"title":"Ozempic is a game-changer. Here’s how it works. ","url":"https://www.vox.com/videos/2023/3/14/23638717/ozempic-semaglutide-hormones-weightloss-glp1"}]}'></div></aside><p id="MPLOOq">Bagnall had been following the news about the medicines for months, reading all about their promise for patients and how they were redefining beauty standards, especially for women, but she had not picked up on the pregnancy concerns, not in the media coverage, nor in online drug ads. “Given the prevalence of Ozempic ads with women in them,” she said, “you think that’s a pretty big [potential] side effect to draw attention to.” </p>
<p id="9yRVca">The overwhelming majority of the dozen obesity, diabetes, obstetrical, gynecological,<strong> </strong>and regulatory experts Vox reached out to for this story said much the same: There’s not enough discussion of the pregnancy risks, and warnings are not featured prominently enough in advertisements or in the drug’s labeling and instructions. “We should be talking more about this,” said <a href="https://www.ucsfhealth.org/providers/dr-diana-thiara">Diana Thiara</a>, a professor and medical director of the UCSF Weight Management Clinic. Or as one obesity researcher, who has associations with the drugmaker and did not feel comfortable speaking on the record, put it: “Given the majority of people accessing these medications are women, and a significant portion will be of childbearing age, this needs more attention.”</p>
<p id="y4vhhu">It’s not yet clear why the birth complications in animals arise; it’s possible they’re driven only by the weight loss the drugs can bring on, not the medications — which both contain the active ingredient semaglutide — themselves. It’s also possible the side effects won’t manifest at all in humans. But like most drugs, semaglutide’s effects haven’t been studied yet in pregnant people, so the risks to human pregnancy are uncertain. </p>
<p id="xC30i2">Even if it’s only the weight loss that led to the animal harm, the need for more awareness remains, said <a href="https://www.lunenfeld.ca/?page=drucker-daniel">Daniel Drucker</a>, a scientist and endocrinologist at the University of Toronto who helped discover GLP-1, the human hormone on which semaglutide is based. Weight gain is an important <a href="https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm">goal of a healthy pregnancy</a>, he said. Given that nearly <a href="https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm">half of pregnancies in the US are unplanned</a>, the time period before a pregnancy is detected may be particularly vulnerable.</p>
<p id="nQ4daY">“This pregnancy issue is a real issue. There’s no question about it,” Drucker said. “The drug manufacturers and most certainly prescribing health care providers should highlight this issue.”</p>
<p id="d2BGCD">But in the Wild West of the Ozempic era, highlighting nuances about potential side effects is a massive challenge. Semaglutide is part of a new class of GLP-1-based prescription medicines, the first-ever that appear to safely cause substantial weight loss, and they have met a hungry market of millions who struggle with their body size. Some patients are circumventing doctor’s offices to get access — buying the drugs <a href="https://edition.cnn.com/2023/03/17/health/ozempic-shortage-tiktok-telehealth/index.html">online</a>, from <a href="https://www.businessinsider.com/americans-buying-cheaper-ozempic-semaglutide-canada-mexico-pharmacy-2023-3">other countries</a>, or through <a href="https://www.statnews.com/2023/01/18/risky-sources-wegovy-ozempic-obesity-drugs/">compounding pharmacies</a>, often without medical supervision. Meanwhile, telehealth companies that advertise directly to patients and operate with <a href="https://www.wsj.com/articles/health-startups-offer-diabetes-drugs-like-ozempic-for-weight-loss-with-little-oversight-f2a69456">little regulatory oversight</a> have been feeding on the frenzy, pushing the weight loss benefits of the medicines in their ads, as <a href="https://www.statnews.com/2023/04/06/weight-loss-drugs-wegovy-ro-telehealth-ozempic/?utm_campaign=morning_rounds&utm_medium=email&_hsmi=253265291&_hsenc=p2ANqtz-_6H01FfkCg2JOnqJnju52tvRlJrTnn-KTwSkzAv1qkbBHi4MR2mN8wdPsbzj6Csbzm5s5M56muD-1rjaA-IF60zzjN1A&utm_content=253265291&utm_source=hs_email">Stat</a> recently reported, without appropriately warning patients about the drug’s risks. </p>
<p id="LI6Di0">The worst-case scenario for human pregnancies is alarming, said <a href="https://medicine.yale.edu/profile/joseph-ross/">Joseph Ross</a>, a professor at Yale School of Medicine who researches pharmaceutical regulation. “If a pregnant woman is taking these drugs and doesn’t realize the risks, and it does bear out the drugs cause human fetal harm,” he said, “we could end up in an awful mess — pregnancies ending in miscarriage or neonates born with birth defects.”</p>
<h3 id="jslodF">What animal studies have found </h3>
<p id="MRfv30">While<strong> </strong><a href="https://www.marchofdimes.org/find-support/topics/pregnancy/prescription-medicine-during-pregnancy#:~:text=Most%20pregnant%20people%20(about%209,depression%20or%20high%20blood%20pressure.">seven in 10 people</a> in the US take a prescription drug during pregnancy, only 10 percent of medicines recently approved by the FDA reach the market after they’ve been studied during human pregnancy, according to an analysis published in <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770046"><em>JAMA</em></a>, because of safety and ethical concerns. </p>
<p id="qpJ8Z6">The hesitance to include pregnant people in studies is intended to protect them and their babies, but “the ultimate effect is to provide care without adequate evidence,” said <a href="https://utswmed.org/doctors/catherine-spong/?_ga=2.147019317.34775463.1680270793-1596424370.1680270793">Catherine Spong</a>, professor and chair of the department of obstetrics and gynecology at UT Southwestern Medical Center. And even though many expert voices and even major task forces have called for the inclusion of pregnant women in clinical trials over the last several decades, she added, “the lack of inclusion persists. This is simply another example.” </p>
<p id="LHfQwj">So we don’t typically have data on the effects of most drugs in pregnant humans. But for some 90 percent of recently approved medicines, there are studies in animals — including the semaglutide products, Ozempic and Wegovy. And in these cases, the animal studies uncovered harms. </p>
<p id="wA1JST">Studies of semaglutide in rats, rabbits, and monkeys found the animals experienced higher rates of miscarriage, and that their babies more often did not grow to full size. In addition, the babies were more often born with “structural abnormalities” in different organs, tissues, and parts of the skeleton: the heart, blood vessels, kidney, liver, cranial bones, vertebra, sternebra, and ribs. This data is outlined in the <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/209637lbl.pdf">Ozempic</a> and <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/215256s000lbl.pdf">Wegovy</a> drug labels — the big sheet of information that comes with all medicines. </p>
<p id="7mY74t">But, again, it’s difficult to tease out whether the effects are driven by the medicines or the weight loss that the medicines can cause, Drucker explained. “During a period of rapid growth, if the fetus is in a caloric deficit and the mother is in a caloric deficit, that will clearly produce some impairment of fetal growth,” he said, and maybe the congenital disorders are a sign “the baby’s just not growing properly.”</p>
<p id="hkSXPr">An FDA spokesperson told Vox the agency takes the view that the pregnancy complications are likely caused by weight loss and poor nutrition. In the animals, the fetal complications happened when mothers did not gain weight or lost weight during their pregnancies. The spokesperson said that the agency is unaware of any humans harmed during pregnancy or in utero because of semaglutide exposure. </p>
<p id="AmETWT">Because of the clear weight loss risks, the agency’s Wegovy pregnancy warning is slightly more stringent than the warning on Ozempic. Wegovy users are advised to stop the drug as soon as a pregnancy is detected, while Ozempic users, ostensibly taking the drug for its indicated diabetes use, may continue “only if the potential benefit justifies the potential risk to the fetus,” according to the Ozempic label.<strong> </strong></p>
<p id="j3zxr5">In practice, experts said, the Ozempic warning may mislead or confuse people, since many use Ozempic off-label only for its weight loss benefits and both labels also advise discontinuing the drugs at least two months before pregnancy. <strong> </strong></p>
<p id="A37gv8">Still, based on the animal data, the spokesperson added, “taking semaglutide during pregnancy may increase the risk of birth defects and miscarriage above background for the US general population,” and the extent of increased risk has not yet been quantified.</p>
<p id="3bC487">When the effects of the drugs on pregnancy are better studied, we could learn about other contributing factors. When asked about potential mechanisms by which semaglutide itself — and not just the weight loss it causes — could do harm, Drucker said, “It’s possible [it] does have effects on, for example, placental blood flow or formation of the placenta. This is not an extensively studied area, and there are gaps in our knowledge.” </p>
<p id="XYRY3z">It may take years to understand the real impact of GLP-1 receptor agonists on pregnancy. At the FDA’s request, Novo Nordisk has organized a study to analyze complications related to Wegovy in pregnancies that already happened, and a <a href="https://urldefense.proofpoint.com/v2/url?u=https-3A__www.accessdata.fda.gov_drugsatfda-5Fdocs_appletter_2021_215256Orig1s000ltr.pdf&d=DwMFaQ&c=7MSjEE-cVgLCRHxk1P5PWg&r=WlXLOx96MMAbd81Y4Kks7Q&m=nHNeCmmL0a-p74vf8bE9OgJ9E4FRy4JKBa_vvFp6q6yletOwtXhJpKXZDGaLNTla&s=Nq3hsBIqay6LlUtq_71YTx1rjVHsbgL4FgAfse0onjw&e=">registry</a> that will prospectively follow the health outcomes of a group of people exposed to Wegovy during pregnancy compared to pregnant people who weren’t. The first will be completed <a href="https://urldefense.proofpoint.com/v2/url?u=https-3A__www.clinicaltrials.gov_ct2_show_NCT05503927&d=DwMFaQ&c=7MSjEE-cVgLCRHxk1P5PWg&r=WlXLOx96MMAbd81Y4Kks7Q&m=nHNeCmmL0a-p74vf8bE9OgJ9E4FRy4JKBa_vvFp6q6yletOwtXhJpKXZDGaLNTla&s=XOYjUOauKxfG9K4kwyrtWwcYgzY8FlmKphQHW31m7iI&e=">in 2027</a>, and the second in 2033. (No such studies are required for Ozempic.) Meanwhile, millions of people will take the drugs, including during pregnancy. </p>
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<h3 id="1e19Nr">The ideal versus real world</h3>
<p id="xKm4TL">Pharmaceutical companies and the FDA have an obligation to make patients and prescribers aware of the potential risks of medications. This typically happens through warnings on drug packages and drug labels, and in official drug ads, as well as patient encounters with physicians and pharmacists who have read the entire drug label. </p>
<p id="4llTgF">But even in the best cases today, where patients actually see a specialist for a prescription, they might not get the pregnancy warnings, Yale’s Ross said. Rather than being featured prominently in the drug labels or side-of-package warnings, he said, the information appears in a section of the label called “use in special populations,” so prescribers are left to “dig through searching for the section on pregnancy where it says clearly the drug should be stopped.” </p>
<p id="ssGdng">In the labels’ instructions for use, which explain how to store and administer Wegovy and<strong> </strong>Ozempic, there’s also no mention of pregnancy, said <a href="https://tdi.dartmouth.edu/about/our-people/directory/steven-woloshin-md-ms">Steven Woloshin</a>, who co-leads the Center for Medicine and Media at the Dartmouth Institute, “but there is a whole bit about how to protect the Wegovy pen. ... That seems like an oversight. Protecting the pregnancy seems a lot more important. So why not repeat the warning?”</p>
<p id="EcuuRS">Even in the official Ozempic and Wegovy commercials, the advice to tell your health care provider if you’re pregnant or planning to be only flashes quickly in text on the screen. </p>
<p id="087mnb">(The FDA spokesperson said the agency would typically only feature a pregnancy-related risk more prominently if “<a href="https://www.ncbi.nlm.nih.gov/books/NBK132140/">teratogenic events</a> have been observed in humans” — that is, when the DNA of a fetus has been altered by a medicine, causing congenital disorders. There’s no semaglutide data showing such harm.)</p>
<p id="FN2Ysd">Yet many patients aren’t even getting the medicines through patient-specialist encounters. The <a href="https://www.glamour.com/story/ozempic-shortage-diabetes-tiktok-weight-loss">rampant off-label use of semaglutide</a>, Ross said, suggests patients are not seeing obesity or diabetes clinicians, which means their health care providers may be even less familiar with any contraindications or side effects. </p>
<p id="D0YRZu">“My guess is most physicians don’t know the concerns,” Ross said. (Bagnall wasn’t the only health researcher unaware of the pregnancy contradiction; even some of the GLP-1 researchers and obesity clinicians Vox reached out to about the pregnancy warnings didn’t know about them.) </p>
<p id="nEC2bR">Or patients, after being bombarded by <a href="https://www.wsj.com/articles/health-startups-offer-diabetes-drugs-like-ozempic-for-weight-loss-with-little-oversight-f2a69456">online ads from telehealth marketers</a> that don’t adhere to FDA marketing guidance, may not see a clinician at all. </p>
<p id="5dhic1">“This is an unusual case,” Ross summed up. There aren’t a lot of drugs like semaglutide: ones originally intended for a narrow use with a desirable benefit for the broader public. On top of that, they’re “increasingly available through direct-to-consumer telehealth companies and for purchase over the internet,” he said. It’s a recipe for confusion. While it’s not clear whether the drugs pose harm to human pregnancy, Ross said, “widespread educational efforts are needed as a precaution.” This can happen through public awareness campaigns or extra messaging in the drug’s marketing materials, he added, including drug labels, ads, and packaging. </p>
<p id="b5IkdT">A Novo Nordisk spokesperson told Vox, “Novo Nordisk does our best to ensure patients and health care providers are educated about the appropriate and responsible use of our medicines. Our efforts are designed to ensure that health care providers are prescribing the right product for the right patient.”</p>
<h3 id="sJKOZJ">What semaglutide users should do </h3>
<p id="KMq5nx">So what are patients to do now?</p>
<p id="wDyul9">Given the unknowns about its effects in pregnant humans, patients taking semaglutide who want to conceive should stop at least<strong> </strong>two months before a pregnancy, the FDA spokesperson said. They should also “know that appropriate weight gain based on pre-pregnancy weight is currently recommended for all pregnant patients, including those who are overweight or obese, because of the obligatory weight gain that occurs in maternal tissues during pregnancy.” </p>
<p id="vQdJ04">At the same time, semaglutide can potentially help prepare a person for a successful pregnancy in the years and months before they plan to have a baby. As <a href="https://www.mrl.ims.cam.ac.uk/research/principal-investigators/professor-sir-stephen-orahilly/">Stephen O’Rahilly</a>, an endocrinologist and director of the University of Cambridge MRC Metabolic Diseases Unit, pointed out, “obesity is also associated with poor fetal outcomes,” heightening a woman’s risk of everything from <a href="https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-complications.html">stillbirth to diabetes and high blood pressure</a>. <a href="https://scholar.harvard.edu/shah/home">Neel Shah</a>, an OB-GYN and chief medical officer of Maven Clinic, agreed, noting the drug may have particular benefits for people with weight-related infertility or conditions such as <a href="https://www.mayoclinic.org/diseases-conditions/pcos/symptoms-causes/syc-20353439">PCOS</a>. </p>
<p id="LycGhm">“For them, Ozempic may actually make them more likely to conceive and the risk-benefit trade-off may be different from the general population,” Shah said. They just have to be prepared to stop taking the drug before trying to get pregnant. </p>
<p id="tfETwL">People with diabetes who are pregnant or thinking of becoming pregnant should switch to older, better-studied drugs to manage their blood sugar, such as insulin, said <a href="https://diabetesresearchcenter.wustl.edu/people/samuel-klein-md/">Samuel Klein</a>, the director of the Center for Human Nutrition at Washington University in St. Louis — an approach that goes further than the FDA (which, again, says pregnant people using the drug for diabetes may continue if the benefits outweigh the risks). In Klein’s view, “there are safer ways to control blood glucose in pregnant women, and [GLP-1 receptor agonists] should not be used to lose weight during pregnancy.”<strong> </strong></p>
<p id="IL3B6f">For her part, UCSF’s Thiara counsels patients of reproductive age who are on semaglutide to use contraception and to bring up the risks related to pregnancy at their regular appointments. (There’s no requirement for contraception with semaglutide, and such requirements for drugs are <a href="https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.14914">rare in general</a>.) Like Klein, she also gets patients — even those with diabetes — off semaglutide before and during pregnancy.</p>
<p id="Iq85H8">But not every patient sees a specialist like Thiara, which means the onus is now on patients to learn about the risks — and that may not change anytime soon, she added.</p>
<p id="FGmzxB">“I suspect the drug companies are downplaying this risk because women are probably the biggest part of the market share,” she said. “The world doesn’t value women, and this is seen in women’s health as well. So perhaps the pessimist in me thinks this might just be another case of the medical system devaluing women.” </p>
https://www.vox.com/science/23683383/ozempic-pregnancy-risks-side-effect-semaglutide-wegovyJulia Belluz2023-02-07T06:00:00-05:002023-02-07T06:00:00-05:00Obesity in the age of Ozempic
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<img alt="An illustration of the infinity mirror effect, with a person peering into a mirror endlessly. " src="https://cdn.vox-cdn.com/thumbor/g5xNKzp2Dz_t3sabf_fsjbNH8Bo=/240x0:1680x1080/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/71948280/Vox_3_Blue.0.png" />
<figcaption>Sargam Gupta for Vox</figcaption>
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<p>Drugs like Ozempic and Wegovy are changing how patients view their own weight struggles. Will society follow?</p> <p id="qjszeK">On a beach in San Sebastian, Spain, Aditi Juneja strutted around in the beige sand wearing a red bikini top with colorful bottoms, her mop of curly hair blowing in the breeze. A close friend and travel companion trailed behind snapping photos. </p>
<p id="BPqLIr">In the years before the Spain trip, Juneja, 32, a lawyer, had put on 50 pounds. She called it the “Fascist 50” — much of it gained during the Trump presidency, when her work dealt with the era’s democracy abuses. </p>
<p id="77mZrm">Diagnosed with clinical obesity, she had come to embrace her larger body size. She’d been steeping herself in literature on fat acceptance and learning about the “<a href="https://asdah.org/health-at-every-size-haes-approach/">Health at Every Size</a>” movement, which seeks to demedicalize obesity and promote an understanding that body size is not necessarily correlated with health. On that beach day, she remembers wanting to document how far she’d come, “to celebrate this beautiful body.” </p>
<p id="mFCkBb">But around the same time, she was also coming to terms with health issues related to her weight. “I was experiencing the physical effects of being in a heavier body,” she says. First there were pain and mobility issues: Her back was regularly going out, and she was frequently rolling over her ankles. </p>
<p id="GQDosG">Then she learned that her cholesterol levels had soared to 10 times the normal range. It was the result of a genetic predisposition and had to be treated by cholesterol medication, her doctor told her, but weight loss could help, too. Juneja was also growing concerned about how her weight would heighten her risk of Type 2 diabetes, for which she has a strong family history, and potentially complicate a future pregnancy. </p>
<aside id="U9Kjt9"><div data-anthem-component="readmore" data-anthem-component-data='{"stories":[{"title":"The pregnancy risks of Ozempic and Wegovy need more attention ","url":"https://www.vox.com/science/23683383/ozempic-pregnancy-risks-semaglutide-wegovy"}]}'></div></aside><p id="2iZGWy">When her doctor broached medication to treat the obesity — such as semaglutide, currently sold by Novo Nordisk under the brand names Wegovy and Ozempic —<strong> </strong>Juneja refused. The fat acceptance literature she’d been studying opposed weight loss as a means to health. Using an obesity drug also felt like an admission that her body was something to be ashamed about at a moment when she’d come to embrace it. </p>
<p id="MwRZ8q">The new class of obesity drugs — referred to as “GLP-1-based,” since they contain synthetic versions of the human hormone glucagon-like peptide-1 — are considered the most powerful ever marketed for weight loss. Since the US Food and Drug Administration <a href="https://www.vox.com/22553793/gila-monster-lizard-venom-inspired-obesity-drug-semaglutide">approved Wegovy</a> for patients with obesity in 2021, buzz on social media and in <a href="https://variety.com/2022/film/actors/weight-loss-ozempic-semaglutide-hollywood-1235361465/">Hollywood</a>’s <a href="https://www.vanityfair.com/hollywood/2022/11/ozempic-hollywood-diet-drug">gossip mills</a> has erupted, helping drive a surge in popularity that’s contributed to ongoing <a href="https://www.nbcnews.com/health/health-news/people-diabetes-struggle-find-ozempic-soars-popularity-weight-loss-aid-rcna64916">supply shortages</a>. While celebrities and billionaires such as <a href="https://www.insider.com/elon-musk-weight-loss-drug-wegovy-semaglutide-fit-ripped-healthy-2022-10">Elon Musk</a> and <a href="https://www.cnbc.com/2023/01/20/trending-glp-1-weight-loss-drugs-are-shipping-to-more-american-homes.html">Michael Rubin</a> praise the weight loss effects of these drugs, regular patients, including those with <a href="https://www.medpagetoday.com/special-reports/features/102773">Type 2 diabetes</a>, <a href="https://www.nytimes.com/2022/05/31/health/obesity-drugs-insurance.html">struggle with access</a>, raising questions about who will really benefit from treatment.</p>
<p id="MR9sWN">But there’s another tension that’s emerged in the GLP-1 story: The medicines have become a lightning rod in an obesity conversation that is increasingly binary — swinging between fat acceptance and fatphobia. </p>
<p id="k6B3sW">“It feels like you have to be like, ‘I love being fat, this is my fat body,’ or, ‘Fat people are evil,’” Juneja told me. </p>
<p id="bOCXqg">While many clinicians and researchers hail GLP-1-based therapy as a “<a href="https://erictopol.substack.com/p/the-new-obesity-breakthrough-drugs">breakthrough</a>,” and one deemed safe and effective by FDA, critics question its safety and usefulness. They argue the drugs unnecessarily medicalize obesity and dispute that it’s an illness in need of treatment at all. They also say the medicines perpetuate a dangerous diet culture that idealizes thinness and weight loss at all costs. </p>
<p id="1cRArg">At the same time, many of the patients currently on treatment tell a story that seems to fall somewhere between “miracle” and “useless” diet drugs. Despite all the TikTok videos decrying obesity medication as the easy way out, progress is not always straightforward. Navigating side effects, dosing, weight plateaus, and access issues are frustrating features of many patients’ journeys. Patients also told me it’s hard to know if and when to come off the drugs, or that a healthy end goal has been reached. A minority don’t respond to the drugs at all. </p>
<p id="h4KEZ6">One thing they had in common: wanting medical help to lose weight, despite the cultural conversation around fat acceptance. Even Juneja, who eventually started using the GLP-1-based drug tirzepatide, sold as Mounjaro by Eli Lilly, argues that the medicines are part of a more nuanced story, one society needs to internalize. Rather than viewing obesity as the result of personal failing or emotional issues, easily reversed with diet and exercise, patients like Juneja say they’re beginning to see it as medical researchers long have: as a condition that arises from complex interactions between our biology and our environments. Like other complex illnesses, such as diabetes, this means it can also benefit from medical treatment. </p>
<p id="EuC0eL">And some patients, including those who accept their larger bodies, may want to try obesity medication for help<strong> </strong>losing weight. “You can be healthy at every size,” Juneja summed up. But “I was not healthy at the size that I was.” </p>
<h3 id="NB0XFV">On GLP-1-based drugs, it’s easier to consume fewer calories </h3>
<p id="8YBauG">At first, Juneja took the cholesterol medicine prescribed by her doctor but resisted the obesity treatment. She hadn’t yet put in the time to really try to improve her health through lifestyle changes alone, she thought. So for the year after her doctor first suggested semaglutide, Juneja focused on eating healthfully — more protein and vegetables, fewer snacks — and exercising five days per week, thinking these measures alone would be enough.</p>
<p id="ciFv6x">A year later, her cholesterol had improved on her cholesterol-lowering drugs but her levels were still too high, and the pain and mobility issues hadn’t fully resolved either. She had also lost “zero weight,” she recalls, and remained “very much concerned about the diabetes and the pregnancy thing,” referring to the fact that <a href="https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/pregnancy-and-obesity/art-20044409">pregnancies with obesity</a> are associated with a greater risk of complications, such as preeclampsia and gestational diabetes, as well as a <a href="https://www.nytimes.com/2019/06/18/magazine/fertility-weight-obesity-ivf.html">higher risk of bias</a> from health care workers. </p>
<p id="D2qDpd">In September 2022, after Juneja returned to New York City from Spain, she filled her first prescription for <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-novel-dual-targeted-treatment-type-2-diabetes">tirzepatide</a>, which was approved for diabetes in 2022 and is now being used off-label for obesity. “I no longer felt guilty about exploring medication assistance as an option for weight loss,” she says.</p>
<p id="eh3aSc">Right away, Juneja noticed it was suddenly easier to consume fewer calories. Her hunger between meals eased, and she felt fuller faster whenever she did eat. The weight also started dropping off — roughly two pounds per week, she said, to the tune of 37 pounds by January 29, after five months on treatment. </p>
<p id="gnmH2F">GLP-1-based drugs “weren’t initially developed for weight loss,” <a href="https://www.lunenfeld.ca/?page=drucker-daniel">Daniel Drucker</a>, a scientist and endocrinologist at the University of Toronto who helped discover GLP-1, says. Instead, they were <a href="https://www.vox.com/22553793/gila-monster-lizard-venom-inspired-obesity-drug-semaglutide">used in patients with Type 2 diabetes</a>, to help manage their blood sugar, and only in those clinical trials did researchers see how many patients were also losing weight. </p>
<p id="LrvKQ9">Researchers still don’t know the precise mechanism by which the drugs work, but they believe it has to do with mimicking the actions of hormones and their impact on the brain. Hormones are the body’s traveling messengers: Manufactured in one area, they move to another to deliver messages through receptors. The gut makes dozens of hormones, including GLP-1.</p>
<p id="TGAWYF">When we eat, GLP-1 is unleashed primarily in the gut (in addition to the brain stem) and stimulates the pancreas to make more insulin, lowering blood sugar and sending a signal to the brain that we’ve had enough food, which then curbs appetite.</p>
<p id="y6Wgr6">Drugs like semaglutide and tirzepatide contain a synthetic version of our native GLP-1, and appear to be safe. There’s more than a decade of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4772785/">safety data</a> on the <a href="https://pubmed.ncbi.nlm.nih.gov/27797785/">effects of the medicines</a> in people with <a href="https://spiral.imperial.ac.uk/handle/10044/1/61644">diabetes</a>, many who also had obesity. “We’ve been studying [GLP-1] in animals for 30 years and in humans for more than 18 years,” Drucker, who has consulted with Novo Nordisk, says.</p>
<p id="83bjKG">So far, both semaglutide and tirzepatide have led to weight loss results <a href="https://www.vox.com/science-and-health/2017/12/7/16587316/bariatric-surgery-weight-loss-lap-band">rivaling bariatric surgery</a> — without the need for an operation. In clinical trials lasting more than a year, patients lose up to 20 percent of their body weight on <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2206038">tirzepatide</a> and 15 percent on <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2032183">semaglutide</a>. Many patients also see their fasting glucose or insulin levels improve and their blood pressure go down. </p>
<p id="BgnIzX"><a href="https://www.ft.com/content/8054d902-1be8-4580-b527-67af455aa4d3">The next generation</a> of GLP-1-based obesity drugs appears to be even <a href="https://pubmed.ncbi.nlm.nih.gov/34626851/">more promising</a>, Drucker says.</p>
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<p id="fKBiMG">Though gastrointestinal side effects — nausea, diarrhea — are common, Juneja didn’t experience any during her first four months on tirzepatide. Things were improving. Her back pain went away, and she could move around with more ease. Her cholesterol levels finally fully normalized, prompting her doctor to raise the possibility that she could reduce her reliance on cholesterol medication. And the weight loss came with an unexpected mental health benefit: It changed how she thought about her obesity, reducing the shame she felt about not being able to control her body size. </p>
<p id="qzdBM5">“I realized that it wasn’t my fault that I couldn’t lose weight despite making tons of lifestyle changes,” she says. “I can see how much hormones are a part of it now.” </p>
<p id="KUPwl8">She added: “Being on these medicines, I was like, ‘Jesus Christ, I didn’t need to have any guilt around this. I didn’t need to have any big feelings around it.’”</p>
<h3 id="JHwjx9">Easing the food stress </h3>
<p id="02IcUg">If anyone has tried dieting and exercise for weight loss, it’s Tracey Yukich. While she was a candidate on the reality TV weight loss contest <em>The Biggest Loser</em>, she had to be airlifted to a hospital to be treated for <a href="https://www.cdc.gov/niosh/topics/rhabdo/default.html#:~:text=Rhabdomyolysis%20(often%20called%20rhabdo)%20is,permanent%20disability%20or%20even%20death.">rhabdomyolysis</a>, a life-threatening condition often caused by overexercising. Still, by the end of the season, which aired in 2009, she had managed to lose 118 pounds. And she kept a lot of the weight off years after her Hollywood stint — by exercising regularly (she’s run the Boston Marathon three times) and eating well.</p>
<p id="kRsF8M">By 2016, Yukich’s struggle changed. No matter how hard she tried, the weight piled on. “I would revolve my entire day around my caloric intake, and when I did splurge or have a normal meal, I gained weight easily and rapidly,” she recalls. </p>
<p id="v7ACg9">In 2021, Yukich decided she needed medical help. She had come to “despise diet culture” which “has consumed so much of my life,” she says, and instead of more calorie cutting and exercise, she sought the care of an obesity doctor in Boston. The doctor recommended semaglutide — Ozempic — which Yukich started taking that May. The drug helped her lose more than 30 pounds, she says. And, as Juneja experienced, it also took away the shame she felt asking for help and the blame she was placing on herself about her weight gain.</p>
<p id="783YfG">“It’s taken me a year to get that weight off” on semaglutide, Yukich says. “I’m still exercising the way I was a year ago. I’m still eating the same as I was a year ago. The only thing I’ve done differently is take prescription medication. Does that not prove medicine is needed for people that are obese? That they need help? I can’t think of any other proof.” </p>
<p id="hnso6w">On semaglutide, Yukich experienced some dizziness and a worsening of existing constipation, but both side effects resolved. In addition to weight loss, the drug’s other major effect was that her stress around food eased. </p>
<p id="Lf6PQb">Suddenly, she was no longer worried about whether she’d made the right choices in her last meal, or what she’d be eating next. “My day didn’t revolve around what I was going to have for food,” she says.</p>
<p id="lu3OgX">Clinicians who have worked with patients with obesity shared a similar view: People on these drugs don’t just shed pounds, they shed food-related anxieties, too. </p>
<p id="5ndJZh">“There is tremendous mental health benefits to no longer stressing around food, to no longer feeling like you’re out of control around food, and to no longer feeling like there’s something broken and wrong with you that prevents you from making those healthy choices you’d like to make,” says <a href="https://uniweb.uottawa.ca/members/2310">Yoni Freedhoff</a>, an obesity doctor based in Ottawa who has also consulted with Novo Nordisk, which has hired many leading diabetes and obesity doctors and scientists as consultants. His patients are telling him this reduction in stress “is as valuable as the weight loss,” he says. </p>
<p id="LVWoPJ">“For the first time in many of these patients’ lives, they have a more neutral feeling toward food,” <a href="https://hobi.med.ufl.edu/profile/cardel-michelle/">Michelle Cardel</a>, associate director for the Center for Integrative Cardiovascular and Metabolic Diseases at the University of Florida who heads research at Weight Watchers, observed. GLP-1-based drugs “reduce the chatter in their brain; they quiet obsessive food thoughts.” </p>
<h3 id="2MOgKF">Critics worry the drugs will only reinforce weight stigma </h3>
<p id="h2RfbB">But not everybody embraces the new obesity medications. </p>
<p id="1QI1sA">Some of the most vocal opposition has come from Health at Every Size<strong> </strong>and weight-neutral health advocates, who criticize how the drugs medicalize obesity. </p>
<p id="lalW8O">They point to the <a href="https://www.nytimes.com/2013/06/19/business/ama-recognizes-obesity-as-a-disease.html">longstanding debate</a> about whether obesity is in and of itself a disease state and argue that body size is not a good health metric.<strong> </strong>Some<strong> </strong>of obesity’s health consequences may also be caused by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866597/">stigma and discrimination</a>, including on the part of health care providers who under-treat patients with obesity, attributing medical issues to excess weight even <a href="https://www.yesmagazine.org/opinion/2022/12/06/weight-fat-liberation">when they have other causes</a>. The situation is especially risky for people of color, who also have <a href="https://www.hsph.harvard.edu/obesity-prevention-source/obesity-trends-original/obesity-rates-worldwide/#:~:text=Roughly%20two%20out%20of%20three,(9)">higher rates of obesity in the US</a> and are less likely to be accurately diagnosed by <a href="https://elemental.medium.com/the-bizarre-and-racist-history-of-the-bmi-7d8dc2aa33bb#:~:text=While%20Quetelet's%20work%20was%20used,fat,%20build,%20or%20health.">body mass index</a>, or BMI — the tool that’s most frequently deployed to gauge obesity and its risks. </p>
<p id="FZbMA5">“The idea of other health issues being ‘obesity-associated’ is scientifically questionable, since weight cycling [also known as yo-yo dieting], weight stigma, and health care inequalities are all correlated with the same health issues to which being higher weight is correlated,” explained <a href="https://danceswithfat.org/">Ragen Chastain</a>, a patient advocate and writer focused on weight stigma and <a href="https://weightandhealthcare.substack.com/p/reader-question-whats-the-difference-acb">weight-neutral health</a>, who, like many of her peers, believes weight loss should not be used as a medical intervention. Instead, she’d like health care providers to “stop <a href="https://elemental.medium.com/the-bizarre-and-racist-history-of-the-bmi-7d8dc2aa33bb#:~:text=While%20Quetelet's%20work%20was%20used,fat,%20build,%20or%20health.">calculating BMIs</a>, stop pathologizing higher weight bodies, stop prescribing weight loss diets/drugs/surgeries, and give fat people the interventions we would give thin people with the same symptoms,” as she summed up on her <a href="https://weightandhealthcare.substack.com/p/reader-question-whats-the-difference-acb">blog</a>. </p>
<p id="20M4c7">This pushback has gained traction in a moment when weight discrimination has been <a href="https://www.economist.com/christmas-specials/2022/12/20/the-economics-of-thinness">holding firm or worsening</a> — even while discrimination based on other factors, such as race or sex, has been declining, and obesity rates have been rising. In the US, obesity affects <a href="https://www.cdc.gov/obesity/data/adult.html">42 percent</a> of the adult population and <a href="https://www.cdc.gov/obesity/data/childhood.html">20 percent</a> of children and adolescents. Globally, the <a href="https://www.who.int/news/item/04-03-2022-world-obesity-day-2022-accelerating-action-to-stop-obesity">World Health Organization</a> estimates more than 1 billion people have obesity, including kids. There are legions who’ve struggled with their weight and share a history of <a href="https://www.vox.com/science-and-health/2018/3/13/17054146/diet-isnt-working-why">failed weight loss attempts</a>. </p>
<p id="nroDrB">Alongside the cultural movement, there’s a growing pile of scientific evidence from obesity and diabetes researchers showing that the health risks of excess fat are more difficult to untangle than the public has been led to believe. </p>
<p id="XEk3PB">Some people develop complications linked to obesity, such as Type 2 diabetes, before reaching clinical obesity, while others manage to avoid obesity’s metabolic risks, including “metabolic syndrome” — a cluster of conditions that typically occur together, including high blood pressure, high blood sugar, cardiovascular disease, and high cholesterol. </p>
<p id="7g5RRi">These insights have led to the “<a href="https://pubmed.ncbi.nlm.nih.gov/25515001/">personal fat threshold</a>” hypothesis — that everybody has a different point at which fat heightens the risk of Type 2 diabetes, and that point isn’t always correlated with a high BMI. A related strand of research explores “metabolically healthy obesity,” a concept that’s been <a href="https://www.nhlbi.nih.gov/events/2022/moving-beyond-bmi-exploring-heterogeneity-obesity">heavily debated</a> since it can take decades for obesity’s complications to surface. People who seem “metabolically healthy” early in life may not be in the future, or they may develop obesity’s non-metabolic complications, which include sleep apnea and mobility problems. </p>
<p id="NQjUbN">Besides questions about the true health costs of obesity,<strong> </strong>critics also express concern that the published GLP-1 weight loss clinical trials to date have only followed up with people for up to <a href="https://www.nature.com/articles/s41591-022-02026-4">two years</a> and patients tend to <a href="https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.14725">keep off most of the weight only</a> as long as they stay on treatment, meaning if they want to maintain their new body weight, they probably have to stay on the medicine for life. </p>
<p id="AtlI7F">Even the obesity clinicians and researchers who view the drugs as a <a href="https://www.vox.com/22553793/gila-monster-lizard-venom-inspired-obesity-drug-semaglutide">major step forward</a> acknowledge uncertainty. While it’s true that drugs containing synthetic GLP-1 alone, such as semaglutide, have been used for years in diabetes patients, some of the newer compounds — such as tirzepatide, which features both GLP-1 and a synthetic version of another similar hormone called GIP — have not. “When we add anything, it’s a very appropriate question to ask, ‘Are you going to take anything away from the safety of GLP-1 alone or maybe ideally add something to the safety,’” Drucker points out. “We cannot assume that [additional drug ingredients] have a neutral or beneficial effect.”</p>
<p id="RSdFuV">Still, like many of his peers, Drucker says he’s puzzled — and concerned — by how people treat obesity differently from other diseases, and downplay “the risks of leaving it untreated.” Of the long-term use of the drugs, he says, “I could give you a list of hundreds of chronic diseases that remit when treatment is discontinued — all forms of diabetes, hypertension, heart disease, atherosclerosis, arthritis. Yet somehow, we hold obesity therapy to a higher standard and ‘complain’ that chronic therapy is necessary.”</p>
<p id="N76qj1"><a href="https://www.imperial.ac.uk/people/tony.goldstone">Tony Goldstone</a>, an Imperial College London endocrinology clinician-researcher who treats patients with obesity and has previously monitored the safety data in GLP-1-based drug trials for Novo Nordisk, shared a similar view. “So we shouldn’t develop treatments for obesity, because there’s a risk that it might get abused by Hollywood celebrities who want to lose a little bit of weight?” he asked. “I mean, that isn’t how medicine works.” </p>
<p id="OflaNp">Goldstone and others pointed out that there’s a mountain of evidence demonstrating that, as body weight increases, people’s health risks do, too, including problems that can’t be explained by discrimination alone, such as sleep apnea and cancer. Weight loss has also repeatedly been shown to improve health outcomes — in everything from <a href="https://cardiab.biomedcentral.com/articles/10.1186/s12933-021-01426-z">rodent research</a> to long-term <a href="https://onlinelibrary.wiley.com/doi/10.1002/oby.23646">controlled</a> human <a href="https://pubmed.ncbi.nlm.nih.gov/22215166/">studies</a> of <a href="https://pubmed.ncbi.nlm.nih.gov/19136998/">bariatric surgery</a>.</p>
<p id="Mdj7CG"><a href="https://profiles.wustl.edu/en/persons/samuel-klein">Samuel Klein</a>, the director of the Center for Human Nutrition at Washington University in St. Louis, who researches metabolically healthy obesity, noted that many weight loss studies include lifestyle changes, like diet or exercise, so it’s difficult to separate out the benefits of the weight loss itself from the benefits of the other changes — a point those skeptical of treating obesity as a disease make, too. “But it’s very unlikely” that weight loss is not the “primary contributor” to health improvements, he added, pointing to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4833627/">research that shows</a> the more weight people lose, the more health benefits accrue.</p>
<p id="XZgEpG">Even with the unknowns, Klein says, people “need to get their heads out of the sand. We know very much that even moderate weight loss can prevent and improve obesity related-diseases. It improves medical health, quality of life, and the ability to be physically active and interact in activities with family and friends.”</p>
<p id="s9x22v">As researchers try to untangle how all this works, and patients’ conceptions evolve, society’s “warped idea” about obesity remains stubbornly in place, journalist <a href="https://www.buzzfeednews.com/article/evettedionne/ozempic-wegovy-weight-loss-harm">Evette Dionne,</a> author of a“fat liberation” <a href="https://www.vogue.com/article/evette-dionne-weightless">memoir</a>, <a href="https://www.buzzfeednews.com/article/evettedionne/ozempic-wegovy-weight-loss-harm">wrote recently</a>. “It is objectively a good move to unlink the idea of moral virtue from fatness. However, in these attempts to complicate our cultural understanding of fatness, the remedy remains the same: lose weight rather than changing the ways in which our society interacts with and treats fat people.” </p>
<p id="ZddYoA">Caught in the middle of the debates are patients who would like to lose weight for myriad health and personal reasons, which may have nothing to do with how they look. </p>
<p id="WcfvcJ">Those reasons can span medical conditions, such as diabetes, to simply wanting to play a sport or with their kids on the playground, to not feeling out of breath when bringing in the groceries, Marian Tanofsky-Kraff, a clinician-researcher at the Uniformed Services University in Maryland, says. But, she adds, “Many of my patients have told me their desire to lose weight due to reasons other than appearance is somehow slowing the fat acceptance movement and they feel invalidated and guilty.”</p>
<p id="i6e6vx">Juneja has come to her nuanced view by reconciling her embrace of body positivity with taking the drugs. Acceptance is not resignation; people can love and accept their bodies while also wanting the health benefits that come with weight loss, she says.<em> </em></p>
<p id="h0zbzM">“While I agree that there’s an obsession with thinness in our culture, some of us do have health challenges that losing weight helps with … which is hard to do with just diet and exercise,” Juneja told me. “And it’s such a gift to be able to get ahead of things like diabetes.” </p>
<p id="wALuar">Yukich sees the drugs as something entirely apart from the diet culture she was so steeped in. “What I seek is a healthy me and while I will never be 132 pounds weighing in on the <em>Biggest Loser</em> stage again, I am the healthiest version of myself today and am more happy than I ever have been.” </p>
<h3 id="qHcWmp">The bumpy road for patients</h3>
<p id="zycZE3">The multifaceted scientific-cultural moment the GLP-1-based medicines have entered into has an additional layer of complexity: Treating obesity as a chronic disease with what experts deem a safe and powerful weight-loss medicine is new — and can be difficult. Even if the drugs themselves continue to be as promising as they currently seem, this change scales up the medical treatment of obesity, bringing it into the realm of all the common conditions marred by the inequalities inherent to the American health system. </p>
<p id="6W1fLU">I’ve talked to many people on obesity medication, and the range of stories I’ve heard is stunning. There are people who report incredible progress and call the drugs life-changing. For others, side effects were unmanageable or weight loss on the drugs didn’t meet their expectations. Most people felt the drugs were helpful but also less of an “easy way out” of weight problems than an entirely new maze to navigate. </p>
<p id="7OWsoN">These patients in the middle — including Yukich and Juneja — have had to switch or add medications after their weight plateaued far from their goal at the highest doses, or they reported interruptions to their access due to changing insurance and coupon policies and other affordability issues — or all of the above. </p>
<p id="6JdYRH">After Yukich shed 33 pounds on her regimen of Ozempic plus diet and exercise, her weight plateaued, 25 pounds shy of her goal weight. Her doctor suggested she switch from Ozempic to the higher-dose version of semaglutide, Wegovy. But her insurer, Blue Cross Blue Shield, would not cover Wegovy. Yukich was able to access tirzepatide but had to stop it after a month because it had the opposite of the desired effect: Her cravings increased, and she gained 10 pounds. This January, after she wrote to her insurer twice a month requesting coverage, she finally got the approval for Wegovy. </p>
<p id="tqdMwb">In her first two weeks on the drug, her weight started dropping again. “I hope to reach my goal, and then slowly taper off and see how I manage without,” she says. </p>
<p id="5zThCW">Juneja has faced similar disruptions — and now she’s wondering whether to continue with the drug at all. After her insurer, UnitedHealthcare, rejected her initial requests to have tirzepatide covered for obesity, she got access to the drug with a coupon from its manufacturer, Eli Lilly, for $25 per month — a fraction of the roughly $1,000 she would have had to pay out of pocket.</p>
<p id="ikuvFy">Then, last December, Juneja learned that Eli Lilly’s coupon policy changed, to only offer the discount to people who already have Type 2 diabetes. So she’s been paying out of pocket for a month while waiting to see if UnitedHealthcare might cover another GLP-1-based drug. So far, all of her prior authorization attempts were rejected. Because of the costs, and diarrhea that surfaced during month five on tirzepatide — which she’s not certain is linked to the drug — she’s contemplating stopping, just 14 pounds short of her goal weight. </p>
<p id="aH1Kuf">If she does quit, she’s hoping she can maintain her current weight loss with her usual diet and exercise routine, but she knows there’s a risk her weight might creep back up, along with the mobility, pain, and cholesterol issues and<strong> </strong>other health risks. And she’s not sure how concerned to be. </p>
<p id="wOgSBa">“Even if I lose the next 14 pounds and I’m no longer obese, I’m simply overweight, does that actually stop me from having Type 2 diabetes?” she told me. </p>
<p id="LaCuj0">What’s more, she’d only ever planned to be on the drug for a year — she had been told by her prescribing doctor that the medicine would reset her body’s “set point,” so that she’d be able to maintain a lower weight without medication. Today, she feels she was misled. “I would’ve never gone on [weight loss drugs] if I thought I’d have to be on them forever.”</p>
<p id="lgYCCi">Apart from the confusion over her own case, she’s wondering about the potential societal effects of the new medicines, and how the gaps in GLP-1 access will play out in a country where <a href="https://www.cdc.gov/obesity/data/prevalence-maps.html#overall">states with some of the highest rates of obesity</a> also have some of the <a href="https://www.census.gov/library/stories/2022/09/uninsured-rate-declined-in-28-states.html">lowest rates of health insurance coverage</a>. </p>
<p id="1MMODh">“I worry that because of the cost — and the marketing — it’s going to perpetuate us having people who are rich and thin, and people who are poor and fat, and it’s not going to change the culture or help people that most need it,” Juneja says. “So while it’ll make a difference for individuals who can access it, our ability to change population-level obesity is still determined by the ability to access healthy foods, access health care, have the time to think about your health. And all of that is not changed by these drugs. It’s exactly where we were before.” </p>
<p id="ssmudJ"><em><strong>Clarification, February 14, 5:30 pm ET: </strong></em><em>Updated to clarify the amount of weight Tracey Yukich lost with Ozempic. </em></p>
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https://www.vox.com/science-and-health/23584679/ozempic-wegovy-semaglutide-weight-loss-obesityJulia Belluz2021-07-05T12:00:00-04:002021-07-05T12:00:00-04:00How a lizard’s venom inspired the promising weight loss drug Wegovy
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<figcaption>A Gila monster is held up on display at an aquarium in Hamburg, Germany. The hormones from the lizard’s venom have led to the development of medicine that treats type 2 diabetes. | Axel Heimken/picture alliance/Getty Images</figcaption>
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<p>Semaglutide is the start of a new chapter in obesity treatments.</p> <p id="nvAv3J">After learning that the venom of a Gila monster lizard contained hormones that can regulate blood sugar, Daniel Drucker started wondering why. And could the venom somehow help treat diabetes?</p>
<p id="3Xv7GL"><a href="https://www.lunenfeld.ca/?page=drucker-daniel">Drucker is a scientist</a> and endocrinologist at the University of Toronto who has dedicated his career to understanding the universe of hormones in the body, which do everything from regulating appetite to helping with digestion. His curiosity about the Gila monster led to a call with a zoo in Utah. In 1995, Drucker had a lizard shipped from Utah to his lab and began experiments on the deadly venom. </p>
<p id="opgUZ7">Ten years later, a synthetic version of a hormone in the venom became the first medicine of its kind approved to treat type 2 diabetes. Known as a GLP-1 (for glucagon-like peptide-1) receptor agonist, the medicine set off a cascade of additional venom-inspired discoveries.</p>
<p id="a2Jpoe">After doctors noticed mice and humans on the drug for diabetes appeared to lose weight, they began to consider its use in obesity science. In June 2021, another effective treatment, this one for obesity, got <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014">Food and Drug Administration approval</a>. Called <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014">semaglutide</a> and marketed as Wegovy, it also takes its structure from the lizard’s venom. </p>
<p id="QAHMaT">If this origin story sounds outlandish, consider the history of obesity treatments. Over the years, people have turned to extreme and unlikely interventions to try to lose weight, from <a href="https://www.ncbi.nlm.nih.gov/pubmed/68326">jaw wiring</a>, laxatives, and <a href="https://pubmed.ncbi.nlm.nih.gov/7309328/">vagotomies</a> to <a href="https://www.vox.com/science-and-health/2017/5/25/15659878/weight-loss-surgery-lap-band-evidence">lap band operations</a> and fen-phen, a <a href="https://www.nytimes.com/1997/09/23/science/how-fen-phen-a-diet-miracle-rose-and-fell.html">“miracle”</a> diet drug that was <a href="https://www.nytimes.com/1997/09/17/us/recall-of-drugs-leaves-many-dieters-hopeless.html">ultimately recalled</a>. </p>
<p id="aimZxd">The new treatment — a once-weekly injectable from Novo Nordisk, a Danish pharmaceutical company that has hired many leading diabetes and obesity scientists as consultants — is poised to safely help many people with health-threatening obesity, physicians and researchers say. It may even illuminate some of the mysteries around how appetite works in the first place. </p>
<p id="CtpxFl">“It’s phenomenal,” says Michael Krashes, a diabetes and obesity investigator at the <a href="https://irp.nih.gov/pi/michael-krashes">National Institutes of Health</a>. Semaglutide is “a big step forward — we finally have something that’s reliable and able to produce sustained effects over time,” adds <a href="https://icahn.mssm.edu/profiles/ivan-e-de-araujo">Ivan de Araujo</a>, a neuroscientist who studies brain-gut interactions at Mount Sinai’s Icahn School of Medicine. Neither scientist is affiliated with Novo Nordisk. </p>
<p id="yllEUi">Doctors who treat obesity patients told Vox they wished they had a treatment option like semaglutide years ago, and patients described the drug as life-altering. </p>
<p id="DBxUny">Yet many people with obesity may not seek out semaglutide, and doctors may not prescribe it to them — not only because of the dangerous history of weight loss medications, but also because of a persistent bias and stigma around a disease that now afflicts <a href="https://www.cdc.gov/obesity/data/adult.html">nearly half of Americans</a>. Obesity is still widely viewed as a personal responsibility problem, despite scientific evidence to the contrary. And history has shown that the most effective medical interventions, such as <a href="https://www.vox.com/science-and-health/2017/12/7/16587316/bariatric-surgery-weight-loss-lap-band">bariatric surgery</a> — currently the gold standard for treating obesity — often go unused in favor of dieting and exercise, which for many don’t work. </p>
<p id="p9adkx">There’s also a practical challenge: Health insurers don’t typically cover obesity medications, says Scott Kahan, an obesity doctor and professor at Johns Hopkins Bloomberg School of Public Health and the George Washington University School of Medicine. “Medicare explicitly excludes weight medications,” Kahan, who consults with Novo Nordisk, says. “And most insurers follow what Medicare does.” </p>
<p id="k1qRnJ">The new drug certainly won’t be a cure-all for obesity, Krashes adds. “You are not taking a 280-pound person and making them 130,” he points out, though reductions that are enough to improve health outcomes are typical. Drucker, who began consulting with Novo Nordisk and other drug companies after his reptilian discovery, agrees that it’s a starting point for obesity: “It will only scratch the surface of the problem in the population that needs to be healthier.” </p>
<p id="H9iO7W">But semaglutide is the most powerful obesity drug ever approved, he adds. “Drugs that will produce 15 percent body weight loss — we did not have that before in the medical therapy of obesity.” With additional, potentially more effective <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2107519">GLP-1 receptor agonists</a> coming online in the future, we’re at the beginning of a promising new chapter of obesity therapeutics. A look at the fascinating science of how the medication works could also go a long way to changing how Americans think about this disease. </p>
<p id="1RcNla">“We have to thank the lizard for that,” Drucker says.</p>
<h3 id="Vxpe89">What semaglutide reveals about weight problems </h3>
<p id="1dhPcM">To understand how semaglutide causes some people to eat less, it’s helpful to understand what hormones do. They’re the body’s traveling messengers: Manufactured in one area, they move to another to deliver messages through receptors — molecules that bind to specific hormones — in distant organs and cells. </p>
<p id="I3qYxZ">The gut makes dozens of hormones,<strong> </strong>and many of them travel to the brain receptors that either curb appetite or stimulate it, Drucker explains. GLP-1 is one such gut hormone. It’s unleashed in the gut in response to food and stimulates the pancreas to make more insulin after a meal, which lowers blood sugar. (GLP-1 is also made in the brain stem, where it may modify appetite.) </p>
<p id="bvPOeg">“It sends a signal to our brain that says, ‘You know, we’ve had enough to eat,’” says Drucker.</p>
<p id="xMBLS4">Enter semaglutide, one of a class of medicines — the GLP-1-receptor agonists — that imitate GLP-1, helping the body lower glucose (in the case of people with diabetes) and, researchers suspect, curb appetite (in the case of people living with obesity who may also have diabetes).</p>
<p id="o6XJvc">The precise way the drug works on obesity is still unknown, in part because scientists don’t understand exactly how appetite works. But researchers generally agree that the drug harnesses the brain’s GLP-1 receptors to curb food intake. When researchers delete the GLP-1 receptors from the brains of mice, the drug loses its appetite-suppressing effects, says Krashes.</p>
<p id="FYET3P">Obesity is “primarily an issue of our brain biology, and the way it’s processing info about the environment we live in,” says <a href="https://medicine.umich.edu/dept/surgery/randy-seeley-phd">Randy Seeley</a>, a University of Michigan researcher focused on obesity treatments, who also consults with Novo Nordisk. </p>
<p id="nzX0Lg">With semaglutide, the idea is that “we’re changing your brain chemistry for your brain to believe you should be at a lower weight,” Seeley added. </p>
<p id="quH13Y">This brain-based pharmacological approach is likely to be more successful than diet and exercise alone, Seeley says, because “the most important underlying part of somebody’s weight has to do with how their brain operates,” not a lack of willpower.</p>
<h3 id="2T83eR">Not quite a “game changer” </h3>
<p id="ddcDPN">Some people with a <a href="https://www.cdc.gov/obesity/adult/defining.html">higher body mass index</a> are perfectly healthy and don’t require any treatment. Semaglutide was only indicated by the FDA for patients who classify as clinically obese — with a body mass index of 30 or greater — or those who are overweight and have at least one weight-related health problem. </p>
<p id="WjkcNs">For the many people who have used it, it has proved safe and effective, according to the FDA. In weight loss <a href="https://jamanetwork.com/journals/jama/fullarticle/2777025">clinical trials</a>, semaglutide helped people lose about <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2032183">15 percent</a> of their body weight on average — significantly more than the <a href="https://jamanetwork.com/journals/jama/fullarticle/2781520?utm_source=twitter&utm_campaign=content-shareicons&utm_content=article_engagement&utm_medium=social&utm_term=062421#.YNQnrLIkggk.twitter">currently available obesity drugs</a> and more than enough to improve health outcomes. </p>
<p id="gmail-Wi3A65">The drug’s most common side effects — nausea, diarrhea, constipation, and vomiting — were mostly short-lived. De Araujo is finding that adverse reactions might be caused by how the drug differs from the naturally occurring peptide hormone: The hormone acts mostly locally and degrades quickly, while the medicine works mainly on the brain and is designed to stick around in the body. “That’s where the nausea, vomiting probably derive from,” De Araujo argues. </p>
<p id="LcyOqK">Patients who have tried semaglutide told Vox that it helped them manage their weight and relationship to food, and that their side effects were manageable and quickly resolved. </p>
<p id="sNLeps">Jim Eggeman, a 911 operator in Ohio, said that before taking semaglutide, “I could sit down and eat a large pizza, and now it’s one to two pieces at the most.” He started on the drug for diabetes after a heart attack in December 2019 and lost 35 pounds, bringing his weight to 220. </p>
<p id="8K6gym">Paula Morris-Kaufman, of Cheshire, UK, used the drug to address weight gain following cancer treatments. It helped her bring her weight back to a normal range, she says, and curb her habit of compulsive eating. “If you give me a plate of food, I just eat a small portion of it — and feel full really quickly.” </p>
<p id="0vxevR">It’s possible that some of the benefits of treatment come in part from lifestyle changes, which were <a href="https://jamanetwork.com/journals/jama/fullarticle/2777025">encouraged</a> by the <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2032183">clinical trials</a>. In many cases, patients on semaglutide also switched to a healthier diet when they started on the drug and added exercise to their routines. But study participants taking the drug still lost significantly more weight than those under the same conditions who received a placebo. </p>
<p id="Z2MlMJ">The need for additional interventions — like diet and exercise — is one reason why Kahan stops short of calling this drug a game changer. “It’s an incremental improvement” over existing drugs, he says, and it’s still out of reach for many of the individuals who could benefit from it. “The ‘game changer’ description is not appropriate, because many people don’t have access to these medicines.” </p>
<h3 id="loNz5H">A mindset shift </h3>
<p id="rGEOPl">Only about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868321/">1 percent of eligible patients</a> were using FDA-approved medications for obesity in 2019, a study showed. The same is true for <a href="https://www.vox.com/science-and-health/2017/12/7/16587316/bariatric-surgery-weight-loss-lap-band">bariatric surgery</a>, currently the most effective intervention for obesity, which can also drive type 2 diabetes into remission.</p>
<p id="zGyVr8">“If someone walks into your office with heart disease and you as a physician don’t try to treat it, that’s malpractice,” Seeley says. “If somebody comes in with a BMI over 30 and you don’t treat it, that’s Tuesday.” He thinks some of the hesitancy for treating patients with obesity medications comes from the history of dangerous weight loss drugs. </p>
<div class="c-float-right"><aside id="2FCxPn"><q>“We would never blame other individuals for developing high blood pressure or cardiovascular disease or cancer”</q></aside></div>
<p id="8tZ8ah">Ingrained biases about obesity have also made it harder for patients to get access, Kahan says. “Obesity tends to be categorized as a cosmetic issue in health insurance policies,” he says. “In order to get coverage, employers have to explicitly decide to buy a rider and sign a contract to add weight management services and products to their insurance plans.” He’d like to see obesity treatments covered by insurers in the same way diabetes and hypertension drugs are. </p>
<p id="lyGPV3">That will require a shift in mindset, Drucker says. “We would never blame other individuals for developing high blood pressure or cardiovascular disease or cancer,” he says. It’s widely known that those conditions are driven by complex biological determinants, including genes, as well as environmental factors. “Obesity is no different.”</p>
<p id="6eoIGQ">When Drucker started in endocrinology in the 1980s, he didn’t have many tools to help patients. With the addition of semaglutide, there are multiple surgical options and drugs for obesity and diabetes. The challenge now is helping those who would benefit gain access.</p>
<p id="lIam1O">“I would be delighted if no one needed GLP-1 for diabetes and obesity,” Drucker says. That might be possible in a food landscape that didn’t nudge people toward the overeating and poor diet that leads to these chronic conditions. But for now, “we have new options that are safe, appear to reduce complications, and are very effective. ... We shouldn’t just throw up our hands and say there’s nothing we can do.”</p>
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https://www.vox.com/22553793/gila-monster-lizard-venom-inspired-obesity-drug-semaglutideJulia Belluz2021-06-23T05:00:00-04:002021-06-23T05:00:00-04:00The doctors are not all right
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<img alt="" src="https://cdn.vox-cdn.com/thumbor/XXlLwFk9Zt7wnmY_pvlJddTKZ9c=/340x0:3049x2032/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/69491633/IMG_6211_20210612_144505_copy.0.jpg" />
<figcaption>Emergency room doctor Scott Jolley was repeatedly denied support from his employer in managing pandemic stress. | Courtesy of the Jolley family</figcaption>
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<p>Doctors need mental health support, but the medical profession often punishes them for getting it.</p> <p id="5iDQta"></p>
<p id="WYnouF"><em>This story is part of </em><a href="https://www.vox.com/23185537/the-aftermath-covid-pandemic-health-care"><em>The Aftermath</em></a><em>, a Vox series about the collateral health effects of the Covid-19 pandemic in communities around the US. This series is supported in part by the </em><a href="https://nihcm.org/grants/journalism-grants"><em>NIHCM Foundation</em></a><em>.</em></p>
<p id="dlpvzj">Last August, Dr. Scott Jolley came home at 3 am from a busy emergency room shift looking pale, far older than his 55 years. It was the middle of the Covid-19 pandemic, and he had been the only physician on duty at his hospital in Salt Lake City, Utah. One of his patients had gone into cardiac arrest after Jolley removed his personal protective equipment to meet his next patient. Jolley, athletic with dusty brown hair, had to frantically gown up and run back to perform a resuscitation. The patient survived, but Jolley felt agitated. </p>
<p id="eoEhfA">When Jolley’s wife, Jackie, woke up at 6, she found him at their kitchen table, hunched over and unable to sleep. He was worrying that in his hurry, he hadn’t put on his PPE correctly, that he might expose Jackie and their three daughters to the coronavirus. He was also mortified about what he’d muttered to himself as he left the patient’s room: “I can’t take this anymore; this is not good for me.”</p>
<p id="zf8E7H">Jackie wasn’t used to seeing her husband in distress. His friends called him “the patriarch.” He was the one everyone else turned to: the kind of guy who talked his way into the ICU to support his daughter after a birth complication, who organized an elaborate fly-fishing trip for the birthday of a friend’s child. Over his 28 years as a doctor, Jolley brought the same attention to detail and compassion to thousands of patients who came into his ER.</p>
<p id="FCRvIU">But as he settled into his 50s, the pace and pressure of the job became unbearable. He began having conflicts with colleagues, who at one point organized a meeting to request Jolley get his anger under control. In 2018, Jolley started thinking about a path to retirement and repeatedly asked his managers at <a href="https://www.utahep.com/utahep/contactus.asp">Utah Emergency Physicians</a> — a physician group that contracts with hospitals in the Intermountain Healthcare system, where he worked — for ways to wind down his schedule.</p>
<p id="baGSvA">With the arrival of the coronavirus pandemic, however, Jolley had to speed up. He was often given evening shifts — usually the busiest in the ER — and because of <a href="https://www.washingtonpost.com/nation/2020/06/01/americans-are-delaying-medical-care-its-devastating-health-care-providers/">pandemic cutbacks</a>, he was the only doctor on duty. Having to don and doff new PPE with every patient, and do it quickly enough to keep up with the chaos of a pandemic ER, “made every shift, and every hour, a lot more stressful than even it had been before,” Myles Greenberg, his best friend and a former ER doctor, says.</p>
<p id="xNCQ45">When Jolley reached out to the head of his department to ask for advice on managing pandemic stresses, Greenberg recalls Jolley telling him, “She said something like, ‘I just wait until it’s over.’ It was like, grin and bear it,” an attitude that reflects the “macho culture of emergency medicine,” he adds.</p>
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<cite>Courtesy of the Jolley family</cite>
<figcaption>Scott and Jackie Jolley hiking in Zion National Park in 2018.</figcaption>
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<cite>Courtesy of the Jolley family</cite>
<figcaption>Scott and Jackie Jolley at home in 2019.</figcaption>
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<p id="AyeoCe">By August, Utah Emergency Physicians had denied Jolley’s requests for another doctor to support his shifts, and did not offer him a pre-retirement schedule because he wasn’t yet 60. (UEP told Vox that the company was looking into pre-retirement options at the time.) He felt he had no other choice but to take an unpaid sabbatical, Jackie recalls, and he planned to use the time to explore his options and “get his mental health back in order.” </p>
<p id="I8IxQP">During his time off, a new stressor emerged: “He was very, very worried about losing his license and credentials,” his wife says.</p>
<p id="KFquVn">Medicine is, ironically, a profession that punishes some doctors for getting mental health care. Many physicians work under intense pressure and are exposed to trauma on the job. A worrying number of doctors die by suicide each year. Yet structural barriers — enforced in part by medical boards and hospital systems — frequently discourage doctors from accessing care that could save their lives.</p>
<p id="fV60cl">One of those barriers is a fear of what can happen to doctors who receive treatment. In dozens of states, medical boards ask physicians sweeping questions about their health histories that would require them to disclose a diagnosis or treatment for mental illness. Similar questions come up when doctors apply for hospital credentials or insurance reimbursements. A disclosure can trigger a call to appear before the state board, a demand for medical records, or even a psychiatric evaluation. In the worst cases, doctors may be restricted in how they practice medicine or even lose their licenses.</p>
<p id="iCjoGl">Even though Utah’s state medical board doesn’t require mental health disclosures, Jolley worried that any support he received during his sabbatical could jeopardize his career and impact his family’s livelihood, Jackie says. He made her promise she’d keep his struggles a secret, even from Greenberg.</p>
<p id="elqk7e">By November, Jolley — who had no history of mental illness prior to the pandemic — was diagnosed with PTSD. He was put on a regimen of medicines to treat depression and anxiety and improve his sleep. They seemed to help a little, Jackie recalls, but soon he became more fatigued and agitated. That was the first time Jackie heard him talking about how he could end his life.</p>
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<p id="UwCeON">Halfway through his sabbatical, on February 5, 2021, Jolley attempted suicide. That evening, he was admitted to the psychiatric unit at his own hospital, the same place he’d sent dozens of his emergency room patients over the years. Being cared for by the colleagues from whom he wanted to conceal his mental health condition was a new, immense source of stress and shame, his wife remembers. But he was one of many US health care workers whose insurance would only cover treatment within the system where he worked.</p>
<p id="oNXT7r">The lights were kept on in Jolley’s room and he had no door, so other patients wandered in and out at all hours, Jackie says. The clothes he was wearing when he arrived were deemed risky by the hospital, so he was given a baggy shirt and pants left behind by another patient, according to Jackie.</p>
<p id="Sla4N6">After two days, he was discharged from the hospital. </p>
<p id="ZOXbVB">Less than two weeks later, on February 19, he killed himself at home.</p>
<p id="Ww2BGV">Jolley’s family and Greenberg are now convinced that the medical profession failed a doctor who dedicated his life to saving the lives of others. They say the stigma and fear of punishment for seeking mental health care delayed his treatment, then added stress in his most vulnerable moments. Jolley asked the management at <a href="https://www.utahep.com/utahep/contactus.asp">his physician group</a> for help at least five times in writing between March and August 2020, according to emails obtained by Vox. Jackie and Greenberg say there were additional phone calls, conversations, and emails.</p>
<p id="su0yvy">“They had a business to run and wanted to survive the pandemic and didn’t recognize Scott was reaching out for help,” Jackie says. “He told me they all thought he was just an old, angry doctor.”</p>
<p id="9WfvjR">In an interview, Dr. David Barnes, the president of Utah Emergency Physicians, told Vox that the experience with Jolley has caused his group to learn that “people can be struggling without it being obvious or apparent on the surface.” </p>
<p id="76NShG">“We recognize emergency medicine is a difficult specialty and can take its toll on physicians of all ages,” he added. “We need to look at ways to support our aging physicians so they can have a satisfying exit to their career.” </p>
<p id="blNJyT">Intermountain Healthcare, the hospital system where Jolley and his colleagues worked, said in a statement: “The loss of a colleague is sad and heartfelt in every circumstance, and our thoughts are with his family and friends.”</p>
<p id="upsxqT">The need to support doctors and address the mental health toll on the health workforce has never been greater. Vox spoke to more than two dozen colleagues, family members, and friends of physicians who died by or attempted suicide, as well as physicians who attempted or contemplated suicide. They said the pandemic has laid bare an inhumane health system that sacrifices the mental health of the medical workers who keep it going. They also spoke of a mental health crisis in medicine that long predates the arrival of the coronavirus — one that could worsen in the pandemic’s aftermath.</p>
<h3 id="lmQur1">An “occupational hazard”</h3>
<p id="W8dC0a">One warning sign of the disproportionate stresses on health workers over the past year and a half emerged in April 2020, when a New York City emergency room physician, <a href="https://www.nytimes.com/2020/07/11/nyregion/lorna-breen-suicide-coronavirus.html">Lorna Breen</a>, died by suicide. Her family still doesn’t know who alerted the press, but Breen’s story was made public without their consent. “Once it was out there we decided to lean into the conversation, to tell the world what happened, because we believe Lorna’s death could have been avoided,” her brother-in-law, Corey Feist, told Vox. “The more we told the story, the more we heard from others throughout the country, and the world, who had similar experiences.”</p>
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<cite>Courtesy of Corey Feist</cite>
<figcaption>Dr. Lorna Breen (seated) with her siblings in 2012.</figcaption>
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<p id="XKCDNx">Long before Breen’s death, suicide was known within the medical field as an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6008186/">occupational hazard</a>. One recent study, based on five years of CDC data from 27 states, <a href="https://pubmed.ncbi.nlm.nih.gov/33861665/">estimated that an average of 119 doctors</a> take their own lives in the US each year. That number is comparable to the suicide rate in the general population, but it’s likely an undercount, says Dr. <a href="https://medicine.umich.edu/dept/family-medicine/katherine-j-gold-md-msw-ms">Katherine Gold</a>, the lead author on the study and an associate professor at the University of Michigan Medical School. The<strong> </strong>toll could be as large as <a href="https://emedicine.medscape.com/article/806779-overview">300 to 400 deaths per year</a> — according to an <a href="https://www.tandfonline.com/doi/abs/10.1080/13548506.2021.1903053?journalCode=cphm20">oft-cited estimate</a> —<strong> </strong>roughly double the suicide rate in the general population. </p>
<p id="OyKlvG">A heightened risk is especially troubling in physicians, Gold pointed out, because they “have access to health care and the health system, and understand mental illness and that [it] is a treatable disorder — and we’re still seeing rates that are [at least] as high as the general population.”</p>
<p id="nAf9AY"><a href="https://www.hsph.harvard.edu/news/press-releases/leading-health-care-organizations-declare-physician-burnout-as-public-health-crisis/">Physicians</a> are also more likely to experience <a href="https://jamanetwork.com/journals/jama/fullarticle/2780002?guestAccessKey=a659d392-ab89-4112-9ac4-7c945d93b368&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=051821">depression</a> than the general population. The problems emerge in the high-stress years of medical school, and by the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7723130/">start of residency</a> — when doctors’ DNA was found to <a href="https://labblog.uofmhealth.org/med-u/new-doctors-dna-ages-6-times-faster-than-normal-first-year">age six times faster than that of their non-physician peers</a> — rates of depression increase fourfold in the first four months. Across all residency programs, <a href="https://ihpi.umich.edu/news/chance-depression-new-doctors-depends-where-they-train">an average of one-third of doctors</a> meet the diagnostic criteria for major depression. Suicide was <a href="https://pubmed.ncbi.nlm.nih.gov/28514230/">the second most common cause of death</a> after cancer among these newly minted doctors between 2004 and 2014. A second peak in suicide risk occurs in late middle age, according to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7723130/">one analysis</a>.</p>
<p id="yLCGux">These phenomena are often referred to as <a href="https://www.aafp.org/fpm/2015/0900/p42.html">burnout</a>, but that’s arguably “a misnomer for what’s happening,” says Oregon family doctor and mental health activist <a href="https://www.idealmedicalcare.org/">Pamela Wible</a>. “It severely minimizes and blames the victim for the situation.”</p>
<p id="tOmP6j">Wible began studying physician suicide in 2012, after three of her colleagues died by suicide in the span of 18 months. She has found more than 1,600 deaths in the ensuing nine years, and her analysis reveals systemic contributors to mental health problems “that are the norm in medical training and practice, and this is pre-pandemic,” she says. The pandemic was like “the icing on the cake,” she adds. “What most people are suffering from goes far beyond this pandemic.”</p>
<p id="2ZfFde">During training, many doctors work shifts that <a href="https://www.ama-assn.org/residents-students/residency/3-tips-new-med-school-grads-facing-old-24-hour-shift">exceed 24 hours</a>, and in some specialties — including emergency medicine, surgery, obstetrics, and critical care — the grueling hours and sleep deprivation continue after residency. Several doctors told Vox that they don’t have time or <a href="https://www.jointcommission.org/standards/standard-faqs/home-care/environment-of-care-ec/000001219/">convenient locations</a> to eat and drink while on their shifts.</p>
<p id="yPevHI">Many of the problems have been allowed to fester, Wible says, because half of US doctors are employed as independent contractors and aren’t protected by many labor laws. Other industries, such as “the airline industry, police, firefighters,” have more stringent protections and “value their workers” more, she argues, adding that even her pet groomer is not allowed to work an eight-hour shift without breaks under Oregon labor law.</p>
<p id="icwjAu">Doctors and nurses also <a href="https://qualitysafety.bmj.com/content/early/2020/08/13/bmjqs-2020-011512">routinely treat patients in understaffed units</a>, and because of business decisions in their health systems and gaps in patients’ access to medical insurance, they often can’t deliver the care they want to and feel they should. “Our moral compass is incredibly compromised by the systemic barriers in the US that have made it about the bottom line rather than what we can do for patients,” says <a href="https://twitter.com/ShrinkRapping?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor">Mona Masood</a>, a Philadelphia psychiatrist who has been treating doctors in crisis over the past year.</p>
<p id="myWnqC">The structural contributors to mental illness and physician suicide are layered on top of the potentially vulnerable psychology of doctors. Medicine attracts people who may be at higher risk for mental health problems, Masood says: high-achieving perfectionists who put tremendous pressure on themselves to succeed and help their patients. “To be a doctor, not only do you have to be intelligent in the subject matter, but you have to be the best of everyone, have all the answers,” she explained. “You are applauded and given so much positive feedback when you self-sacrifice.”</p>
<p id="oYRnKM">That psychology has led to another paradox: Despite strong evidence about the importance of treating mental health issues, “there’s a tremendous stigma in medicine to getting help, to asking for help, to admitting you have at all suffered,” says Jessi Gold, a Washington University psychiatrist who specializes in treating health workers. “Emotions, struggling, are an imperfection, and medicine is a field of perfection.” </p>
<div class="c-float-right c-float-hang"><aside id="RlEP0U"><q>“Health workers haven’t processed what they have experienced yet. We’ve still been in a state of perpetually going and caring for people.” —Dr. Katherine Gold</q></aside></div>
<p id="j2t5uw">Untreated <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2755851">physician depression</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4938539/">burnout</a> has been consistently linked with a higher risk of <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2755851">medical errors</a>,<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4938539/"> poor patient safety</a>, and, for doctors, a <a href="https://www.aafp.org/membership/benefits/physician-health-first/phf/mental-health-suicide.html">risk of suicide</a>. It’s not yet clear how Covid-19 has affected the physician suicide rate. Though the <a href="https://abcnews.go.com/Health/increase-depression-pandemic-suicides-decreased-studies/story?id=77039876">rate in the general population declined</a> in the early months of the pandemic, there are worrying health worker indicators. </p>
<p id="eB2IN3">A <a href="https://www.washingtonpost.com/context/washington-post-kff-frontline-health-care-workers-survey-feb-11-march-7-2021/ba15a233-9495-47a9-9cdd-e7fa1578b1ca/">Washington Post-Kaiser Family Foundation poll</a> found that six in 10 health workers reported pandemic stress had harmed their mental health, three in 10 had considered leaving health care, and more than 50 percent said they are burned out. Research on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016733/">US emergency department</a> health workers uncovered <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7361565/pdf/ACEM-9999-na.pdf">levels of exhaustion and burnout increasing</a> during Covid-19, with as many <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7862892/">as one-fifth at risk for PTSD</a>. These findings echo studies done during the pandemic from <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763229">China</a>, <a href="https://potloc.com/blog/en/potloc-study-canadian-health-workers-insights-front-lines-covid-19-pandemic/">Canada</a>, <a href="https://www.medrxiv.org/content/10.1101/2020.04.16.20067801v1">Italy</a>, and other countries.</p>
<p id="XLjhyZ">In the midst of the pandemic crisis, Masood created the <a href="https://www.physiciansupportline.com/">Physician Support Line</a>, a support hotline for doctors and medical students that protects their privacy. She says her service has been met with an explosive demand: They’ve fielded more than 2,500 calls from doctors over the past year. Wible runs another helpline for doctors who experience suicidality, and says demand increased so much during the pandemic that she started offering group Zoom calls.</p>
<p id="wQM8bg">Now that Covid-19 vaccines are rolling out and the stresses of the pandemic are easing in the US, many people want to move on. But Masood worries about doctors who might be unable to, and who may feel they have nowhere to turn. Over the past year and a half, she says, many of her colleagues have expressed some version of the same sentiment: “We felt we were left to die.”</p>
<h3 id="TZ2S9G">“How am I going to come back from this?”</h3>
<p id="Ha8kC4">Like Scott Jolley’s family, the family of Lorna Breen, the New York doctor who took her own life in April 2020, says she had no history of mental illness. But Breen was a perfectionist who lived and worked in a pressure-cooker environment that didn’t allow her space to recover after she got sick in the pandemic.</p>
<p id="7djBpX">When she wasn’t directing the busy emergency room at NewYork-Presbyterian’s Allen Hospital in New York City, she was playing the cello semi-professionally, training for marathons, and studying for an MBA. On March 13, the 49-year-old worked her first coronavirus shift. Five days later, she came down with a fever and later tested positive for Covid-19 — then worked through her illness remotely.</p>
<p id="ljadLZ">On April 5, she returned to the hospital — a lineup of nine 12-hour shifts for the month, according to her colleagues. But at a moment when the city’s death rate was exploding to six times its usual level, and the hospital’s capacity was stretched thin, the 12-hour shifts lasted 18 hours, Feist says.</p>
<div class="c-float-left"> <figure class="e-image">
<img alt=" " data-mask-text="false" src="https://cdn.vox-cdn.com/thumbor/jJDKwRbVRUS7Tg1_9zA20iO1UsQ=/800x0/filters:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/22658621/IMG_2116_copy.jpg">
<cite>Courtesy of Corey Feist</cite>
<figcaption>Dr. Lorna Breen, a New York City emergency room physician, took her own life in April 2020.</figcaption>
</figure>
</div>
<p id="7cKNUS">More than her own health and recovery, she was worried about her patients, and how any failure to care for them was going to impact her career, says her brother-in-law Corey Feist. “She started to articulate over the course of the week she was back that people were starting to notice she couldn’t keep up, and this was going to be a career limiter,” he recalls. Yet she was “depleted from being very sick,” he says, and working unthinkably hard.</p>
<p id="zvvPxD">By April 9, she was “<a href="https://nam.edu/stigma-compounds-the-consequences-of-clinician-burnout-during-covid-19-a-call-to-action-to-break-the-culture-of-silence/">nearly catatonic</a>,” unable to stand up from her chair, according to her sister Jennifer Feist. The family reached out to Breen’s boss, <a href="https://www.emergencymedicine.columbia.edu/profile/angela-m-mills-md">Angela Mills</a>, the chief of emergency medicine services at NewYork-Presbyterian, to check in on Breen at her apartment. Mills says she found Breen sitting on a small bench in her doorway, hunched in a fetal-like position, with a scarf wrapped around her. </p>
<p id="w959kc">“She was having a hard time making eye contact, and wasn’t speaking very much,” Mills recalls. She says Breen managed to repeatedly articulate her worry about whether she’d be allowed to work again. “She made a couple of comments about, ‘I’m not going to be able to come back from this. How am I going to face people?’” Mills tried to reassure her while waiting for another of Breen’s friends to arrive.</p>
<p id="QKxv1w">The Feists arranged to have Breen driven from New York to their home in Virginia. When Breen reached her family, they could hardly recognize her. “Her eyes were dull and she seemed dazed. Her entire affect was different. She was slow moving, slow speaking,” Corey Feist recalls. “She could not answer simple questions about whether she was hungry or not, which fast food restaurant she wanted to stop at.” Her family speculates the coronavirus may have affected Breen’s <a href="https://www.cedars-sinai.org/blog/covid-19-brain-fog.html">brain function</a>, but they’re convinced that her work stress, and her concern that mental health problems would derail her medical practice, contributed to her suicide the next month.</p>
<p id="CS9R0g">“She had enough cognition to realize — particularly once she was admitted to the University of Virginia psychiatric unit — that there’s a stigma on getting mental health care for physicians,” Corey Feist says, “such that it can impact your medical license and your ability to be a physician.</p>
<h3 id="ucw8Xs">A “hidden curriculum” </h3>
<p id="4WXxtQ">Medical boards in <a href="https://jamanetwork.com/journals/jama/fullarticle/2780002?guestAccessKey=a659d392-ab89-4112-9ac4-7c945d93b368&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=051821">37 US states and territories</a> ask some type of question that could require a doctor to disclose mental health conditions or treatment, according to a recent analysis published in <a href="https://jamanetwork.com/journals/jama/fullarticle/2780002?guestAccessKey=a659d392-ab89-4112-9ac4-7c945d93b368&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=051821"><em>JAMA</em></a><em>.</em> In the most intrusive states, the questions are sweeping. Wyoming asks: Have you “ever shown signs of any behavioral, drug or alcohol problems?” Or in Idaho: “Have you been diagnosed and/or treated for any mental, physical, or cognitive condition including substance use disorder that may affect your ability to practice medicine with reasonable skill and safety?”</p>
<p id="kOA7t3">Doctors also waive their medical privacy rights, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140021/">particularly</a> when it comes to <a href="https://labblog.uofmhealth.org/industry-dx/state-medical-licensing-boards-practices-may-hurt-physician-mental-health">mental health conditions</a>, to the boards that regulate them. Nearly 40 percent of physicians reported being reluctant to get care or treatment for a mental health condition because of medical license repercussions, according to a survey <a href="https://www.mayoclinicproceedings.org/article/S0025-6196(17)30522-0/fulltext">published in 2017 in <em>Mayo Clinic Proceedings</em></a>. In <a href="https://www.sciencedirect.com/science/article/abs/pii/S0163834316301281?via=ihub">another survey of women physicians</a>, half said they believed they had a mental illness but had not sought care, in part for fear of licensing boards.</p>
<p id="xt5iVv">Even if state regulators omitted all mental health questions, as 17 US states currently do, they can still probe doctors’ mental health histories in other ways, according to Ariel Brown, who co-authored the <a href="https://jamanetwork.com/journals/jama/fullarticle/2780002?guestAccessKey=a659d392-ab89-4112-9ac4-7c945d93b368&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=051821"><em>JAMA</em> analysis</a>. “A board may call the applicant in for an interview to explain anything they find fishy,” says Brown, a founder of the <a href="https://www.emotionalppe.org/">Emotional PPE Project</a>, a nonprofit that connects health workers with no-cost and confidential therapy. </p>
<figure class="e-image">
<img alt="In 33 states, license boards are asking doctors about their mental health" data-mask-text="false" src="https://cdn.vox-cdn.com/thumbor/Y5sp5Ubo1eiALw38vpsFUgEdD_Q=/800x0/filters:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/22672576/yZ9RR_in_33_states_license_boards_are_asking_doctors_about_their_mental_health.png">
<cite>Tim Ryan Williams/Vox</cite>
</figure>
<p id="Ol0g79">Hospital credentialing — the process used to vet providers who work in hospitals — may be even more intrusive, says <a href="https://www.muhealth.org/doctors/amanda-kingston-md">Amanda Kingston</a>, a psychiatrist and assistant professor at the University of Missouri who has been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7723130/">studying physician suicide</a>. A HIPAA waiver, granting an institution access to a doctor’s health records, has become a common part of hospital credentialing packages. “Many end up signing it because it’s part of a 40-page packet they are trying to get through to start their job. But even if they’re paying close attention, there’s the concern if they don’t [sign], there might be a suspicion about why,” she says.</p>
<p id="w1EQbK">For years, a broad coalition of medical groups and health advocates, including the American Medical Association and the American Psychiatric Association, have called on states to stop punishing doctors for seeking help. They argue that regulators should only inquire about mental illnesses that <a href="https://pubmed.ncbi.nlm.nih.gov/28633174/">currently impair</a> a doctor’s ability to safely practice medicine, or even <a href="https://www.amjmed.com/article/S0002-9343(20)30414-9/fulltext">abolish mental health questions</a> altogether. Overly broad questions, reformers argue, can <a href="https://www.sciencedirect.com/science/article/abs/pii/S0163834316301281?via=ihub">discourage</a> physicians from <a href="https://www.fsmb.org/siteassets/advocacy/policies/policy-on-wellness-and-burnout.pdf">getting support</a> and <a href="https://pbieducation.com/what-happens-when-boards-ask-about-mental-health/">may violate</a> the <a href="https://www.statnews.com/2017/10/16/doctors-mental-health-licenses/">Americans With Disabilities Act</a>.</p>
<p id="xSjJ9g">Slowly, state policies are changing. The Medical Board of California, for example, used to ask for a full mental health history, but acknowledged in a statement to Vox that its old policy “may have discouraged physicians from seeking needed treatment.” The board said that in response to feedback, it has shifted the focus of mental health inquiries to current impairments only. </p>
<p id="TuDmtM">But in many corners of the country and the health care system, broader questions persist. “State medical boards are worried that they could be liable if they remove the questions and something happens,” says the University of Michigan’s Katherine Gold. And unlike lawyers, doctors have mounted <a href="https://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/74104">few legal challenges</a> against the practice. She doesn’t know of any data showing these questions make patients safer, “and we certainly have anecdotal data that asking these questions prevents physicians seeking care.”</p>
<p id="XojqrC">Most of the physicians Vox talked to for this story said they’ve avoided getting mental health care, gone out of state for treatment, or paid out of pocket to avoid billing their health insurer. Kingston says that in the past few months, she’s heard from several colleagues who prescribed their own antidepressants or wrote prescriptions for colleagues, then paid cash for them so there’s no electronic record or billing trail. Jessi Gold, the Washington University psychiatrist, said she routinely gets requests not to document sessions, or to use paper charts that won’t show up in electronic medical records.</p>
<div class="c-float-right"><div id="SzkjC0"><div data-anthem-component="aside:10619062"></div></div></div>
<p id="hlh8Ph">Even in places that are more permissive of doctors who have been diagnosed with or treated for mental illness, confusion and fear about licensing issues runs deep enough to drive problems underground. “It’s part of the ‘hidden curriculum’ of medicine that licensing applications ask about mental health, and that can affect you,” Jessi Gold adds.</p>
<p id="TuHCxJ">Lorna Breen may not have been aware that her state licensing board does not ask questions that would require a mental health disclosure. Still, she believed her career was in jeopardy when her mental health faltered, her family told Vox. “Lorna said, ‘I’m going to lose my license,’” Feist recalls. “‘I’m never going to be able to practice medicine again.’ What’s increasingly tragic about the fact she was wrong — and she wasn’t wrong about a lot of things — this is such an ingrained concept for doctors.”</p>
<h3 id="Lnf3Gu">“This all had nothing to do with my job”</h3>
<p id="m3wC3r">When doctors disclose a mental health problem to their employers, even voluntarily, the consequences can be traumatic and profound.</p>
<p id="HBubWv">Justin Bullock, a medical resident, says UCSF Medical Center asked him<strong> </strong>to submit to a month-long fitness-for-duty assessment shortly after he was admitted to the same hospital for mental health treatment, following a suicide attempt in March 2020. Going into the process, Bullock was transparent about his mental health, including the diagnosis of bipolar disorder he had received in medical school. After the assessment, he says, he’s “so much less likely to ever want to get help, to ever be transparent about when I’m struggling.”</p>
<figure class="e-image">
<img alt=" " data-mask-text="false" src="https://cdn.vox-cdn.com/thumbor/_2Tv0GkSx7V6BuszG9ZfKtYtEVE=/800x0/filters:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/22658641/VOX_Bullock_MD_pgannaway06_copy.jpg">
<cite>Preston Gannaway for Vox</cite>
<figcaption>Dr. Justin Bullock outside the UCSF Parnassus Medical Center in San Francisco on June 13.</figcaption>
</figure>
<p id="pjaPTi">Bullock says he underwent hair, blood, and urine testing for illicit drug use, a personality test, and a psychiatric evaluation involving probing questions about his childhood traumas, including sexual abuse. “I felt like this all had nothing to do with my job,” he says. “They never discussed or had questions about my performance at work in this evaluation.”</p>
<p id="3vXiwE">Indeed, Bullock had an outstanding clinical and academic record; he won numerous <a href="https://alumni.ucsf.edu/gold-headed-cane-society-members">honors</a> and <a href="https://meded.ucsf.edu/sites/meded.ucsf.edu/files/2019-10/Teaching%20Awards-Program-booklet-FINAL1025.pdf">awards</a> during his residency, and got consistently glowing feedback about his performance with patients. </p>
<div class="c-float-right c-float-hang"><aside id="vAzgrM"><q>“There are a lot of parts of this process where they rip you of your humanity” —Dr. Justin Bullock</q></aside></div>
<p id="Wsf5ND">But if he’d had any serious mistakes on his record, he could have faced practice restrictions or even lost his medical license. Bullock says he has recovered from his suicide attempt, but not from the assessment. “There are a lot of parts of this process where they rip you of your humanity,” he says.</p>
<p id="wvzi0W">UCSF Medical Center did not comment on Bullock’s specific case, but wrote in a statement to Vox: </p>
<blockquote><p id="7lrK1u">The mental health of our physicians is of tremendous importance as they face the ongoing stresses of their training and profession, compounded in the past year by the personal and professional challenges of the COVID-19 pandemic. It is an issue that UCSF has taken very seriously for years and for which we continuously work to improve the support we provide.</p></blockquote>
<p id="ZpRb4F">USCF also called the program Bullock went through “entirely voluntary,” a characterization Bullock — who recently <a href="https://www.journalofhospitalmedicine.com/jhospmed/article/241363/hospital-medicine/trauma-informed-transformation-evaluation-and-licensure?channel=28090">detailed</a> the experience in an academic paper — disputes. “It is voluntary,” he says, “in that you can leave UCSF or let them put your license at risk by reporting you to the medical board.”</p>
<h3 id="lC4XlW">“There’s too much denial, too much shame”</h3>
<p id="yfOzMn">The movement to improve mental health care for doctors is gaining momentum, thanks to campaigning physicians and grieving families like the Jolleys and Feists. Jackie Jolley is working with the University of Utah to try to give doctors the option of receiving treatment outside their own health systems. “We recognize it’s difficult for doctors to get help” in their own system, David Barnes, the president of Utah Emergency Physicians, told Vox. “We are looking for solutions.”</p>
<p id="faSH4c">Last year, Breen’s family created the <a href="https://drlornabreen.org/">Dr. Lorna Breen Heroes’ Foundation</a>, and in July 2020, they got a bill <a href="https://www.congress.gov/bill/116th-congress/senate-bill/4349/text">introduced in the Senate</a> with bipartisan support. </p>
<p id="HUECu5">In March 2021, nearly a year after Breen’s death, the Senate Health, Education, Labor, and Pensions Committee unanimously passed the legislation. If adopted by Congress, the law would immediately support suicide and burnout prevention training for all health care workers. It also provides research funding to study the causes of burnout in the profession, naming “stigma and concerns about licensing and credentialing” as key drivers to examine.</p>
<figure class="e-image">
<img alt=" " data-mask-text="false" src="https://cdn.vox-cdn.com/thumbor/xThN4TBtDv2E7mvM7AxGsVJJ4IQ=/800x0/filters:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/22660032/IMG_5919_20210417_182532.jpg">
<cite>Courtesy of the Jolley family</cite>
<figcaption>Scott and Jackie Jolley seen sitting outside Scott’s grandparents’ farmhouse on Christmas Eve in 2019. Since losing her husband, Jackie has taken part in the movement to improve mental health care for doctors.</figcaption>
</figure>
<p id="gkIR46">We need better data not only about the drivers of the problem, but also about the precise number of doctors who die by suicide. Concerns about an elevated suicide rate in medicine have circulated since at least the 1920s, but we still don’t have definitive numbers. </p>
<p id="atv0ux">“If it’s a problem anyone actually cares about, then there should be publicly available tracking and some effort to stop it,” one Boston-area doctor, who has lost two colleagues to suicide and spoke on condition of anonymity for fear of workplace<strong> </strong>retaliation, told Vox. “In what other industry would it be acceptable for talented and high-profile people to be jumping off buildings and everyone to stand by scared to comment?”</p>
<p id="a7hQVL">The University of Michigan’s Katherine Gold suggests one fix for the data problem: State medical boards should cross-reference their members’ deaths each year with the CDC data she uses, on violent deaths by occupation, to make sure all physician suicides are tracked and accounted for. “That has not happened to date,” she says.</p>
<p id="pJGHHd">Several states, including <a href="https://www.msms.org/About-MSMS/News-Media/safehaven-now-offering-michigan-physicians-health-care-providers-resources-to-manage-stress-and-burnout">Michigan</a> and <a href="https://www.wtvr.com/news/local-news/new-program-helps-virginia-medical-workers-find-mental-health-support">Virginia</a> (where Breen was treated before her death), have introduced “safe haven” laws that protect the mental health medical records of health care professionals and allow them to seek care without fearing any repercussions.</p>
<p id="k9zpfR">But “the biggest systemic fix is simply to remove the mental health questions,” Gold says, echoing other reformers. This would have to happen not just on state licensing applications but everywhere doctors face them, from hospital credentialing to insurance reimbursement forms.</p>
<figure class="e-image">
<img alt=" " data-mask-text="false" src="https://cdn.vox-cdn.com/thumbor/b-mbLeL0ebUHfx5br-tah_wczko=/800x0/filters:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/22666156/IMG_2639.jpg">
<cite>Courtesy of the Jolley family</cite>
<figcaption>Scott and Jackie Jolley (right) snowshoeing with friends Myles and Carolyn Greenberg in 2019.</figcaption>
</figure>
<p id="kOHtrv">That might help with an equally urgent task: ending the stigma about mental health problems, says Jolley’s friend Myles Greenberg, the former ER doctor. “Like every other medical problem, you catch it early and intervene early and have a much better chance of a positive outcome,” he says. “There’s too much denial, too much shame — this cultural bullshit in medicine that’s preventing people from getting the care they need.”</p>
<p id="p2ydJi">“The good that can come out of this is to repeatedly tell this story,” he continues. “Not just the Scotts and Lornas, but the other people who suffered from this. The powers that be need to start getting it through their heads that this is a problem.”</p>
<p id="y4e41Y"><strong>CREDITS</strong><br><strong>Editors: </strong>Eliza Barclay, Katherine Harmon Courage, Daniel A. Gross<br><strong>Visuals editor: </strong>Kainaz Amaria<strong> </strong><br><strong>Copy editors: </strong>Elizabeth Crane, Tanya Pai, Tim Williams<br><strong>Fact-checker: </strong>Becca Laurie<strong> </strong><br><strong>Engagement editor: </strong>Kaylah Jackson</p>
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https://www.vox.com/22439911/doctors-mental-health-suicide-coronavirus-pandemicJulia Belluz2021-06-16T11:45:00-04:002021-06-16T11:45:00-04:00The World Health Organization broke its own rules to spend millions on BCG consultants
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<figcaption>World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus at the WHO’s World Health Assembly in Geneva on May 29, 2021. | Fabrice Coffrini/AFP via Getty Images</figcaption>
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<p>The agency paid the consultants a total of $11.7 million — enough to buy 600,000 Covid-19 vaccines.</p> <p id="ROd8d4">The world’s leading health organization, the WHO, repeatedly broke its own rules and spent millions of dollars on high-priced management consultants, according to a <a href="https://apps.who.int/gb/ebwha/pdf_files/WHA74/A74_34-en.pdf">new independent audit</a> — even as the United Nations agency has struggled to pay for lifesaving equipment and vaccines in its global Covid-19 response.</p>
<p id="JLpg4u">An unnamed consulting company, which <a href="https://cdn.who.int/media/docs/default-source/procurement/2020_contract_awards_services.pdf?sfvrsn=415befcc_5">Vox has identified as BCG</a>, charged the World Health Organization $11.72 million since the start of the pandemic for contracts that were dubiously<strong> </strong>awarded, according to the audit. </p>
<p id="UNw2NK">These revelations, which one expert called “disturbing” in an interview with Vox, came after a Vox investigation <a href="https://www.vox.com/science-and-health/2019/12/13/21004456/bill-gates-mckinsey-global-public-health-bcg">showed how management consulting firms</a> such as BCG and McKinsey have become ubiquitous in global public health organizations, despite the concerns of many health practitioners about multimillion-dollar price tags, potential conflicts of interest, and the opaque nature of consulting work.</p>
<p id="qRXZme">WHO researchers told Vox that the auditor report raised questions about the agency’s ability to responsibly and transparently spend public money from the 194 member countries that fund it. In recent months, the WHO has <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/donors-and-partners/funding">requested donations</a> from its members and the general public, citing a funding gap of more than a billion dollars for its pandemic response.</p>
<p id="b3XTzC">Given that the WHO’s 2020-21 budget is $5.84 billion, $12 million may not sound like a massive amount — “but $12 million for a health care system in a low-income country would comprise a significant portion of their funding,” says <a href="https://twitter.com/adamkams?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor">Adam Kamradt-Scott</a>, the incoming global health chair at the School of Transnational Governance in Florence, who studies the WHO. That amount could pay for <a href="https://www.bmj.com/content/372/bmj.n281">about 600,000</a> Covid-19 vaccine doses from Pfizer/BioNTech or Moderna. (The WHO is part of Covax, whose aim is to ensure all countries have equitable access to vaccines.) “If it’s money being wasted, that’s a lot of vaccines that could have been purchased,” Kamradt-Scott added.</p>
<p id="xOY70p">The audit, which examines a sampling of<strong> </strong>the WHO’s biggest contracts, analyzed the agency’s work with BCG, known as “Consulting Firm A” in the report, and uncovered multiple violations of WHO policies.<strong> </strong>The auditors claim WHO staff sought to circumvent the organization’s public procurement rules in order to help BCG win a contract. Staff at the agency also broke WHO rules by repeatedly starting work with the firm before seeking formal approval to do so, according to the report. </p>
<p id="RMWUy1">Before the pandemic, Vox revealed the WHO committed at least $12 million on consultants to support the agency’s reform, approximately a quarter of which has been paid for directly by the <a href="https://www.gatesfoundation.org/">Bill and Melinda Gates Foundation</a>. At the time, a WHO spokesperson said the agency welcomed consultants’ work. “The [consulting] companies have supported WHO in areas where we lack in-house expertise or want to tap the current best-in-class standards.” </p>
<p id="sDWVlR">But controversy has surrounded high-priced consultants in a field dedicated to improving the health of the world’s poorest people. The consulting firm McKinsey <a href="https://www.propublica.org/article/how-mckinsey-helped-the-trump-administration-implement-its-immigration-policies">advised the Trump administration on how to cut spending</a> on food and medical care for migrants and played a role in <a href="https://www.nytimes.com/2021/02/03/business/mckinsey-opioids-settlement.html">increasing sales</a> of <a href="https://www.vox.com/policy-and-politics/2019/8/29/20836719/opioid-epidemic-fentanyl-rand-report">prescription opioids</a>, which have been linked to the deaths of <a href="https://www.who.int/news-room/fact-sheets/detail/opioid-overdose">hundreds of thousands of people</a> around the world. <a href="https://www.vox.com/science-and-health/2019/12/13/21004456/bill-gates-mckinsey-global-public-health-bcg">Vox also documented</a> how BCG helped boost sales of sugary drinks in India, although the WHO has called for <a href="https://apps.who.int/iris/bitstream/handle/10665/260253/WHO-NMH-PND-16.5Rev.1-eng.pdf;jsessionid=BF2858297955BBCD4F634D1152B5B566?sequence=1">reducing sugary drinks consumption</a> and supports <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4358191/">taxing the products</a>.</p>
<p id="NQCzca">The findings in the audit were recently accepted by the WHO’s member states at the annual World Health Assembly. In a statement, the WHO said it “takes seriously the recommendations of our oversight bodies and uses the constructive comments to address any identified weaknesses in our control environment — we are a learning organization, and these reports help us to continuously improve in all identified areas.” </p>
<p id="BTHckf">The international agency said the contracts were awarded in the context of an unprecedented health emergency, but added that the agency is taking the recommendations in the report seriously, and has “already begun implementing many of those related to procurement.” </p>
<p id="ENH9Qb">In a statement, BCG said, “As the global pandemic unfolded last year, BCG rapidly mobilized teams to support worldwide efforts to fight the spread of the virus. We are extremely proud of our work that contributed to saving lives in this unprecedented time and remain committed to providing our best minds and efforts to support the progress of public health.” </p>
<p id="Vqu1zJ">It’s possible “the high stress and the insufficient human resources at the onset of the pandemic made things worse and made WHO even more in need of consultants’ support and more vulnerable to their conditions,” said <a href="https://www.graduateinstitute.ch/academic-departments/faculty/gian-luca-burci">Gian Luca Burci</a>, the WHO’s former legal counsel. </p>
<p id="O1Q6zM">But “this seems to have been a misuse of funds,” Kamradt-Scott said. “This is disturbing. At least on the surface, it would appear that due diligence checks in how external agencies are engaged don’t appear to have been followed.” </p>
<p id=":1x5">“The auditor’s report raises a red flag, and the issue of WHO’s contracts with management consulting firms deserves more scrutiny,” said <a href="https://www.graduateinstitute.ch/academic-departments/faculty/suerie-moon">Suerie Moon</a>, co-director of the Global Health Centre at the Graduate Institute of Geneva. At the end of the day, Kamradt-Scott said, the WHO has a “moral obligation to ensure every cent is spent appropriately.”</p>
<h3 id="jQgDkl">How the WHO broke its rules to work with BCG</h3>
<p id="Tpv4Cp">Publicly funded agencies, including those that are part of the UN system like the WHO, are supposed to follow stringent rules when hiring external contractors such as management consultants. According to <a href="https://www.who.int/about/accountability/procurement/guiding-principles">WHO policy</a>, staff should “obtain the best value for money” when hiring external contractors, allow for “transparent competition among prospective providers,” and treat contractors equally.</p>
<p id="MOGG5o">According to the audit, BCG won eight contracts with the WHO in 2020 for a total value of $11.72 million, and the auditors closely scrutinized the two highest-value contracts, for which the WHO paid $5.4 million. </p>
<p id="UoJqTp"><strong>1) The auditors found WHO staff changed criteria to help BCG win work at the agency. </strong>For a contract that lasted from December 2020 to May 2021, the organization asked consultants for competitive proposals to “support the long-term vision for WHO supply chain and to build capabilities to execute the long-term supply chain vision.” Of the four consultants that submitted bids, BCG was one of two that were deemed technically qualified. But another firm won the highest score and should have been awarded the contract, the audit found. “WHO changed the evaluation criteria and re-evaluated the bids as per which Consultant A [BCG] scored higher and was awarded the consultancy,” the report said. </p>
<p id="gmail-m_2240994224598528293gmail-UoJqTp">“The findings of the independent auditor suggest this doesn’t seem to be a case of negligence where protocols haven’t been followed because someone didn’t know what to do,” Kamradt-Scott told Vox. “It would appear WHO staff knowingly sought to circumvent the rules in order to engage a preferred provider.” </p>
<p id="5Vy39l"><strong>2) BCG started working for the WHO ahead of formal approval</strong>, according to the report.<strong> </strong>For the second contract, which ran from March to October 2020, BCG was hired to help the WHO purchase personal protective equipment and other essential supplies during the pandemic. Here, too, the auditors uncovered multiple irregularities.</p>
<p id="N8xnU7">The WHO started the work with BCG “without due approval of the competent authority, despite the fact that it entailed payment of $2.53 million by WHO,” the auditors wrote. WHO staff only sought formal approval four months after BCG started work for the agency and three of the four phases of their contract were complete, the audit found.</p>
<p id="Lk3G2m">In the report, the WHO says it didn’t have the human resources to go through the proper procurement processes, but the auditors rejected this reasoning. “We are of the view that the formal process of approval should have been adopted before accepting the offer of [BCG] and engaging the firm. The delay in getting the approval of the competent authority was not justified.” </p>
<p id="279DHk"><strong>3) The auditors questioned whether BCG provided value for money.</strong> In one of the nine purchase orders that BCG negotiated on behalf of the WHO, the consultants got a 20 percent price reduction on protective gowns. The WHO and the consultants placed the order and approved the quality of the gowns. But an external PPE supplier, which was supporting the WHO, deemed the gowns low-quality and canceled the order. In another case, auditors flagged a missed opportunity for savings. Consultants negotiated a discount of 0.08 percent off N95 masks, for a savings of $9,750. In the same month, the same supplier fulfilled another mask order with a discount that amounted to $303,200. “We noted that [BCG] did not negotiate this price, which had better potential for saving,” the auditors wrote.</p>
<p id="weOgZw"><strong>4) WHO paid millions of dollars for “pro bono” work.</strong> Another revealing finding from the audit was that BCG characterized its PPE procurement work as “pro bono,” even though one seven-month contract cost $7.3 million, of which $2.53 million was paid for by the WHO. Only the cost of the first of three phases and a transition period was covered by the consulting firm.<strong> </strong>“We are of the view that calling this engagement pro bono is not correct,” the report says. </p>
<p id="WbFQIl">The report comes at a time when the WHO is trying to strengthen its finances and wrangle more flexibility over how it spends money. The agency is asking for more support from countries that fund it — known as “assessed contributions” — which can be spent on a variety of expenses. The WHO is also funded by donors, such as the Gates Foundation, but that money tends to be earmarked for specific purposes.</p>
<p id="xax6dK">As troubled as Moon was by the audit report’s findings, she suggested that scrutiny from the auditors is a step toward a stronger World Health Organization. “You can only have less earmarking if it’s followed by more accountability and transparency,” she said. “Heightened scrutiny of contracts with management consulting firms is one place to start.” </p>
https://www.vox.com/2021/6/16/22527665/world-health-organization-who-12-million-bcg-consultantsJulia Belluz2021-04-29T08:19:39-04:002021-04-29T08:19:39-04:00Poorer countries might not get vaccinated until 2023
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<figcaption>Relatives, friends, and graveyard workers prepare to lower the body of a Covid-19 coronavirus victim during the burial at a graveyard in New Delhi on April 28, 2021. | Sajjad Hussain/AFP via Getty Images</figcaption>
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<p>This inequality is baked into every step of the vaccine manufacturing process. </p> <p id="72V6LL">High-income countries have purchased more than half of the Covid-19 vaccine supply to date, and low-income countries, just 9 percent, according to Duke University’s Global Health Innovation Center. This is why a country like the <a href="https://ourworldindata.org/covid-vaccinations">US is close to vaccinating half its population</a> with one dose while the rate in a place like <a href="https://ourworldindata.org/covid-vaccinations">Guinea is less than 1 percent</a> and not budging. </p>
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<p id="uA235G">If these glaring inequities in vaccine access continue, it will take at least two years for the world’s poorest countries, which couldn’t afford to compete for early doses of vaccines, to immunize <a href="https://www.washingtonpost.com/world/interactive/2021/coronavirus-vaccine-inequality-global/">the majority of their populations</a>. And we’re on track for a long period where people in rich countries enjoy the benefits and safety of being fully immunized, while people in poorer countries continue to get sick and die from the coronavirus. </p>
<p id="OIGx85">“That’s not just unconscionable, but it also is very much against the interests of high-income countries,” Georgetown global health law professor Lawrence Gostin told <a href="https://www.vox.com/2021/1/29/22253908/rich-countries-hoarding-covid-19-vaccines">Vox in January</a>. With the virus continuing to circulate, and variants picking up pace around the globe, outbreaks in the poorest countries will pose a threat to the world. </p>
<p id="0oqsdI">To learn more about the root causes of the problem, and how inequalities are baked into the vaccine manufacturing system, check out our new Vox video and read on. </p>
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<h3 id="bC8eCj">Wealthier countries had a home-court advantage to<strong> </strong>develop vaccines</h3>
<p id="gmail-RBJueu">It’s not an accident that many of the world’s first-approved Covid-19 vaccines — from companies like Pfizer, AstraZeneca, and Moderna — were developed and rolled out in high-income countries. As the pandemic took hold last year, wealthier nations — including the US, UK, and EU block — began making deals with the pharmaceutical companies that were developing Covid-19 vaccines, which also happened to be headquartered within their borders. </p>
<p id="JRzV5H">These bilateral deals involved governments essentially giving the companies billions of dollars to speed up research and development in exchange for priority access to vaccines, should they prove to be effective. But the deals also pushed poorer countries, which didn’t have the resources to pre-purchase millions of doses of vaccines that might not even get approved for market, further down the access line.</p>
<p id="gmail-r2Img8">In May 2020, for example, the US government gave <a href="https://www.hhs.gov/about/news/2020/05/21/trump-administration-accelerates-astrazeneca-covid-19-vaccine-to-be-available-beginning-in-october.html">AstraZeneca $1.2 billion for 300 million</a> doses — a Covid-19 vaccine that still hasn’t even been approved in the US. That was just one deal of many. By January 2021, rich countries had already pre-purchased <a href="https://www.bmj.com/content/371/bmj.m4809">96 percent</a> of the doses BioNTech/Pfizer was scheduled to make for the year, while <a href="https://www.bmj.com/content/371/bmj.m4809">100 percent of Moderna’s</a> supply was spoken for. And the EU now appears ready to finalize a <a href="https://www.nytimes.com/2021/04/28/world/europe/european-union-pfizer-von-der-leyen-coronavirus-vaccine.html">1.8 billion-dose deal</a> with Pfizer.</p>
<p id="eFvkY3">Together, the early agreements covered the populations of rich countries many times over in the event that some of the vaccines failed. By March, Canada had secured enough vaccine for<a href="https://launchandscalefaster.org/covid-19/vaccineprocurement"> five times its population</a>, and the US bought <a href="https://launchandscalefaster.org/covid-19/vaccineprocurement">at least double</a> the amount of vaccine it’d need. In terms of doses administered, while high-income countries are home to 16 percent of the world’s population, they’ve doled out 46 percent of the <a href="https://www.nytimes.com/interactive/2021/world/covid-vaccinations-tracker.html?action=click&module=Top%20Stories&pgtype=Homepage">one billion Covid-19 vaccine doses</a> already administered. The poorest countries, home to 10 percent of the world’s population, have given out just 0.4 percent of doses, according to <a href="https://ourworldindata.org/covid-vaccinations">Our World In Data</a>, and lower-middle income countries, with 40 percent of the world population, 19 percent of doses. </p>
<p id="U04qAt">“[Since] vaccine makers are headquartered in high-income countries, and [vaccines are] developed there for the most part, many of the ones that made it across the finish line first were from high-income countries, and because of that, they had a home-court advantage,” said <a href="https://globalhealth.duke.edu/people/taylor-andrea">Andrea Taylor</a>, a researcher with <a href="https://globalhealth.duke.edu">Duke Global Health Institute</a> who has been analyzing the deals.</p>
<h3 id="yeETN1">Vaccine-producing nations have used export controls to hoard supplies</h3>
<p id="yBGTXv">Through this home-court advantage, wealthier countries not only ensured first dibs — they’ve also used export restrictions to control vaccine supplies and doses leaving their borders. </p>
<p id="NxQMYb">On April 16, for example, the head of the Serum Institute of India — the world’s biggest producer — <a href="https://twitter.com/adarpoonawalla/status/1382978713302683653">took to Twitter</a> to ask President Joe Biden to lift embargoes on raw material exports that were hampering vaccine production there: </p>
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<p lang="en" dir="ltr">Respected <a href="https://twitter.com/POTUS?ref_src=twsrc%5Etfw">@POTUS</a>, if we are to truly unite in beating this virus, on behalf of the vaccine industry outside the U.S., I humbly request you to lift the embargo of raw material exports out of the U.S. so that vaccine production can ramp up. Your administration has the details. </p>— Adar Poonawalla (@adarpoonawalla) <a href="https://twitter.com/adarpoonawalla/status/1382978713302683653?ref_src=twsrc%5Etfw">April 16, 2021</a>
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<p id="8ZTxFc">The result of the pressure: The <a href="https://www.nytimes.com/2021/04/24/climate/inda-covid-vaccines.html">US lifted the restrictions</a> to help speed production overseas, and President Biden vowed to share <a href="https://www.ft.com/content/db461dd7-b132-4f08-a94e-b23a6764bdb3">60 million doses of the AstraZeneca</a> vaccine. <a href="https://www.economist.com/science-and-technology/2021/04/22/american-export-controls-threaten-to-hinder-global-vaccine-production">India</a> — currently battling a <a href="https://www.vox.com/2021/4/24/22400986/india-coronavirus-surge-hospitals-deaths">devastating Covid-19 outbreak</a> — is also now using export restrictions to hang on to Covid-19 doses produced there. </p>
<p id="uIevRQ"><a href="https://www.reuters.com/article/us-health-coronavirus-eu-vonderleyen-idUSKBN2AP2RS">American and British vaccine export bans</a>, meanwhile, have been a source of diplomatic tensions with the EU, which put in <a href="https://www.nytimes.com/2021/03/23/world/europe/eu-curbs-vaccine-exports.html">place its own export restrictions</a> in March to alleviate supply shortages. </p>
<h3 id="nrrWwA">Rich countries undermined Covax, the global group set up to deliver vaccines to the world’s poor </h3>
<p id="uu1klk">The vaccine hoarding has happened in parallel with an unprecedented multilateral effort to support the development and equitable distribution of 2 billion doses of Covid-19 vaccines to the world’s poorest countries before the end of 2021, called Covax.</p>
<p id="LtKJyM">The initiative has two parts: a purchasing pool for higher-income countries, and a fundraising effort for poorer countries. By promising to buy a certain number of vaccine doses from manufacturers, countries that join get access to any <a href="https://www.gavi.org/vaccineswork/covid-19-vaccine-race">vaccines that are approved</a> in Covax’s portfolio, while also creating a global market for the shots and driving prices down.</p>
<div class="c-float-right"><aside id="iICKzj"><q>Covax has only delivered about one in five of the doses that were expected by the end of May</q></aside></div>
<p id="UdNnb8">More than <a href="https://www.gavi.org/sites/default/files/covid/pr/COVAX_CA_COIP_List_COVAX_PR_15-12.pdf">190 countries signed on</a> — including rich ones. “Covax was trying to create a reality — they appealed to the better angels of all countries,” said Saad Omer, director of the Yale Institute for Global Health. </p>
<p id="AiGzSt">But the bilateral deals took a lot of power away from Covax. Rich countries “want to have it both ways,” Gostin said. “They join Covax so they could proclaim to be good global citizens, and at the same time rob Covax of its lifeblood, which is vaccine doses.” </p>
<p id="dBLsCf">Rich countries also <a href="https://www.devex.com/news/covax-facility-seeks-an-additional-2b-for-covid-19-vaccines-99671">didn’t fund Covax’s</a> purchasing pool to the levels the group called for. And <a href="https://www.wsj.com/articles/indias-covid-19-agonies-highlight-growing-rich-poor-gap-in-vaccinations-11619542171">for the majority of its supply,</a> Covax also relies on India, which, again, is currently restricting exports. </p>
<p id="8IkYfH">The result: Covax, according to Duke, has only delivered about one in five of the doses that were expected by the end of May. </p>
<h3 id="IN59vl">There are other bottlenecks even waiving patents can’t fix </h3>
<p id="42B7KK"><a href="https://www.theguardian.com/commentisfree/2021/apr/02/india-in-charge-of-developing-world-covid-vaccine-supply-unsustainable">Some have suggested</a> Covid-19 vaccine-makers should <a href="https://www.reuters.com/world/us/white-house-says-its-considering-intellectual-property-waiver-covid-19-vaccines-2021-04-27/">waive their patents</a>, making it possible for more manufacturers to come online and produce vaccines. But that’s only part of the solution to vaccine inequality, Taylor said. “We know there is manufacturing capacity that isn’t being used.” </p>
<p id="3a68q3">That’s because of another bottleneck that’s emerged in recent months. Vaccine makers have been reporting that they’re struggling to access basic supplies needed to safely manufacture vaccines. For example, there have been reports that the <a href="https://www.theguardian.com/world/2021/apr/10/global-covid-vaccine-rollout-threatened-by-shortage-of-vital-components">filters used in the manufacturing process</a>, and <a href="https://www.ft.com/content/b2f4f9cf-af80-428f-a198-2698ceb4c701">large plastic bags</a> (for lining bioreactors where pharmaceutical ingredients are mixed) have run short. It’s unclear how big this problem is — we don’t have systematic data on global shortages — but many suppliers and even countries have cited these shortages as a reason for delays.</p>
<p id="M5VnaK">Companies can’t just turn to anybody to meet their needs — they can only use qualified suppliers that meet the global standards set by regulators like the US Food and Drug Administration. These suppliers sell products that have been vetted through studies proving their plastic bags, for example, don’t leak toxins into vaccines or cause allergic reactions.</p>
<p id="CkmeeO">“Those tests take time — it’s months of lab studies and animal studies,” said Matthew Johnson, associate director of the Duke Human Vaccine Institute. So even companies that could pivot to producing the vaccine products in short supply would need to take time to study them and ensure safety. </p>
<p id="1evySM">There’s another problem IP waivers can’t solve: Technology transfer, from one vaccine maker to another, involves sharing trade secrets, know-how, and even trained personnel. The companies currently making Covid-19 vaccines “might not have 20 to 40 people to send to these other locations” to help new producers get up to speed, Johnson added. So while waiving patents would help — it’s only part of the solution. </p>
<h3 id="1lEdla">Vaccinating the world doesn’t need to take so long — rich countries could take action now </h3>
<p id="MlqsFW">Still, it’s not a given that it’ll take years to vaccinate the world from Covid-19. There are ways to speed up the process. </p>
<p id="TS8mEJ">Rich countries could donate more doses to poorer countries — a move global health groups have been calling for for months and one that’s starting to <a href="https://www.cidrap.umn.edu/news-perspective/2021/04/indias-covid-19-crisis-prompts-global-response">happen in response to the crisis in India</a>. </p>
<p id="0Jy01n">Rich countries could also simply start investing more in helping poorer countries respond to the crisis. They could answer <a href="https://www.devex.com/news/covax-facility-seeks-an-additional-2b-for-covid-19-vaccines-99671">Covax’s call for more donor funds</a>, for example. Or Omer called for something akin to <a href="https://www.pepfar.gov/about/">PEPFAR</a>, America’s global health program to combat AIDS around the world. Launched under George W. Bush in 2003, to date, it’s provided $90 billion toward fighting AIDS.</p>
<p id="7Ysv9X">“It sounds lofty but the cost to everyone, including high-income countries, is huge with each passing month or week where there is transmission going on around the world,” Omer added. “What is happening in India can happen in other large chunks of population and that should concern us all.”</p>
https://www.vox.com/2021/4/28/22405279/covid-19-vaccine-india-covaxJulia Belluz2021-04-23T04:00:00-04:002021-04-23T04:00:00-04:00Vietnam defied the experts and sealed its border to keep Covid-19 out. It worked.
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<figcaption>People commuting and shopping on the last day before the Lunar New Year holiday in Hanoi’s Old Quarter on February 10, 2021.</figcaption>
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<p>How the country has kept coronavirus deaths to just 35, and grew its economy in 2020.</p> <p id="Je9rpQ"><em>This story is one in our six-part series The Pandemic Playbook.</em><em><strong> </strong></em><a href="https://www.vox.com/22381700/pandemic-playbook"><em>Explore all the stories here</em></a>.</p>
<p id="O0N7bM">Every January or February, Le The Linh and his wife pack their children into their car and drive 80 miles to visit family in Haiphong, a port city east of Vietnam’s capital, Hanoi, for Lunar New Year. But this time, as they reached the last stretch of the Hanoi-Haiphong Highway, a police officer approached and pointed them toward a group of guards in face masks under a makeshift tent. It was one of 16 checkpoints erected around Haiphong to control travel into and out of the city ahead of the Tet Festival holiday.</p>
<p id="wPyN0k">They joined a lineup of other travelers, nervously waiting for their turn in the rain. When they reached the front, the officials asked for proof of their travel plans, residency, and Covid-19 status.</p>
<p id="j2KmKi">“Don’t worry!” Linh exclaimed tensely. He could show, with his identity card, that they lived in an area that had no coronavirus cases recently.</p>
<p id="BeDTGU">The family was among the lucky ones let through. Travelers from areas near Haiphong that had recently recorded Covid-19 cases got turned away; a group of young people on motorbikes who tried to circumvent <a href="https://nld.com.vn/thoi-su/34-thanh-nien-hai-duong-vuot-chot-kiem-soat-dich-benh-covid-19-vao-hai-phong-20210214101919059.htm">the checkpoint were arrested</a>; still others chose not to travel at all, opting to meet family over FaceTime or <a href="https://www.techinasia.com/move-whatapp-zalo-vietnams-favorite-messaging-app">Zalo</a> (Vietnam’s answer to WhatsApp).</p>
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<figcaption>Le The Linh (second from right) and his wife have their documents checked by police and military officials at a checkpoint before entering the Hanoi-Haiphong Highway.</figcaption>
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<figcaption>A driver is asked to write down his health and travel history at the Hanoi-Haiphong Highway checkpoint.</figcaption>
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<figcaption>Travelers on the Haiphong Highway trying to enter the city from areas that have recorded any Covid-19 cases are turned away.</figcaption>
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<p id="f0fsl1">As the pandemic took hold last year, travel restrictions quickly proliferated — they were the <a href="https://www.nature.com/articles/s41562-021-01079-8/figures/3">second-most-common policy governments</a> adopted to combat Covid-19. According to <a href="https://webunwto.s3.eu-west-1.amazonaws.com/s3fs-public/2020-04/TravelRestrictions%20-%2028%20April.pdf">one review</a>, never in recorded history has global travel been curbed in “such an extreme manner”: a reduction of approximately<a href="https://gh.bmj.com/content/6/3/e004537"> 65 percent</a> in the first half of 2020. More than a year later, as countries experiment with <a href="https://www.vox.com/recode/22384340/vaccine-passport-vaccine-record-covid-19-clear-commonpass-excelsior-pass">vaccine passports</a>, <a href="https://www.nytimes.com/2021/04/19/world/australia-new-zealand-travel-bubble.html">travel bubbles</a>, and a new round of measures to <a href="https://www.nytimes.com/2021/04/16/travel/international-summer-travel-coronavirus.html">keep virus variants at bay</a>, a maze of confusing, ever-changing restrictions remains firmly in place.</p>
<p id="INt2YG">But few countries have gone as far as Vietnam, a one-party communist state with a GDP per capita of <a href="https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=VN">$2,700</a>. The Haiphong checkpoints timed for Tet were the equivalent of closing off Los Angeles to Americans ahead of Thanksgiving — within a country that was already nearly hermetically sealed. Last March, the government canceled all inbound commercial flights for months on end, making it almost impossible to fly in, even for Vietnamese residents. </p>
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<p id="m6KjeX">Today, flights are limited to select groups, like businesspeople or experts, from a few low-risk countries. Everybody who enters needs <a href="https://home.kpmg/xx/en/home/insights/2020/09/flash-alert-2020-401.html">special government permission</a> and must complete up to 21 days of state-monitored quarantine with PCR tests. (Positive cases are immediately isolated in hospitals, regardless of disease severity.) </p>
<p id="LRCMfJ">This strict approach to travel, global health experts say, is directly connected to Vietnam’s seeming defeat of Covid-19. Thirty-five people have reportedly died in total, and a little more than 2,700 have been infected with the virus during three small waves that have all been quickly quashed. Even on the worst days of the pandemic, the country of <a href="http://data.un.org/en/iso/vn.html">97 million</a> has never recorded more than 110 new cases — a tiny fraction of the 68,000 daily case high in the United Kingdom, which has a population one-third smaller than Vietnam, or the record 300,000-plus cases per day only the <a href="https://www.bloomberg.com/news/articles/2021-04-22/india-records-world-s-highest-one-day-surge-in-covid-cases">US and India</a> managed to tally.</p>
<p id="mbav7w">Last year, Vietnam’s economy even grew <a href="https://www.worldbank.org/en/country/vietnam/overview">2.9 percent</a>, defying economists’ predictions and <a href="https://www.scmp.com/economy/global-economy/article/3120453/chinas-gdp-growth-2020-truly-hard-won-outcome-says-premier">beating China</a> to become the <a href="https://www.cnbc.com/2021/01/28/vietnam-is-asias-top-performing-economy-in-2020-amid-covid-pandemic.html">top performer in Asia</a>.</p>
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<p id="RCuMq8">In this series, the <a href="https://www.vox.com/22381700/pandemic-playbook">Pandemic Playbook</a>, Vox is exploring the Covid-19 strategies used by six nations. Vietnam’s travel restrictions — supported by other measures, including enforced quarantining and contact tracing — help explain the country’s apparent mastery over the virus. And while the political leverage of a single-party government might have helped Vietnam respond faster and more unilaterally than others, “I don’t think this is simply about totalitarianism versus Western democracies,” said Kelley Lee, a Simon Fraser University global health professor who has been studying the <a href="https://gh.bmj.com/content/bmjgh/6/3/e004537.full.pdf">impact of travel restrictions</a>. </p>
<p id="qGIcas">That’s why Vietnam is now among a few countries upending the global health community’s “almost religious belief that travel restrictions are bad,” said <a href="https://www.law.georgetown.edu/faculty/lawrence-o-gostin/">Lawrence Gostin</a>, a Georgetown University global health law professor who helped write the international law governing how countries should deal with outbreaks.</p>
<p id="7mSywW">“I have now realized,” Gostin added, “that our belief about travel restrictions was just that — a belief. It was evidence-free.”</p>
<h3 id="q2afEo">Covid-19 changed the thinking about travel restrictions in a pandemic</h3>
<p id="5g3Nih">At a time when people still thought diseases originated with imbalances in the “four humors” and doctors routinely used treatments like bloodletting, governments tried to manage travel to prevent outbreaks. In <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3559034/">1377</a>, quarantine measures were introduced <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3559034/">in Dubrovnik</a>, on Croatia’s Dalmatian Coast, to<a href="https://www.history.com/news/quarantine-black-death-medieval"> keep out sailors potentially carrying the bubonic plague</a>.</p>
<p id="wBGgW8">The law stipulated that anyone from “plague-infested areas shall not enter [Dubrovnik] or its district unless they spend a month on the islet of Mrkan ... for the purpose of disinfection.” For <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7133622/">land travelers</a>, the disinfection period lasted even longer — 40 days.</p>
<p id="A8PdEg">But in the age of mass travel and globalization, it seemed <a href="https://www.tandfonline.com/doi/full/10.1080/13523260.2020.1771955">virtually impossible</a> — counterproductive, even — for cities or countries to isolate themselves. The mantra in global health became “<a href="https://www.tandfonline.com/doi/full/10.1080/13523260.2020.1771955">diseases know no borders</a>.” Just before the pandemic, 2019 was a <a href="https://www.traveldailymedia.com/unwto-records-1-5-billion-tourism-arrivals-in-2019/#:~:text=About%201.5%20billion%20international%20tourist,in%202019%20%E2%80%93%20a%20new%20record.%20Show%20less">record year</a> for tourist arrivals. The travel and tourism sector had generated a tenth, or US <a href="https://www.unwto.org/restarting-tourism">$8.9 trillion</a>, of global GDP. “It [was like] the cat’s out of the bag,” Gostin said.</p>
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<cite>Son Nguyen/AFP via Getty Images</cite>
<figcaption>Officials inside the Van Don airport in Vietnam’s Quang Ninh province check details of Vietnamese citizens repatriating from Wuhan, China, on February 10, 2020.</figcaption>
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<p id="DyaAqI">Many of the measures countries tried in recent years, after the first SARS virus emerged in 2002 — including banning flights or visas for particular cities or countries, and screening for disease at airports — didn’t seem to deliver much protection.</p>
<p id="NRNbjx">Research on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7106206/">SARS</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415609/">Ebola</a>, and the <a href="https://journals.plos.org/plosmedicine/article/info:doi/10.1371/journal.pmed.0030401">seasonal flu</a> found these targeted restrictions <a href="https://slate.com/technology/2021/01/plague-cycle-excerpt-coronavirus-covid-travel-bans.html">merely delayed infections</a> and carried a slew of social and economic costs. They unfairly punished the economies of places that were unlucky enough to be plagued by disease, interfered with the global flows of people and goods, drove infections underground, and made it hard for aid workers and supplies to reach those who urgently needed them.</p>
<p id="k6dIOY">I knew these costs intimately. I grew up in Toronto, where a rare travel advisory imposed on the city <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC155962/">by the World Health Organization</a> in the wake of the first SARS outbreak cratered <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7106206/">tourism to the entire province</a> — so much so that the <a href="https://en.wikipedia.org/wiki/Molson_Canadian_Rocks_for_Toronto">Rolling Stones eventually intervened</a> with a charity concert (dubbed “SARSStock”). The measures also failed to avert outbreaks. According to a <a href="https://www.canada.ca/en/public-health/services/reports-publications/learning-sars-renewal-public-health-canada/executive-summary.html">Canadian government report</a>, putting arriving passengers through health assessments and thermal scanners didn’t root out a single case.</p>
<p id="TtbVWC">During the 2014-2016 West Africa Ebola epidemic and early in the Covid-19 pandemic, I co-wrote popular stories detailing this evidence and arguing against the use of such restrictions. And I wasn’t alone.</p>
<p id="y0O4OY"><a href="https://www.marketwatch.com/story/that-travel-ban-trump-touts-bill-gates-says-it-made-the-pandemic-worse-11600626062">Bill Gates pointed out that then-President Donald Trump’s</a> approach to Covid-19 travel bans probably made the US epidemic worse. The WHO’s <a href="https://www.who.int/publications/i/item/9789241580410">International Health Regulations</a>, an international law governing 196 countries’ responses to outbreaks, says countries should “avoid unnecessary interference with international traffic and trade” and follow the WHO’s expert advice. With every global health emergency declared after SARS, the WHO has <a href="https://www.statnews.com/2020/04/08/trump-faulted-who-coronavirus-response-guided-by-rules-u-s-helped-write/">not recommended travel restrictions</a>.</p>
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<p lang="en" dir="ltr">.<a href="https://twitter.com/WHO?ref_src=twsrc%5Etfw">@WHO</a> doesn’t recommend limiting trade & movement.<br>Travel restrictions can cause more harm than good by hindering info-sharing & medical supply chains & harming economies. We urge countries & companies to make evidence-based, consistent decisions. <a href="https://t.co/ksxOV6sbDN">https://t.co/ksxOV6sbDN</a></p>— Tedros Adhanom Ghebreyesus (@DrTedros) <a href="https://twitter.com/DrTedros/status/1223288481159503873?ref_src=twsrc%5Etfw">January 31, 2020</a>
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<p id="3zPetl">At the same time, speaking out against travel bans had become synonymous with opposing nationalism and wall-building, said Lee. “There were these progressive, human rights values that were upheld by not using travel measures.”</p>
<p id="8485nW">But it’s now clear that the well-meaning advice and previous research findings didn’t match up with the situation the world was facing in early 2020. The new virus was different — more contagious and harder to stop. SARS-CoV-2 can be transmitted prior to the onset of symptoms, if they ever occur — while with SARS and Ebola, for example, people are only contagious when they are very ill or symptomatic.</p>
<p id="SXtTMa">The new coronavirus contagion inspired drastic measures. After China locked down Wuhan in January 2020, a move many called “<a href="https://time.com/5796425/china-coronavirus-lockdown/">draconian</a>,” countries around the world scrambled and experimented with their own travel restrictions. </p>
<p id="xWK6It">Only a few, though, did something that “seemed unfathomable” prior to the pandemic, said University of Hong Kong public health professor Karen Grépin: They completely closed their borders. It was an approach experts had no evidence for. “No one [had] modeled out a scenario in which borders would be shut,” she said, and stay shut. </p>
<p id="lvAHxA">Yet that’s essentially what happened in Vietnam — and in a few states or regions, mostly islands including Taiwan and New Zealand, that have virtually eliminated the virus.</p>
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<h3 id="J186n7">Vietnam started building a “wall” to the world in January</h3>
<p id="dZQtVP">Early last year, when the US and European countries still focused on keeping out travelers from places with known Covid-19 cases, Vietnam closed its borders to the world.</p>
<p id="eIqU9G">It was the culmination of months of escalating travel restrictions. On January 3, the same day China reported a mysterious cluster of viral pneumonia cases to the WHO, Vietnam’s Ministry of Health issued a directive to increase disease <a href="https://zingnews.vn/bo-y-te-chi-dao-kiem-soat-chat-tranh-nguy-co-lay-virus-qua-cua-khau-post1032354.html">control measures on the border with China</a>. By the end of January, Vietnam’s then-Prime Minister Nguyen Xuan Phuc banned all flights to and from Wuhan and other areas where the virus was spreading in China and shut off every transport link between the two countries, making it the <a href="https://gh.bmj.com/content/6/1/e004100?__cf_chl_jschl_tk__=040fbad1f9655393d1f7166f4f0ba43bfd0d02ff-1616596035-0-AQBgxOr6rmFv4SZ7hsF2oQn0ouj0pdEttVKNX3koMnjjuXMDl0kSbhMDENpZguOMCRBvpDPIpPsX0C7SVm_qkGRtQeXZ0zi_l5Ltp89LvF4T9dG40-e82STyhh841No03faPaRFayWLF8xZIkVWjCXYbtpohDMYya4oG4ln8NkGQG2oS6IDoGehti21OzXLNjitB-33sofR5QCab9KCIdpQZ6iek2ALfWYawRu-iX27bDL0avC4RXijxNCzsqQXv_O3uvw-2Q_1UAi2Icacznge_dDA06oP4dnM8dLVEVKuDLx_OtG89y69Oaq6ltvQKHkvBKEToJFfxnC745y3Y3c_eUGfvQPWksxgHyLPCijf6">first place in Southeast Asia</a> to close out Chinese travelers.</p>
<p id="TL9E1H">By mid-March, Vietnam suspended visas for all foreigners and then stopped all commercial flights. Only diplomats, citizens, and other officials could get in or out on repatriation flights, and they needed authorization from the government to enter. </p>
<p id="hbx2g1">Limited air travel has now resumed with other low-risk neighbors — such as <a href="https://www.ttrweekly.com/site/2021/03/vietnam-cautiously-resumes-flights/">South Korea</a>, <a href="https://e.vnexpress.net/news/business/companies/vietnam-airlines-resumes-international-commercial-flights-4254235.html">Taiwan, and Japan</a> — but only for Vietnamese people and foreign businesspeople and experts. And while Vietnamese nationals can cross land borders from <a href="https://vnembassy-vientiane.mofa.gov.vn/vi-vn/News/EmbassyNews/Trang/Th%C3%B4ng-b%C3%A1o-v%E1%BB%81-vi%E1%BB%87c-Ch%C3%ADnh-ph%E1%BB%A7-L%C3%A0o-cho-ph%C3%A9p-c%C3%B4ng-d%C3%A2n-Vi%E1%BB%87t-Nam-v%E1%BB%81-n%C6%B0%E1%BB%9Bc.aspx">Laos</a> or <a href="https://nhandan.com.vn/tin-tuc-y-te/kien-giang-co-35-truong-hop-nhap-canh-duong-tinh-voi-sars-cov-2-642381/">Cambodia</a>, everybody who does get into the country — by air, land, or sea — has to submit to PCR tests and wait out a mandatory 14- to 21-day quarantine period under state supervision in a military-run facility or designated hotel.</p>
<p id="vUoOQa">So where Western countries introduced travel restrictions late, targeted their measures at countries with confirmed Covid-19 cases (or <a href="https://www.nytimes.com/2021/04/18/world/france-covid-variant-brazil-argentina-south-africa.html">variants</a> now), made quarantine optional or didn’t enforce it, and allowed loopholes (like excluding certain groups from travel restrictions, or letting people arriving over land avoid quarantine), Vietnam walled itself in.<strong> </strong>While Western countries continue to roll measures back <a href="https://www.kiwi.com/stories/germany-others-remove-uk-list-risk-countries/">whenever case counts come down</a>, Vietnam has kept its wall up — even during periods when the country recorded zero new coronavirus cases. </p>
<p id="xNAsJ2">“This is the lesson about border measures that’s changed,” Grépin said. “The value of border restrictions goes up the fewer cases you have.”</p>
<p id="KrqVEk">The restrictions also appear to work best if they’re implemented when they most seem like overkill, said London School of Hygiene and Tropical Medicine epidemiologist <a href="https://www.lshtm.ac.uk/aboutus/people/jit.mark">Mark Jit</a>. That is, before (or after) community transmission takes place, he added.</p>
<p id="ldjR8K">“The natural thing is to think, ‘When we have a big problem, there are many Covid cases, that’s the point when we need to start doing a lot of things.’ But for travel restrictions — these are the solution to stop the problem from happening in the first place,” Jit explained. “It seems obvious in retrospect, but it’s very paradoxical.”</p>
<h3 id="UdKWFd">Vietnam saw China’s epidemic as a threat right away</h3>
<p id="2m002R">So why did Vietnam take this early and comprehensive approach when so many other countries didn’t? The short answer: The country’s fraught relationship and porous border with China — which put it at higher risk for outbreaks — may have been its savior.</p>
<p id="nfwBsO">“[The] two countries taking the quickest action are Taiwan and Vietnam — they shared the same reasons: geographical proximity to and distrust in China,” explained Nguyen Xuan Thanh, a member of the Prime Minister’s Economic Advisory Group, which is composed of experts who counsel the government on economic development strategy and policy. (Vietnam may have had information that other countries didn’t early on: A cybersecurity firm, <a href="https://www.fireeye.com/blog/threat-research/2020/04/apt32-targeting-chinese-government-in-covid-19-related-espionage.html">FireEye</a>, has said that<a href="https://thediplomat.com/2020/05/did-vietnamese-hackers-target-the-chinese-government-to-get-information-on-covid-19/"> since at least January</a>,<a href="https://www.reuters.com/article/us-health-coronavirus-cyber-vietnam/vietnam-linked-hackers-targeted-chinese-government-over-coronavirus-response-researchers-idUSKCN2241C8"> Vietnamese hackers</a> spied on the Chinese government to collect intelligence about Covid-19 — reports the government has denied.)</p>
<p id="MO5IJV">Whatever the reason, officials in Vietnam didn’t entertain the possibility that the coronavirus was just like the seasonal flu, nor did they consider herd immunity. When China locked down Wuhan last January and bought other countries time to react, Vietnam was one of only a handful of countries that used that time wisely.</p>
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<cite>Hoang An/AFP via Getty Images</cite>
<figcaption>All arriving passengers at Noi Bai International Airport in Hanoi are screened through a thermal scanner on January 21, 2020.</figcaption>
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<p id="LA7WvV">“Outside of the Asia-Pacific region, most of the world did very little to prepare for the real possibility that this virus was about to spread globally,” Grépin said. In January, the Vietnamese government set up a national task force specialized in handling Covid-19, headed by the deputy prime minister, and defined a “double goal” of combating the virus and growing the economy.</p>
<p id="7sjkwg">The country’s officials and Communist Party made battling Covid-19 a patriotic act. “Fighting this epidemic is like fighting the enemy,” the prime minister said in a <a href="https://vietnamnews.vn/politics-laws/591545/fighting-against-ncov-like-fighting-against-enemies-pm.html">government meeting</a> last January.</p>
<p id="m6TZMn">They transmitted health messages to the public using <a href="https://www.theguardian.com/commentisfree/2020/may/01/testing-vietnam-contained-coronavirus">creative tactics</a>, like texts to mobile phones or a viral pop song about hand-washing. They <a href="https://ourworldindata.org/covid-exemplar-vietnam">ramped up testing (starting in January 2020)</a> and <a href="https://e.vnexpress.net/news/news/5-000-staffs-patients-at-hanoi-hospital-to-take-covid-19-test-4074971.html">shortly thereafter</a> began checking <a href="https://e.vnexpress.net/news/news/vietnam-seeks-to-produce-test-kits-for-coronavirus-4048220.html">even asymptomatic people</a> for the virus. By the end of last year, Vietnam was processing <a href="https://ourworldindata.org/covid-exemplar-vietnam">1,000 tests per Covid-19 case</a>, compared to 12.8 in the US or 21.7 in the UK. </p>
<p id="VdZTcB">Contact tracing became so widespread that the population now speaks the language of epidemiologists: It’s not unusual to hear Vietnamese people refer to the “F1” through “F5” system — how contact tracers denote a person’s proximity to an “F0,” or index case. (And, yes, where Western governments largely abandoned contact tracing or didn’t even seriously attempt it, Vietnam continues to ferret out potential cases by testing all F1s — a patient zero’s immediate contacts — and quarantining them in a state facility, while also asking F2s to quarantine at home.)</p>
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<cite>Linh Pham/Getty Images</cite>
<figcaption>Empty roads are seen in Hanoi on April 5, 2020. Nguyen Xuan Phuc, Vietnam’s then-prime minister, officially declared Covid-19 a national epidemic on the same day, which was followed by a nationwide social distancing campaign and a shutdown of nonessential businesses.</figcaption>
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<p id="qYN0x4">When a single person tests positive, it can trigger a <a href="http://daidoanket.vn/lua-to-khoanh-to-lua-nho-khoanh-nho-503108.html">targeted lockdown</a>, “isolating a large area when the fire is big, isolating a small area when the fire is small,” Mai Tien Dung, the chair of the Office of the Government, said.</p>
<p id="PcllHE">In practice, this meant that last February, just as Lunar New Year travel and Vietnam’s third wave was picking up, a Hanoi apartment block, where more than 1,000 people live, closed down one evening after a woman tested positive for the virus. The entrances were barricaded and guarded by police as hundreds of residents spilled out, masked and social distancing, waiting for a free Covid-19 test.</p>
<p id="s5NadE">Only those who tested negative were allowed to leave, and results took at least six hours to come in — a fact that frustrated those who weren’t prepared to spend the night, like gym staff members. By the next morning, everyone who had been tested got a negative result, and the barricades were removed — but everybody living on the two floors around the index patient was asked to quarantine for two weeks.</p>
<div class="c-float-right c-float-hang"><aside id="OFc1Mc"><q>“Politicians make decisions based on the pressure from the society and inner political system. Vietnam had no such pressure.”</q></aside></div>
<p id="3t3MpY">Vietnam also bet that the early overreaction, including closing down international borders, might save the domestic economy and prevent the health system from becoming overwhelmed, Thanh said. Just before SARS-CoV-2 started spreading in China, Vietnam <a href="https://www.ghsindex.org/wp-content/uploads/2019/10/2019-Global-Health-Security-Index.pdf">ranked 73 out of 195 countries</a> on epidemic response and mitigation, according to the Global Health Security Index from the Johns Hopkins Bloomberg School of Public Health. (The US, meanwhile, ranked No. 2 after the UK; the top 10 included the Netherlands and Brazil.)</p>
<p id="kwPheT">Vietnam had another vulnerability to contend with. “The reality [is] that Vietnam does not have enough budget to sacrifice the economy and support businesses and individuals who had to cease operation,” Thanh said.</p>
<p id="aTZR6c">More than a year later, Vietnam’s success with keeping case counts, hospitalizations, and deaths low laid bare the <a href="https://nymag.com/intelligencer/2021/03/how-the-west-lost-covid-19.html?utm_source=tw&utm_campaign=nym&utm_medium=s1">arrogance and faulty assumptions</a> that went into determining which countries would win or lose in their battles with the virus. With the exception of short-lived, targeted lockdowns, life in Vietnam today largely resembles the Before Times in a way many Westerners can only envy. People go to bars, share drinks with friends, and enjoy live music. Restaurants and cafes are open. Children attend school and see their grandparents in person.</p>
<p id="xunKTc">The population never experienced the disorientation, economic pain, and mental health toll of rolling national lockdowns. Hospitals never buckled under the strain of masses of coronavirus patients. Kids didn’t miss a year of school. (There was a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7417980/#:~:text=After%20imposing%2015%20d%20of,new%20cases%20within%20its%20borders.">brief nationwide social distancing</a> order last April when all schools were shut for three weeks.)</p>
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<figcaption>People commuting and shopping on the last day before Lunar New Year in Hanoi’s Old Quarter on February 10, 2021. In 2020, Vietnam’s economy grew 2.9 percent.</figcaption>
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<p id="NPUSeP">Vietnam is also one of a handful of countries whose economies grew in 2020 — the same year the country <a href="https://www.ft.com/content/ffa50623-b86f-4456-a6f0-9abceeb1ef7a">introduced three trade deals</a> and saw per capita income rise. “At the beginning of the crisis, if you asked an economist what would happen here, most of us were pessimistic because of the [cutting off of] connections to the rest of the world,” said Jacques Morisset, the World Bank’s lead economist for Vietnam. </p>
<p id="GwNszz">But because the virus was quickly contained internally, the domestic economy rebounded, just as Thanh and his colleagues had hoped. Manufacturing continued, and exports grew by <a href="http://ven.vn/foreign-trade-a-highlight-on-vietnams-2020-economic-picture-44301.html">6.5 percent</a> — not far off from the usual export turnover increase of 8 percent, according to Thanh.</p>
<p id="waBebh">That growth more than made up for losses in the shrinking tourism and transport sectors. The successes also helped foster public support for the anti-virus measures. Whenever the tourism or travel industries lobbied for open borders, the economic pressure didn’t crack the borders open. According to a <a href="https://vnexplorer.net/citizens-support-for-governments-covid-19-policies-survey-a202094947.html">survey</a> released in December by the UN Development Program and the Mekong Development Research Institute, 89 percent of Vietnamese respondents said they supported the government’s approach — higher than the global average of 67 percent.</p>
<p id="rU0teW">“Politicians make decisions based on the pressure from the society and inner political system,” Thanh said. “Vietnam had no such pressure. Vietnamese people supported the government to continue having strict measures.”</p>
<h3 id="YZjRcF">Vietnam’s state security apparatus bolstered its public health response</h3>
<p id="thR60E">In a one-party system like Vietnam’s, there are few avenues to voice opposition. This political context has arguably strengthened certain anti-virus measures, like the country’s extensive <a href="https://ourworldindata.org/covid-exemplar-vietnam">contact tracing</a> program. The Communist Party has for decades employed “surveillance, physical monitoring, and censorship to manage the population,” <a href="https://foreignpolicy.com/2020/05/12/vietnam-coronavirus-pandemic-success-repression/">Foreign Policy reported in May last year</a>. These “tools of Communist Party control ... have now been repurposed in the service of health protection.”</p>
<p id="bJXSV4">Local officials and busybody neighbors also exert social pressure on others to conform, said <a href="https://thediplomat.com/authors/carl-thayer/">Carl Thayer</a>, a Southeast Asia specialist and emeritus professor at the University of New South Wales. “Vietnam has block wardens, village wardens, household registration, and inquisitive locals that intrude on people’s lives. They have a society where people report people.”</p>
<p id="uLp7q8">The government can and does share details with the public about positive cases (including the age, gender, and neighborhood where the person lives, as well as a flight number for travelers), sometimes leaking additional information for use as cautionary tales.</p>
<p id="aTjNiu">Perhaps the most infamous example: <a href="https://www.newyorker.com/magazine/2020/09/28/the-public-shaming-pandemic">Vietnam’s case number 17</a>, a <a href="https://tuoitrenews.vn/news/society/20200306/vietnam-confirms-17th-covid19-patient-in-hanoi/53341.html">socialite who traveled to Italy</a> without disclosing it at the border and faced severe public shaming. Her Covid-19 experience was the subject of government press conferences, and social media users tracked her down. Her story scared people who didn’t want to be responsible for others’ infections, said Hanoi-based American health economist Sarah Bales. “Everybody knows her,” she said. “She was notorious, and people hated her.”</p>
<p id="hQBcF0">This heavy-handedness would not be tolerated in many Western countries, where concerns about personal freedom and privacy have often trumped public health throughout the pandemic, Thayer said. The Foreign Policy authors also pointed out that the country’s human rights violations have repeatedly been overlooked in examinations of Vietnam’s Covid-19 response: “While the international community has criticized Vietnam’s security apparatus in the past for violating its citizens’ rights, the country has received near-unanimous praise for its successful handling of the current pandemic. But the tools used are the same.”</p>
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<figcaption>Business owner Phuong Nha speaks to her mother via video, along with her son Than Gia Hung, from their home in Hanoi. Nha says she will miss not seeing her family for the Tet holiday but trusts the government’s response to Covid-19.</figcaption>
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<figcaption>Ta Hoang Tuan (left) sits with his family in Hanoi. Tuan traveled to a nearby province earlier this year, which meant the family had to quarantine upon his return. Health officials would come every day to check their progress.</figcaption>
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<figcaption>Convenience store employees make a delivery to a building in Hanoi that was temporarily locked down due to recent Covid-19 cases, on February 11.</figcaption>
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<p id="naM9Qn">Yet to reduce Vietnam’s Covid-19 success to its system of authoritarian governance is a mistake, Lee said, pointing out that democracies, like South Korea, Taiwan, and New Zealand, have employed similar tactics as Vietnam. And analysts have repeatedly <a href="https://thediplomat.com/2021/01/the-role-of-political-culture-in-taiwans-covid-19-success/">struggled to</a> link a<a href="https://carnegieendowment.org/2020/03/31/do-authoritarian-or-democratic-countries-handle-pandemics-better-pub-81404"> country’s political system to its Covid-19 success</a>.</p>
<p id="p6lDb8">Vietnam’s is “a very scientific approach and has merit on its own no matter which regime chooses to apply these types of measures,” said Bales, who has lived and worked in Vietnam since 1992. “They did extensive contact tracing. ... They did massive testing. They closed down the provinces so if there was transmission, it would stay local. Most people are living a normal life, and the few people who have been exposed or infected have to bear the brunt of quarantine, testing, and isolation.”</p>
<p id="jkJP3O">Watching the pandemic unfold in the US and Europe, Bales was among several Vietnam-based Westerners who told Vox they believe the privacy and personal liberty costs during the pandemic were worth the benefits of living a relatively free life.</p>
<p id="ubvOOL">“You don’t have to worry and be afraid like you do in the West — where every time you go out, it must be stressful [wondering] about if you’re exposed, and if you’re exposed, will you have <a href="https://www.vox.com/22298751/long-term-side-effects-covid-19-hauler-symptoms">long Covid</a> or die,” Bales said. “On a day-to-day basis, I don’t worry.” </p>
<h3 id="ZLhNBz">When Vietnam’s wall comes down</h3>
<p id="G1pPpg">One morning in early March, a taxicab pulled up to the international terminal at <a href="https://www.hanoiairportonline.com/">Hanoi’s Noi Bai airport</a>. The last time the driver took someone there was half a year ago, he said, when a Vietnamese customer wanted to fly to Taiwan for work. Today, though, a repatriation flight had just landed — one of 16 arriving in Vietnam so far this year. </p>
<p id="nHzyRe">Inside, the airport is a skeleton of its former self. There are no crowds waiting to greet friends and family. Cafes and restaurants are closed, and the terminal halls are quiet and dark. A group of the newly arrived passengers waiting at the luggage conveyer belt look distinctly like they’ve come from a biosafety hazard lab: wearing blue full-body protection suits and masks, provided by Vietnam Airlines staff when they boarded their flight in Paris.</p>
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<cite>Giap Nguyen for Vox</cite>
<figcaption>Inside Hanoi’s Noi Bai Airport, more than 300 Vietnamese citizens arrive from Paris in full protective gear. They will be moved to centralized quarantine camps to guard against the spread of Covid-19.</figcaption>
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<p id="8R8Yr0">The only loud noise echoing across the terminal is a voice broadcasting instructions for what the passengers need to do next: Everybody will be transported to state-supervised quarantine facilities. One by one, their names and year of birth are called out before they walk to buses to be ferried off. When they arrive, they’ll be tested for Covid-19 — and, if positive, forwarded directly to the hospital for isolation and treatment. </p>
<p id="Pbcbrv">“We will try our best to organize so that families, parents, and children can stay together,” the voice on the speaker says, “but with friends, we may not be able to do so. We are sorry for that.”</p>
<p id="v2Lz9o">This scene feels unimaginable in Western cities like New York or Paris — but so did ubiquitous mask-wearing and lockdowns over a year ago. With travel set to boom as the pandemic eases, and the next outbreaks on the horizon, I wondered what the rest of the world should take away from Vietnam.</p>
<p id="8DHqvH">Lee — and the other global health researchers I spoke to — advised caution. This pandemic showed travel restrictions can be helpful, but we should not make the same mistake we did in the past and assume what worked for the coronavirus will work for other health threats. “We don’t want countries to automatically control borders whenever a cluster of atypical pneumonia occurs,” Lee said. “Not all outbreaks require borders to be closed.”</p>
<p id="kksquw">Shutting borders comes with costs — all the people who lost <a href="https://e.vnexpress.net/news/travel/covid-19-shutdown-puts-tour-guides-out-of-jobs-4140690.html">travel and tourism jobs</a> in Vietnam over the past year, or those who have been stranded far from home. Because of the very limited access to <a href="http://kinhtedothi.vn/nguoi-viet-tai-nga-mua-dai-dich-bai-3-cho-doi-nhung-chuyen-bay-cuu-tro-396861.html">repatriation flights</a>,<a href="https://www.rfa.org/vietnamese/in_depth/vietnamese-trapped-overseas-plea-for-help-07062020090830.html"> thousands</a> are <a href="https://thanhnien.vn/doi-song/hang-nghin-nguoi-viet-ket-o-nhat-lien-tuc-bi-huy-ve-chat-vat-doi-ngay-ve-1207303.html">waiting</a> for their applications to get approved, and a black market for repatriation flight access sprang up. The wealthy agree to pay as much as <a href="https://thanhnien.vn/thoi-su/trong-dich-covid-19-nguoi-ta-dong-y-tra-10000-usd-de-duoc-ve-viet-nam-1320157.html">$10,000 US</a> for seats, while some have been <a href="https://vietnamnews.vn/society/832816/civil-aviation-authority-of-viet-nam-warns-over-fraud-repatriation-flights.html">scammed</a>. </p>
<p id="7ZkzjY">“Even if we conclude that travel restrictions and trade restrictions and migration restrictions — under certain targeted circumstances — can be an effective part of the package,” Gostin said, “we still have to take into account the fact that by implementing [them], you’re causing harms in other regards.”</p>
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<figcaption>Thirty-five people have reportedly died in total and a little more than 2,700 have been infected with the coronavirus in Vietnam, a country of 97 million<strong> </strong>people.</figcaption>
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<p id="JCLAdc">Grépin also warned that the border closures countries like Vietnam put in place were “very extreme,” and pointed out that less intensive measures might prevent cases and carry fewer costs. Places like South Korea, Singapore, and Hong Kong, for example, have shown that “if you quarantine incoming travelers you can limit public health risk without border closure,” she said. But she also noted the approach isn’t foolproof. Hong Kong, for example, is currently struggling with the virus because of its travel links with India: A single April 4 flight from New Delhi has led to more than <a href="https://www.scmp.com/news/hong-kong/health-environment/article/3130422/coronavirus-hong-kong-health-experts-warn">50 Covid-19 cases</a>.</p>
<p id="ppFEqV">This raises another challenge: Travel restrictions are difficult to calibrate correctly, said <a href="https://www.globalstrategylab.org/team/steven-hoffman">Steven Hoffman</a>, a global health professor and the director of York University’s Global Strategy Lab. “If we are going to make use of [total border closures,] we need to [acknowledge] the fact that it might be implemented for events that don’t go pandemic,” he said. “And there’s something like 200 events every year that could go pandemic.”</p>
<p id="BbBjyP">For now, as Vietnam weighs the benefits of <a href="https://vietnamnews.vn/society/916684/covid-19-vaccine-passport-scheme-needs-to-be-done-step-by-step-health-official.html">Covid-19 vaccine passports</a> and <a href="https://vietnamnews.vn/economy/916909/viet-nams-aviation-authority-proposes-resumption-of-international-flights.html">how to resume international travel</a>, one thing is certain: The walls the country has built up will come down. People will hop on trains, planes, and buses, bringing their germs with them. The world will get smaller again, and proximity will be “more determined on the basis of the quantity of travel connections than kilometers,” Hoffman added.</p>
<p id="rPjOTh">Vietnam’s early, quick response to Covid-19 was inspired, in part, by the country’s shared border with China. But what other countries need to learn is that, in a globalized world, they share borders with China, too.</p>
https://www.vox.com/22346085/covid-19-vietnam-response-travel-restrictionsJulia Belluz2021-04-14T08:00:00-04:002021-04-14T08:00:00-04:00Scientists haven’t figured out long Covid. Here are 5 of their best hypotheses.
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<figcaption>Christina Animashaun/Vox</figcaption>
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<p>From disturbing the gut microbiome to lingering in the brain, there are many ways the coronavirus might cause lasting symptoms. </p> <p id="4oO68o">Most people who get the coronavirus will fully recover and go right back to their lives. But the latest research suggests that at least <a href="https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complications">10 percent</a> have long-term symptoms, even after their body has apparently cleared the virus. </p>
<p id="C6H18J">The condition, known as “long Covid,” has emerged as a scary feature of the pandemic — a reminder that even as hospitalizations and deaths come down, millions of people will continue to suffer from the aftermath of infection. </p>
<p id="RQ9jk6">And, as it turns out, “this isn’t unique to Covid,” <a href="https://medicine.yale.edu/profile/akiko_iwasaki/">Akiko Iwasaki</a>, an immunologist at the Yale School of Medicine, told Vox.<strong> </strong></p>
<p id="9ICzAV">Instead, Covid-19 appears to be one of many infections, from <a href="https://www.vox.com/22298751/long-term-side-effects-covid-19-hauler-symptoms">Ebola to strep throat</a>, that can give rise to stubborn symptoms in an unlucky subset of patients. “It is more typical than not that a virus infection leads to long-lasting symptoms in some fraction of individuals,” Iwasaki said. </p>
<p id="D8ldtC">The difference now is that, with 137 million Covid-19 cases worldwide and counting, long-haulers are more visible: Their suffering has come on in unprecedented numbers. It’s also possible the coronavirus causes <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(21)00084-5/fulltext">long-term symptoms even more frequently</a> than other infections. </p>
<p id="JD7yLY">In this week’s episode of <a href="http://vox.com/unexplainable"><em>Unexplainable</em></a>, we dive into what we know about long Covid and what other viruses can teach us about the condition, including the leading hypotheses for what might be driving symptoms in Covid long-haulers. </p>
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<div id="dGUVHl"><iframe src="https://open.spotify.com/embed-podcast/episode/0xB6Ot5XMQvKhXXB2rEeVr" style="border: 0; width: 100%; height: 232px;" allowfullscreen="" allow="encrypted-media"></iframe></div>
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<p id="aluvvK">We also look at what we can learn from patients who have been grappling with medically unexplained symptoms — the kind that don’t correspond to problematic diagnostic test results or imaging — for years before the pandemic hit. Here’s a rundown of what scientists think could explain the mysterious symptoms, and why even the vaccine might not help. </p>
<h3 id="G2nCZQ">1) The virus and “viral ghosts” didn’t actually leave the body</h3>
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<cite>Jane Barlow/PA Images via Getty Images</cite>
<figcaption>Cell nuclei (blue) being infected by SARS-CoV-2 (red areas), the virus that causes Covid-19.</figcaption>
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<p id="9wlWCI">The first explanation for what might cause persistent symptoms in people who’ve been infected with Covid-19 is the simplest: The virus or its components might still be lurking in the body somewhere, long after a person starts testing negative. </p>
<p id="wkZfyz">We’ve learned from other long-term viral illnesses that, in some cases, pathogens do not fully clear the body. “It’s out of the blood but gets into tissue in a low level — the gut, even maybe the brain in some people who are really sick — and you have a reservoir of the virus that remains,” PolyBio Research Foundation microbiologist <a href="https://polybio.org/team/amy-proal/">Amy Proal</a> told Vox. “And that drives a lot of inflammation and symptoms.”</p>
<p id="TBKF8D">These viral reservoirs have been documented following infections with many other pathogens. During the 2014-2016 Ebola epidemic, studies emerged showing the <a href="https://www.nytimes.com/2015/05/08/health/weeks-after-his-recovery-ebola-lurked-in-a-doctors-eye.html">Ebola virus could linger in the eye</a> and <a href="https://www.newscientist.com/article/2104238-ebola-virus-has-lurked-in-a-mans-semen-for-more-than-500-days/">semen</a>. There were similar findings during the <a href="https://www.vox.com/2016/2/23/11101500/zika-sexual-transmission">2015-2016 Zika epidemic</a> when health officials warned about the possibility that Zika could be sexually transmitted. (Viral reservoirs are also why the moniker “post-viral” can be problematic, Proal added.)</p>
<p id="9X6ybp">A related explanation for what might be happening with long-Covid patients is what Iwasaki calls “viral ghosts.” While the intact virus may have left the body, “there may be RNA and protein from the virus that’s lingering and continuing to stimulate the immune system,” Iwasaki said. “It’s almost like having a chronic viral infection — it keeps stimulating the immune system because the virus or viral components are still there, and the body doesn’t know how to shut it off.” </p>
<p id="4my6dS">Recent studies in <a href="https://www.nature.com/articles/s41586-021-03207-w"><em>Nature</em></a> and <a href="https://www.thelancet.com/article/S1474-4422(20)30308-2/fulltext"><em>The Lancet</em></a> documented coronavirus RNA and protein in a variety of body systems, including the gastrointestinal tract and brain. </p>
<p id="eC2f6e">In autopsies of people with chronic fatigue syndrome, researchers also found <a href="https://me-pedia.org/wiki/Autopsy_in_Myalgic_Encephalomyelitis">enterovirus</a> RNA and proteins in patients’ brains, including, in one case, in the <a href="https://www.acpjournals.org/doi/10.7326/0003-4819-120-11-199406010-00020?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&">brain stem region</a>. The brain stem controls sleep cycles, autonomic function (the largely unconscious system driving bodily functions, such as digestion, blood pressure, and heart rate), and the flu-like symptoms we develop in response to inflammation and injury. </p>
<p id="AxzScD">“If that area of the brain signaling becomes dysregulated [by viruses],” Proal said, “[that] can result in sets of symptoms that meet a diagnostic criteria for [chronic fatigue syndrome], or even for long Covid.” </p>
<h3 id="uvSn5o">2) Other pathogens lurking in the body reawaken </h3>
<p id="bxnVO1">Other pathogens already lurking in the body prior to a coronavirus infection might also exacerbate symptoms. For example, viruses in the herpes family — such as <a href="https://www.cdc.gov/epstein-barr/about-ebv.html">Epstein-Barr</a> (the cause of mono) or <a href="https://en.wikipedia.org/wiki/Varicella_zoster_virus">varicella zoster</a> (the cause of chickenpox and shingles) — stay dormant in the body forever. Under normal conditions, the immune system can keep them in check. </p>
<p id="9fcUUX">“So, for example, 90 percent of people in the world already have herpes viruses,” said Proal. “But in those patients, the immune system keeps them in a place where they can’t replicate, where they can’t express proteins. They’re kind of controlled.” </p>
<p id="7V7Yjp">But then Covid-19 comes along, and all of a sudden these other viruses get a chance to gain a foothold again. With the immune system tied up fighting Covid-19, the other viruses may reawaken. And they — not the coronavirus — drive symptoms. </p>
<h3 id="LAjMmK">3) The immune system turns on the body </h3>
<p id="Y2Uwg8">Another key hypothesis: Long-Covid patients have developed an <a href="https://www.nature.com/articles/d41586-021-00149-1">autoimmune disorder</a>. The virus interrupts normal immune function, causing it to misfire, so that molecules that normally target foreign invaders — like viruses — turn on the body.</p>
<p id="loIvT8">These “rogue antibodies,” known as autoantibodies, “attack either elements of the body’s immune defences or specific proteins in organs such as the heart,” according to <a href="https://www.nature.com/articles/d41586-021-00149-1"><em>Nature</em></a>. The assault is thought to be distinct from <a href="https://www.nejm.org/doi/full/10.1056/NEJMra2026131">cytokine storm</a>, an acute immune system disorder that appeared as a potential threat early in the pandemic. </p>
<p id="QQKseB">“Under that scenario, we talk about <a href="https://www.biorxiv.org/content/10.1101/2021.01.28.428642v1.full">molecular mimicry</a>,” Proal said. “Basically, the virus creates proteins that look like human proteins or tissue, and that kind of tricks the immune system.” Here, the the immune system tries to target the virus, which “if it has a similar size and shape to a human tissue or protein, it fires on the human tissue or protein as well,” she added.</p>
<h3 id="5UM7JK">4) The microbiome gets thrown out of whack </h3>
<p id="pTkFLy">It’s also possible the coronavirus might <a href="https://gut.bmj.com/content/70/4/698">deplete important microorganisms</a> in the gut microbiome — the trillions of bacteria, viruses, and fungi that live in and on the body. </p>
<p id="gmail-p-4">In <a href="https://gut.bmj.com/content/70/4/698">one study</a>, researchers tracked blood and stool samples from 100 patients hospitalized with SARS-CoV-2 infection, testing some up to 30 days after they cleared the virus. (They also collected samples from a control group for comparison.) And they found Covid-19 infection was linked to a “dysbiotic gut microbiome,” even after the virus cleared the respiratory tract; they also hypothesized that it might contribute to the persistent health problems some patients are experiencing.</p>
<p id="gCNX86">“Under conditions of health, those communities are in a state of balance. It’s like a forest, like different organisms are doing different things, but it’s in a harmonious state,” Proal said. But Covid-19 could lead to an imbalance in the microbiome. “And a huge number of symptoms are tied to microbiome dysbiosis. Irritable bowel syndrome or even neuro-inflammatory symptoms can be driven by these ecosystems when they go out of balance, too.” </p>
<h3 id="M60G3k">5) The body is injured</h3>
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<img alt="Radiologists observe CT scans of covid-19 hospital in Cremona" data-mask-text="false" src="https://cdn.vox-cdn.com/thumbor/bKyauGZy3li3kF8GmZzm90TEJ9I=/800x0/filters:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/22440784/1289176732.jpg">
<cite>Nicola Marfisi/AGF/Universal Images Group via Getty Images</cite>
<figcaption>Radiologists observe CT scans of Covid-19 patients’ lungs.</figcaption>
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<p id="TUt3yj">The virus might have cleared the body but left injuries in its wake — scars in the lungs or damage to the heart, for example — and these injuries might give rise to symptoms. </p>
<p id="s2QxhM">According to a <a href="https://www.medrxiv.org/content/10.1101/2020.10.14.20212555v1.full.pdf">recent preprint</a> involving 201 patients, 70 percent had impairments in one or more organs four months after their initial Covid-19 symptoms set in. In other <a href="https://www.nature.com/articles/d41586-020-02598-6">unpublished research</a>, radiologists at the University of Southern California tracked hospitalized patients’ lung recovery using CT scans. They found one-third had scars caused by tissue death more than a month later. Other patients may have <a href="https://www.nature.com/articles/d41586-020-02599-5">brain damage that causes neurological symptoms</a>. </p>
<p id="KUnOPC">There’s also growing evidence of widespread cardiac injury, even in patients who aren’t hospitalized. In a <a href="https://jamanetwork.com/journals/jamacardiology/fullarticle/2768916"><em>JAMA Cardiology</em> study</a>, researchers performed cardiac MRIs on 100 patients in Germany who had recovered from Covid-19 within the past two to three months. An astounding 78 percent still had heart abnormalities.</p>
<div class="c-float-right"><div id="YdnaEm"><div data-anthem-component="aside:9733921"></div></div></div>
<p id="tfOnOj">For coronavirus patients who had to be admitted to intensive care units, there’s a related explanation: Long before the pandemic, the <a href="https://www.sccm.org/MyICUCare/THRIVE/Post-intensive-Care-Syndrome">intensive care community</a> coined a term for the persistent symptoms people frequently experience following stays in an ICU for any reason, from cancer to tuberculosis. These symptoms include muscle weakness, brain fog, sleep disturbances, and depression — the aftermath of a body lying around in a hospital bed for days on end and injuries or side effects from treatments patients received, including intubation. </p>
<p id="Wr94RS">The term “post-intensive care syndrome” was<strong> </strong>“created to raise awareness and education, because so many of our ICU survivors were going to their primary care doctor saying they were fatigued,” said <a href="https://www.hopkinsmedicine.org/profiles/details/dale-needham">Dale Needham</a>, who has been treating Covid-19 patients in the ICU at Johns Hopkins. “They had trouble remembering, and they were weak. Their primary care doctor would do some lab tests and say, ‘Oh, there’s nothing wrong with you.’ The patient might walk away and feel like the doctor was saying, ‘It’s all in your head. You’re making it up.’” </p>
<h3 id="FVwqqT">The Covid-inspired medical revolution</h3>
<p id="30PoLB">So what might help alleviate the nagging symptoms of Covid long-haulers? One idea that’s been circulating is the Covid-19 vaccine: Some long-haulers are reporting <a href="https://www.npr.org/2021/03/30/982805660/long-haulers-are-finding-relief-after-getting-their-covid-19-vaccine">their symptoms improving</a> after they’ve gotten immunized. But others have reported feeling worse — and still others, no different. So researchers are racing to understand the effects of vaccination on long Covid, but it isn’t looking like a silver bullet just yet. </p>
<p id="WKmrIR">Proal had a simpler solution that could be implemented today: “It’s time for medicine to be rooted in just believing the patient.” </p>
<p id="2nGV2I">Even with growing awareness about long Covid, patients with the condition — and other chronic “medically unexplained” symptoms — are still too often <a href="https://blogs.bmj.com/bmj/2020/10/09/minna-johansson-caring-for-patients-with-long-covid-a-compassionate-tightrope/">minimized and dismissed</a> by health professionals. </p>
<p id="ROfiBF">People “want disease to kill you, or they want you to return to miraculous good health,” said <a href="https://www.linkedin.com/in/jaime-seltzer-b23abb14">Jaime Seltzer</a>, director of scientific and medical outreach at the chronic fatigue syndrome advocacy group <a href="https://www.meaction.net/about/">ME Action</a>. “When you stay sick, compassion can fade. And that is not just friends and family. That is your clinicians as well; they want somebody fixable.” </p>
<p id="DDASHu">But long-haulers of any chronic condition can exist in a space between sickness and health for years, sometimes without a diagnosis. Their unexplainable symptoms can elicit outright skepticism in health professionals who are trained to consider patient feedback the “lowest form of evidence on [the evidence hierarchy], even under research on mice,” Proal said. </p>
<p id="F42UHz">The situation can be even more challenging for patients who never had a positive PCR test confirming their Covid-19 diagnosis. Of the dozens of medical appointments one Covid-19 long-hauler, Hannah Davis, had for her ongoing symptoms — which include memory loss, muscle and joint pain, and headaches a year after her initial disease — one of the best experiences involved a doctor who simply said, “I don’t know.”</p>
<p id="2ZNwkl">“The doctor [told me], ‘We are seeing hundreds of people like you with neurological symptoms. Unfortunately, we don’t know how to treat this yet. We don’t even understand what’s going on yet. But just know you’re not alone,’” she recounted. “And that’s the kind of conversation that needs to be happening. Because we can wait, but we can’t have the doctor’s anxiety being projected onto us as patients.”</p>
https://www.vox.com/22369734/long-hauler-covid-vaccineJulia Belluz2021-04-07T15:14:34-04:002021-04-07T15:14:34-04:00Long Covid isn’t as unique as we thought
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<img alt="" src="https://cdn.vox-cdn.com/thumbor/IE0gClllCBiGHuUU9Tf7yStfB1o=/150x0:2817x2000/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/68948156/GettyImages_1219234664.0.jpg" />
<figcaption>Firefighter and EMS captain Hugo Sosa, who survived Covid-19, works on his recovery with a physical therapist in White Plains, New York. | Jabin Botsford/The Washington Post via Getty Images</figcaption>
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<p>The nagging symptoms long-haulers experience reveal a frustrating blind spot in medicine. </p> <p id="GXydhx"><a href="https://craig-a-spencer.medium.com/">Craig Spencer</a>, an emergency room doctor in New York City, was no stranger to dangerous viruses when a brush with one landed him in <a href="https://www.nychealthandhospitals.org/bellevue/health-care-services/">Bellevue Hospital</a> for 19 days. But it was only after he was discharged, and declared virus-free, that the really bizarre symptoms set in.</p>
<p id="TYtSHu">Back at home, he noticed he couldn’t taste anything for several days. For months, he was tired all the time and his joints felt heavy and painful. When he woke up in the morning, his back was “stiff like a bamboo rod.” His weight dropped, and clumps of hair fell out. Though the physical effects eventually faded, cognitive complications persist to this day — what he describes as “a subtle but noticeable difference in concentration and ability to form new memories.”</p>
<p id="EPRknr">If Spencer’s constellation of ongoing symptoms — fatigue, muscle and joint pain, memory issues — sounds familiar, it’s because it has become a <a href="https://www.medrxiv.org/content/10.1101/2020.12.24.20248802v2">frightening feature of some coronavirus infections</a>, an <a href="https://www.scientificamerican.com/article/the-problem-of-long-haul-covid/">epidemic of long-term illness within the pandemic</a>.<strong> </strong>For the Covid-19 “<a href="https://www.medrxiv.org/content/10.1101/2020.12.24.20248802v2">long-haulers</a>,” symptoms can persist for weeks or even months, long after being discharged from the hospital or testing positive for the virus, if they even saw a doctor or got diagnosed at all. </p>
<p id="nigCXM">But Spencer never had Covid-19. His persistent aches, pains, and memory problems arose after contracting Ebola in late 2014, when he was<strong> </strong>working with <a href="https://www.msf.org/statement-msf-aid-worker-dr-craig-spencer">Doctors Without Borders</a> in Guéckédou, Guinea, the epicenter of the <a href="https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html">West Africa Ebola epidemic</a>. The experience led him to join the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00446-3/fulltext">growing chorus</a> of health professionals, <a href="https://www.bmj.com/content/371/bmj.m4938/rr">patient advocates</a>, and <a href="https://www.medscimonit.com/download/index/idArt/931447">researchers</a> who argue we need to reframe how we think about coronavirus long-haulers. </p>
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<cite>Spencer Platt/Getty Images</cite>
<figcaption>Dr. Craig Spencer, right, seen with New York Mayor Bill de Blasio after recovering from Ebola in 2014.</figcaption>
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<p id="br9rNh">The dominant narrative about long Covid has been that it’s a <a href="https://www.vox.com/22166236/long-term-side-effects-covid-19-symptoms-heart-fatigue">uniquely perplexing</a> feature of Covid-19. Reports of “<a href="https://www.nytimes.com/2020/10/11/health/covid-survivors.html">Covid brain fog</a>” or “<a href="https://www.thetimes.co.uk/article/i-left-a-tap-on-and-flooded-my-flat-long-covids-dementia-symptoms-in-germany-d9sjg8r5d">Covid dementia</a>,” for example, suggest a disturbing and extraordinary ability of the coronavirus to destroy the lives of survivors. Even <a href="https://www.theguardian.com/society/2021/feb/20/long-covid-still-suffering-effects-virus-months-nhs-clinics">a year later</a>, some patients are still <a href="https://www.cnbc.com/2020/10/07/long-covid-sufferers-struggle-to-return-to-work.html">struggling to return to work</a> or have their illness recognized, let alone access disability benefits.</p>
<p id="lDMm4l">While there’s no doubt long Covid is a real condition worthy of diagnosis and treatment, “this isn’t unique to Covid,” <a href="https://medicine.yale.edu/profile/akiko_iwasaki/">Akiko Iwasaki</a>, an immunologist at the Yale School of Medicine, said.<strong> </strong>Covid-19 appears to be one of many infections, from Ebola to strep throat, that can give rise to stubbornly persistent symptoms in an unlucky subset of patients. “If Covid didn’t cause chronic symptoms to occur in some people,” PolyBio Research Foundation microbiologist <a href="https://polybio.org/team/amy-proal/">Amy Proal</a> told Vox, “it would be the only virus that didn’t do that.” </p>
<p id="Zg5WfP">Even with growing awareness about long Covid, patients with chronic “medically unexplained” symptoms — that don’t correspond to problematic blood tests or imaging — are still too often <a href="https://blogs.bmj.com/bmj/2020/10/09/minna-johansson-caring-for-patients-with-long-covid-a-compassionate-tightrope/">minimized and dismissed</a> by health professionals. It’s a frustrating blind spot in health care, but one that can’t be as easily ignored with so many new patients entering this category, said <a href="https://www.hopkinsmedicine.org/profiles/details/megan-mastalerz">Megan Hosey</a>, assistant professor at the Johns Hopkins Department of Physical Medicine and Rehabilitation. </p>
<p id="zQRDSp">“It has always been [and] is the case that patients who get sick experience high levels of symptoms like those described by long-Covid patients,” she said. “We have just done a terrible job of acknowledging [and] treating them.” </p>
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<h3 id="19pFXC">Doctors have noticed long-term illnesses after an infection since at least 1889</h3>
<p id="qnWgCa">For a while after<strong> </strong>the coronavirus began spreading in China in late 2019, many doctors viewed it as a “viral pneumonia” that mainly threatened the lives of elderly people. The virus seemed to cause only a short list of symptoms, including fever, dry cough, and difficulty breathing. According to a <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200306-sitrep-46-covid-19.pdf?sfvrsn=96b04adf_4">February 2020 World Health Organization</a> report, mild cases recovered within two weeks, while it took up to six weeks for those with severe or life-threatening illness to get better. </p>
<p id="bh5LwI">By March, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539940/">patients on social media started drawing attention</a> to a longer list of persistent symptoms, which sometimes appeared after mild cases in young, otherwise healthy people. In April, Fiona Lowenstein, a Covid-19 advocate and founder of the long-Covid support group <a href="https://twitter.com/itsbodypolitic">Body Politic</a>, <a href="https://www.nytimes.com/2020/04/13/opinion/coronavirus-recovery.html">penned one of the first widely circulated</a> long hauler accounts, sharing her experience of symptoms like gastrointestinal issues and loss of smell. The 27-year-old presciently warned that a “wave of chronically ill and slow-healing survivors is an inevitability we can and must prepare ourselves for.” </p>
<p id="6qqcgf">Today, doctors are more aware<strong> </strong>that Covid-19 can affect every <a href="https://www.vox.com/2020/10/28/21528116/covid-19-death-rates-hospitalizations-icu-beds">system</a> in the body. There’s still no official name for long Covid — which also goes by chronic Covid syndrome, <a href="https://www.idsociety.org/covid-19-real-time-learning-network/disease-manifestations--complications/post-covid-syndrome/">post-Covid-19 syndrome</a>, and post-acute Covid-19. There’s also no official medical definition. Researchers generally use time to make a diagnosis: patients who experience at least three or four weeks of symptoms that develop during or following a confirmed or suspected coronavirus infection. </p>
<p id="RPRA4Y">What is now coming into focus: the true spectrum of long-Covid symptoms. And it’s vast. A <a href="https://www.medrxiv.org/content/10.1101/2020.12.24.20248802v2.full.pdf+html">recent preprint (non-peer-reviewed) paper</a>, from a Covid-19 <a href="https://patientresearchcovid19.com/">patient-led research collaborative</a>, surveyed 3,762 patients from 56 countries who were sick for at least four weeks. They documented an array of 205 symptoms involving 10 organ systems, from tremors, tingling and skin burning, to sleep disturbances, nausea, chest tightness, and hearing loss. </p>
<div class="c-float-right c-float-hang"><aside id="A9lmf2"><q>“I can’t find a single thing that the SARS-CoV-2 virus can do, that other viruses cannot”</q></aside></div>
<p id="nN0HbJ">Most common were fatigue, cognitive dysfunction, and post-exertional malaise, defined as a “worsening or relapse of symptoms after physical or mental activity” during Covid-19 recovery. More than 90 percent of those in the study hadn’t been admitted to a hospital. Most (nearly 80 percent) were women.<strong> </strong>One in five reported severe symptoms persisting after six months.</p>
<p id="o5G6KC">The <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(21)00084-5/fulltext#.YG2sUyoWlfE.twitter">largest study</a> thus far on the neurological and mental health impact of Covid-19 found one-third of patients had developed problems including dementia, stroke, and mood and anxiety disorders up to six months after infection. </p>
<p id="UMVZkE">These effects, though unnerving, aren’t unprecedented. Chronic symptoms, especially fatigue, have lingered after the typical recovery periods for <a href="https://www.frontiersin.org/articles/10.3389/fmed.2020.606824/full">viruses as varied</a> as West Nile, Polio, Dengue, Zika, seasonal flu, and H1N1 as well as the new coronavirus’s cousins <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192220/">MERS</a> and <a href="https://www.hkmj.org/system/files/hkm0912sp8p21.pdf">SARS-1</a>. Run-of-the-mill <a href="https://www.cdc.gov/groupastrep/diseases-public/rheumatic-fever.html">strep throat</a> can develop into <a href="https://www.cdc.gov/groupastrep/diseases-public/rheumatic-fever.html">rheumatic fever</a>, which can cause fatigue, painful joints, and fluid buildup around the heart.<strong> </strong>While reporting this story, I realized I was once a long hauler. I lost a summer in college to <a href="https://www.mayoclinic.org/diseases-conditions/mononucleosis/symptoms-causes/syc-20350328">mononucleosis</a>, caused by the Epstein-Barr virus; for weeks, I had no appetite and could hardly muster the energy to get out of bed.</p>
<p id="9ICzAV">The phenomenon, sometimes called “post-viral syndrome,” has been documented for more than a century, as far back as the <a href="https://time.com/5915616/long-flu-1918-pandemic/">1918 Spanish flu</a>, when there were <a href="https://time.com/5915616/long-flu-1918-pandemic/">Spanish flu long-haulers</a> — scores of people who survived the deadly virus but had long-term symptoms, including depression, sleeplessness, “loss of muscular energy,” and “nervous complications.” </p>
<p id="FiyWD8">Even “Covid dementia” isn’t really new: According to a <a href="https://www.medscimonit.com/download/index/idArt/931447">recent historical review</a>, early reports of the “common symptom of altered cognition” surfaced during the Russian flu pandemics of 1889 and 1892. </p>
<p id="J72cde">“I can’t find a single thing that the SARS-CoV-2 virus can do, that other viruses cannot,” Proal said. “It’s well understood and it’s been understood for decades that every major pathogen capable of infecting people has a syndrome associated with it in which a certain number of patients who get that pathogen,” she continued, “will develop chronic symptoms that never go away.” </p>
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<cite>Underwood Archives/Getty Images</cite>
<figcaption>The Oakland Municipal Auditorium was used as a temporary hospital during the influenza pandemic of 1918 in Oakland, California.</figcaption>
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<p id="t5gOXf">The Ebola long-hauler, Craig Spencer, only began to contemplate this pattern after the initial pandemic emergency in his New York City hospital abated late last spring. No longer filled to capacity, a broader spectrum of patients — not just the deathly ill — started seeking care. </p>
<p id="2NI1Xh">The “tide reced[ed] and you’re there to observe the damage,” he told me recently. “I saw a lot of people saying they’d been to a bunch of different doctors. They know they had Covid. [The doctors told them] they didn’t know how to help them or that it was all in their head and that they probably needed to see a psychiatrist.”</p>
<p id="HydjuW">In September, Spencer <a href="https://www.washingtonpost.com/health/covid-slow-recovery-long-hauler-complications--/2020/09/18/73c2fd20-f45c-11ea-bc45-e5d48ab44b9f_story.html">wrote about</a> the parallels between his experience with long-haul Ebola and what he was hearing from these Covid-19 patients. “That’s when I started recognizing that this toll was going to be a lot bigger than anyone had recognized,” he said. </p>
<p id="L68qY9">The wave of patients is still growing. Of the more than 118 million coronavirus cases around the world, at least <a href="https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complications">10 percent</a> of those affected may have long-term symptoms. That means that in the US alone,<strong> </strong>there could already be 3 million long-haulers — <strong> </strong>nearly six times the official US Covid-19 death toll. With numbers this large, Spencer said, maybe those with other little-understood chronic conditions, who have been “cast aside or undermined, disbelieved by the medical community” for decades, will finally get the recognition they’ve been waiting for. </p>
<h3 id="1hMVXy">It’s not just viruses that can trigger long-haul illnesses</h3>
<p id="Fju3SP"><a href="https://www.cdc.gov/me-cfs/index.html">Myalgic encephalomyelitis/chronic fatigue syndrome</a> is one of those persistently under-recognized, <a href="https://www.researchgate.net/publication/342324057_Research_update_The_relation_between_MECFS_disease_burden_and_research_funding_in_the_USA">underfunded</a>, chronic conditions. ME/CFS, as it’s known, afflicts <a href="https://www.cdc.gov/me-cfs/about/index.html">up to 2.5 million Americans</a> every year, mostly women, with persistent symptoms ranging from fatigue and dizziness to sore throat and muscle pain. Recently, <a href="https://edition.cnn.com/2020/08/07/health/chronic-fatigue-syndrome-covid-19-survivors-wellness/index.html">ME/CFS patients</a> and <a href="https://www.nytimes.com/2021/01/21/magazine/covid-aftereffects.html">their doctors</a> have been pointing to the overlap with long Covid, conditions that US health official Anthony Fauci has called “very strikingly similar.”</p>
<div class="c-float-right c-float-hang"><aside id="ZSj6Kg"><q>“A proportion — usually around 30 percent — of survivors of any medical condition report high rates of fatigue, sleep disturbance, brain fog, pain, depression, and anxiety”</q></aside></div>
<p id="cGUiJ8">Diagnoses of ME/CFS are made on the basis of symptoms, and some long-Covid patients meet the <a href="https://www.frontiersin.org/articles/10.3389/fmed.2020.606824/full">diagnostic criteria for the syndrome</a>. Post-exertional malaise, for example, is considered “the cardinal symptom” of ME/CFS, said <a href="https://www.linkedin.com/in/jaime-seltzer-b23abb14">Jaime Seltzer</a>, director of scientific and medical outreach at the ME/CFS advocacy group <a href="https://www.meaction.net/about/">ME Action</a>. It’s also something nearly 75 percent of long-Covid patients reported in the recent long-hauler <a href="https://www.medrxiv.org/content/10.1101/2020.12.24.20248802v2.full.pdf+html">preprint</a>. In another <a href="https://www.frontiersin.org/articles/10.3389/fmed.2020.606824/full">recent paper</a>, researchers called on physicians to familiarize themselves with ME/CFS as the pandemic could “at least double” the number of cases. </p>
<p id="5f1w0w">There’s debate about what causes ME/CFS. The dominant view among researchers is that it’s a genetic disease triggered by an immunological stressor, like a viral infection. A <a href="https://www.bmj.com/content/333/7568/575">2006 study</a> followed 253 patients who’d been diagnosed with Epstein-Barr virus (the cause of mono), Coxiella burnetii (Q fever), or Ross River virus (epidemic polyarthritis) for a year and found 12 percent were diagnosed with ME/CFS within six months. </p>
<p id="RYNVPW">Post-viral syndrome and ME/CFS also parallel other contested and little-understood chronic disorders, including <a href="https://www.vox.com/2018/5/2/17303516/lyme-disease-symptoms-treatment-test">chronic Lyme disease</a>, which is thought to occur after infection with the tick-borne <a href="https://en.wikipedia.org/wiki/Borrelia"><em>Borrelia</em></a> bacterium. Johns Hopkins’s Megan Hosey opened the long-haul umbrella even wider, beyond viruses and bacteria, to illnesses like cancer, multiple sclerosis, Type 1 and 2 diabetes, and lupus. </p>
<p id="LtV59m">“A proportion — usually around 30 percent — of survivors of any medical condition report high rates of fatigue, sleep disturbance, brain fog, pain, depression, and anxiety that interfere with their ability to live fully,” she said. Diseases like cancer and Covid-19 may have different causes, but they share something in common when symptoms persist: If doctors can’t find a biological explanation for what’s troubling their patients, patients have trouble being believed. “I think a lot of patients [feel], ‘This physician doesn’t get it,’ or, ‘This physician thinks it’s all in my head.’”</p>
<p id="8Hcbjf">The idea that long-Covid symptoms have a psychological basis came up at a recent research meeting Proal attended. A colleague noted the fact that more women than men present with the condition. “[What] was really thrown out as one of the top scenarios: Women are very anxious,” Proal recalls. Researchers who’ve investigated psychiatric and psychosomatic triggers for chronic conditions like ME/CFS, for example, haven’t found a consistent link. “So maybe that really would not be the first direction you would go in with long Covid. ... These are biological diseases driven by biological causes and they really don’t seem to be diseases of the psyche.” </p>
<h3 id="7WU4gJ">Other chronic illnesses make long Covid less mysterious</h3>
<p id="hUdmUu">Seeing long Covid in this context makes the condition less mysterious. Other long-haul illnesses also shed light on what might be sickening coronavirus long-haulers. </p>
<p id="eAIT2l">We’ve learned from other viral infections that, in some cases, pathogens do not fully clear the body. “It’s out of the blood but gets into tissue in a low level — the gut, even maybe the brain in some people who are really sick — and you have a reservoir of the virus that remains,” Proal explained. “And that drives a lot of inflammation and symptoms.”</p>
<p id="TBKF8D">These reservoirs have been documented following infections with many other pathogens. During the 2014-2016 Ebola epidemic, studies emerged showing the <a href="https://www.nytimes.com/2015/05/08/health/weeks-after-his-recovery-ebola-lurked-in-a-doctors-eye.html">Ebola virus could linger in the eye</a> and <a href="https://www.newscientist.com/article/2104238-ebola-virus-has-lurked-in-a-mans-semen-for-more-than-500-days/">semen</a>. There were similar findings during the <a href="https://www.vox.com/2016/2/23/11101500/zika-sexual-transmission">2015-2016 Zika epidemic</a> when health officials warned about the possibility that Zika could be sexually transmitted. (Viral reservoirs are why the moniker “post-viral” can be problematic, Proal added.)</p>
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<cite>Mauro Pimentel/AFP via Getty Images</cite>
<figcaption>The Zika epidemic in Brazil that started in 2015 caused an exponential increase in the number of babies with microcephalia and other neurological defects, particularly in the northeast, the country’s poorest region.</figcaption>
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<p id="9X6ybp">A related explanation for what might be happening with long-Covid patients is what Yale’s Iwasaki calls “viral ghosts.” While the intact virus may have left the body, “there may be RNA and protein from the virus that’s lingering and continuing to stimulate the immune system,” Iwasaki said. “It’s almost like having a chronic viral infection — it keeps stimulating the immune system because the virus or viral components are still there, and the body doesn’t know how to shut it off.” </p>
<p id="4my6dS">Recent studies in <a href="https://www.nature.com/articles/s41586-021-03207-w"><em>Nature</em></a> and <a href="https://www.thelancet.com/article/S1474-4422(20)30308-2/fulltext"><em>The Lancet</em></a> documented coronavirus RNA and protein in a variety of body systems, including the gastrointestinal tract and brain. </p>
<p id="eC2f6e">In autopsies of people with chronic fatigue syndrome, researchers have also found <a href="https://me-pedia.org/wiki/Autopsy_in_Myalgic_Encephalomyelitis">enterovirus</a> RNA and proteins in patients’ brains, including, in one case, in the <a href="https://www.acpjournals.org/doi/10.7326/0003-4819-120-11-199406010-00020?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&">brain stem region</a>. The brain stem controls sleep cycles, autonomic function (the largely unconscious system driving bodily functions, such as digestion, blood pressure, and heart rate), and the flu-like symptoms we develop in response to inflammation and injury. “If that area of the brain signaling becomes dysregulated [by viruses],” Proal said, “[that] can result in sets of symptoms that meet a diagnostic criteria for [chronic fatigue syndrome], or even for long Covid.” </p>
<p id="uvSn5o">Other pathogens already lurking in the body prior to a coronavirus infection might also exacerbate symptoms. For example, viruses in the herpes family — such as <a href="https://www.cdc.gov/epstein-barr/about-ebv.html">Epstein-Barr</a> (the cause of mono) or <a href="https://en.wikipedia.org/wiki/Varicella_zoster_virus">varicella zoster</a> (the cause of chickenpox and shingles) — stay dormant in the body forever. Under normal conditions, the immune system can keep them in check. But when we’re under stress or fighting off another disease, the herpes viruses may activate again. In this case, part of what’s causing the long-Covid symptoms could be the body’s immune response to non-coronavirus pathogens that have reawakened. </p>
<p id="Y2Uwg8">Another key hypothesis: Long-Covid patients have developed an <a href="https://www.nature.com/articles/d41586-021-00149-1">autoimmune disorder</a>. The virus interrupts normal immune function, causing it to misfire, so that the molecules that normally target foreign invaders — like viruses — turn on the body itself. These “rogue antibodies,” known as autoantibodies, “attack either elements of the body’s immune defences or specific proteins in organs such as the heart,” according to <a href="https://www.nature.com/articles/d41586-021-00149-1"><em>Nature</em></a>. The assault is thought to be distinct from <a href="https://www.nejm.org/doi/full/10.1056/NEJMra2026131">cytokine storm</a>, an acute immune system disorder that appeared as a potential threat early on in the pandemic. </p>
<p id="tfOnOj">For coronavirus patients who had to be admitted to intensive care units, there’s yet another explanation: Long before the pandemic, the <a href="https://www.sccm.org/MyICUCare/THRIVE/Post-intensive-Care-Syndrome">intensive care community</a> coined a term for the persistent symptoms people frequently experience following stays in an ICU for any reason, from cancer to tuberculosis. These symptoms included muscle weakness, brain fog, sleep disturbances, and depression.</p>
<p id="Wr94RS">The term “post-intensive care syndrome” was<strong> </strong>“created to raise awareness and education, because so many of our ICU survivors were going to their primary care doctor saying they were fatigued,” said <a href="https://www.hopkinsmedicine.org/profiles/details/dale-needham">Dale Needham</a>, who has been treating Covid-19 patients in the ICU at Johns Hopkins. “They had trouble remembering, and they were weak. Their primary care doctor would do some lab tests and say, ‘Oh, there’s nothing wrong with you.’ The patient might walk away and feel like the doctor was saying, ‘It’s all in your head. You’re making it up.’”</p>
<h3 id="FVwqqT">The Covid-19-inspired medical revolution</h3>
<p id="30PoLB">Needham was getting at something I heard again and again from the many patients, researchers, and health professionals I spoke to for this story: If long Covid changes anything, it has to be this knee-jerk reaction in medicine to discount and give up on patients with symptoms that have no identifiable biological basis. The experience is so pervasive that researchers at the Mayo Clinic in Minnesota gave it a name: “<a href="https://minimallydisruptivemedicine.org/2019/05/09/undercared-for-chronic-suffering-experiences-with-medically-unexplained-and-contested-illnesses-and-symptoms/">undercared-for chronic suffering</a>.” </p>
<p id="WKmrIR">There are certainly many systemic explanations for under care — from a lack of access to health care or medical insurance to the <a href="https://www.reuters.com/article/us-doctor-checkup-duration-idUSKBN1DS2Z2">mere minutes</a> that now characterize the length of the average medical appointment. But it’s also true that something more basic is exacerbating the problem.<strong> </strong>Simply put, medicine hasn’t cracked how to deal with patients who have chronic syndromes, like ME/CFS or long Covid, that don’t have one-size-fits-all treatment regimens. </p>
<p id="ROfiBF">People “want disease to kill you, or they want you to return to miraculous good health,” said Seltzer. “When you stay sick, compassion can fade. And that is not just friends and family. That is your clinicians as well; they want somebody fixable.” </p>
<p id="DDASHu">Instead, long-haulers of any chronic condition can exist in a space between sickness and health for years, sometimes without a diagnosis. Their unexplainable symptoms can elicit skepticism in health professionals, Proal said, who are trained to consider patient feedback the “lowest form of evidence on [the evidence hierarchy], even under research on mice.” </p>
<p id="qPWJiO">With wartime levels of long-Covid patients now flooding health systems around the world, “it’s time for medicine to be rooted in just believing the patient,” Proal added. And not only believing patients, but also acknowledging and having compassion for the uncertainty they’re facing, Hosey said. Even without understanding the cause of someone’s suffering, “We can immediately start talking about treatment of symptoms and returning to life that’s full and meaningful because I think that that’s really what patients are asking for in the long run.” </p>
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<cite>Paul Bersebach/Orange County Register via Getty Images</cite>
<figcaption>Daniel Kim listens as occupational therapist Cathy Comeaux reads a poem during Kim’s release from St. Jude Medical Center in Fullerton, California. Kim spent five months in the hospital, including five weeks in a medically-induced coma, while battling Covid-19.</figcaption>
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<p id="lQymZs">This means doctors partnering with experts in other disciplines, such as rehabilitation psychologists or physical therapists, to tackle the unique problems a patient is experiencing. </p>
<p id="zGNVtX">It also means tailoring treatment. “It would be silly to assume that every patient that gets [long Covid] label has the exact same thing going on,” Proal said. For example, some long-Covid patients may have an ongoing infection while others, lung damage. The first group might benefit from “<a href="https://me-pedia.org/wiki/Pacing">pacing,”</a> a concept borrowed from the ME/CFS community that advises patients to listen to their bodies and avoid over-exerting themselves. The second group might benefit from physical therapy.</p>
<p id="F42UHz">For now, many long-haulers report <a href="https://www.nbcnews.com/news/us-news/these-women-s-coronavirus-symptoms-haven-t-gone-away-doctors-n1235091">being gaslit and disregarded</a> by medical professionals, especially if they don’t have a positive PCR test confirming the diagnosis. Of the dozens of medical appointments one Covid-19 long-hauler, Hannah Davis, had for her persistent symptoms — which include memory loss, muscle and joint pain, and headaches a year after her initial disease — one of her best experiences involved a doctor who simply said, “I don’t know.”</p>
<p id="2ZNwkl">“The doctor [told me], ‘We are seeing hundreds of people like you with neurological symptoms. Unfortunately, we don’t know how to treat this yet. We don’t even understand what’s going on yet. But just know you’re not alone,’” she recounted. “And that’s the kind of conversation that needs to be happening. Because we can wait, but we can’t have the doctor’s anxiety being projected onto us as patients.”</p>
https://www.vox.com/22298751/long-term-side-effects-covid-19-hauler-symptomsJulia Belluz2021-02-26T17:58:07-05:002021-02-26T17:58:07-05:00FDA advisers unanimously recommend Johnson & Johnson’s Covid-19 vaccine
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<img alt="A view of the Johnson &amp; Johnson offices in Irvine, California, on October 23, 2020." src="https://cdn.vox-cdn.com/thumbor/QRdnmucBRIxReln5EEmGVtvHWhE=/317x0:2861x1908/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/68739526/GettyImages_1229247259t.7.jpg" />
<figcaption>The Johnson & Johnson vaccine doesn’t require a booster shot, circumventing the two-dose problems posed by its competitors. The company plans to seek FDA approval in early February. | AaronP/Bauer-Griffin/GC Images/Getty Images</figcaption>
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<p>The FDA could make an emergency use authorization as soon as this weekend, paving the way for distribution.</p> <p id="5Gj0Qk">A panel of expert advisers to the Food and Drug Administration (FDA) voted unanimously on Friday afternoon to recommend the one-dose <a href="https://www.vox.com/coronavirus-covid19">Covid-19</a> vaccine developed by Johnson & Johnson for an emergency use authorization. The next step is for the FDA to accept the recommendation, which could happen as soon as this weekend, clearing the way for distribution.</p>
<p id="gXGumE">Earlier this week, the <a href="https://www.fda.gov/media/146217/download">FDA posted a briefing</a> going over the results of the phase 3 clinical trials of the Johnson & Johnson vaccine, which included 40,000 participants in several countries divided randomly into placebo and treatment groups. </p>
<p id="9w0K3c">The most important finding: The vaccine was 100 percent effective after 28 days at preventing deaths and hospitalizations from Covid-19 among the clinical trial participants who received the treatment. (Two vaccine recipients were hospitalized with Covid-19 two weeks after receiving the injection.) </p>
<p id="h9stE4">The vaccine was also 66.1 percent effective at preventing symptomatic Covid-19 illness after four weeks, with consistent results across all age groups. When looking at blocking severe and critical cases of Covid-19, the Johnson & Johnson vaccine was 85.4 percent effective.</p>
<p id="ATlqPb"><a href="https://johnsonandjohnson.gcs-web.com/static-files/28c17ae4-9a10-4bd6-a022-1c829054c1e9">Mathai Mammen</a>, global head of research and development for Janssen Pharmaceutical Companies, said during a press conference last month that the vaccine also had “plain vanilla safety results,” with the vast majority of recipients experiencing no problems. Most of the reported symptoms were mild, including fatigue, arm pain, and fever.</p>
<p id="QGwRdt">The efficacy levels against severe to critical Covid-19 changed depending on where the vaccine was tested. It was 85.9 percent in the United States after four weeks, while in <a href="https://www.vox.com/2021/1/21/22240475/covid-new-variant-south-africa-uk-brazil-vaccine-coronavirus">South Africa, where a coronavirus variant</a> with worrisome mutations that help it escape vaccines has been spreading widely, efficacy against severe disease was reduced to 81.7 percent. </p>
<p id="amrxy4">Health officials say that while the Johnson & Johnson efficacy results are not as high as those from Moderna and Pfizer/BioNTech, the two vaccines that have already received emergency use authorizations from the FDA, the new vaccine’s performance is still superb. </p>
<p id="DW2SgN">“If this had occurred in the absence of a prior announcement and implementation of a 94, 95 percent efficacy [vaccine], one would have said this is an absolutely spectacular result,” said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, during the press conference last month. The vaccine was developed by Janssen Pharmaceuticals, a division of Johnson & Johnson based in Belgium, together with Boston’s Beth Israel Deaconess Medical Center.</p>
<p id="8riTlR">But unlike the vaccines from Moderna and Pfizer/BioNTech,<strong> </strong>Johnson & Johnson’s doesn’t require a booster shot, circumventing the <a href="https://www.vox.com/coronavirus-covid19/22163315/covid-19-vaccines-doses-pfizer-moderna">two-dose problems</a> posed by its competitors. There’s no need to track people down for their second dose, which means more people could be vaccinated faster. The shots also don’t require deep-cold storage, which means they’re less costly and somewhat easier to distribute. </p>
<p id="w7MWYz">“It’s a complete game changer,” said Georgetown University health law professor Lawrence Gostin. “It completely changes the equation.” </p>
<p id="9aPn3E">The Johnson & Johnson vaccine is also different in another way. It uses an adenovirus vector to deliver instructions for making the spike protein of the coronavirus, which is also less expensive to manufacture than the mRNA platform used for the other vaccines. (It’s estimated to cost around <a href="https://www.reuters.com/article/uk-health-coronavirus-usa-johnsonandjohn-idUKKCN2511V7?edition-redirect=uk">$10 per vaccine dose</a> — roughly half the cost of the Pfizer/BioNTech vaccine.) </p>
<p id="ypS3k2">Johnson & Johnson has promised enough vaccines for <a href="https://www.wsj.com/articles/johnson-and-johnson-covid-19-vaccine-fda-review-11614118867?mod=e2tw">20 million Americans</a> by the end of March and <a href="https://www.cnbc.com/2021/01/21/jj-plans-to-have-100-million-vaccines-for-americans-by-spring-board-member-says.html?utm_term=Autofeed&utm_medium=Social&utm_content=Main&utm_source=Twitter#Echobox=1611281085">100 million Americans</a> by the end of June despite <a href="https://www.politico.com/news/2021/01/13/johnson-johnson-vaccine-production-458941">production challenges</a>. It would be a huge boost to the <a href="https://www.npr.org/sections/health-shots/2021/01/28/960901166/how-is-the-covid-19-vaccination-campaign-going-in-your-state">65 million Covid-19 vaccine doses</a> that have been administered in the US so far.</p>
<p id="odaxQs">So even with an overall efficacy level that’s lower than the two other vaccines on the US market, the Johnson & Johnson vaccine could become a major player. It’s the vaccine that “can increase equity,” said <a href="https://medicine.yale.edu/yigh/profile/saad_omer/">Saad Omer</a>, the director of the Yale Institute for Global Health, particularly “if it’s deployed strategically in nations that are hard to reach and where that would be a particular challenge under a two-dose schedule.” Johnson & Johnson expects to distribute a billion doses of its vaccine worldwide this year. </p>
<p id="U4RSHz">But as amazing as it is to see several effective Covid-19 vaccines developed in record time, it’s now clear that the technology alone won’t save the day. An orchestra of supply chains, manufacturing, logistics, staff, and public trust needs to harmonize in order to actually get billions of shots into arms around the world<strong> </strong>and finally draw the pandemic to a close. And we also have other hurdles to overcome: controlling the spread of variants that seem to be threatening the effectiveness of all the vaccines we have. </p>
<h3 id="qigHwB">What we learned about the safety and efficacy of the Johnson & Johnson Covid-19 vaccine</h3>
<p id="8kVugO">Johnson & Johnson launched <a href="https://www.jnj.com/johnson-johnson-initiates-pivotal-global-phase-3-clinical-trial-of-janssens-covid-19-vaccine-candidate">separate clinical trials</a> testing both a one-dose and a two-dose regimen to see how well these strategies provided long-term protection against Covid-19. The one-dose<strong> </strong>phase 3 trial <a href="https://www.jnj.com/johnson-johnson-announces-single-shot-janssen-covid-19-vaccine-candidate-met-primary-endpoints-in-interim-analysis-of-its-phase-3-ensemble-trial">arm yielded efficacy results first</a>. </p>
<p id="uxe3IK">But hints that this vaccine could be safe and effective have been trickling out for months. The company published some of its early phase 1 and phase 2 trial data in a preprint paper in September, and the final version of the paper in January, in the <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2034201"><em>New England Journal of Medicine</em></a>. The papers showed the vaccine was well tolerated among the participants, and seemingly very effective: With one dose, after 29 days, the vaccine ensured that 90 percent of participants had enough antibodies required to neutralize the virus. After 57 days, that number reached 100 percent.<strong> </strong></p>
<p id="FwPvyP">“When I looked at that, I thought, wow, this Johnson & Johnson product is very powerful after the first dose in terms of immunogenicity,” said <a href="https://medicine.ucsf.edu/people/monica-gandhi">Monica Gandhi</a>, a professor of global medicine at the University of California San Francisco. “The Pfizer and Moderna vaccines needed two doses to get that level of [virus] neutralization.” </p>
<p id="m2SWyf">Like Pfizer/BioNTech, Johnson & Johnson “didn’t rush to phase 3 [trials],” said Hilda Bastian, a scientist who has been tracking the global vaccine race. Instead, it tested multiple vaccine doses and candidates at the outset to figure out which might perform the best in humans, and then proceeded through clinical trials. </p>
<p id="mMIcru">The vaccine was also tested in nine countries — the <a href="https://absolutelymaybe.plos.org/2020/09/30/meet-the-women-leading-vanguard-covid-19-vaccine-trials-a-sign-of-progress-reminder-of-whats-at-risk/">largest single international phase 3</a> trial in the world, with more than 60,000 participants — meaning many ethnic groups were represented in the data, Bastian said. “As if all that’s not enough, it’s one of the ones that could be manufactured in South Africa and other places,” since Johnson & Johnson has manufacturing capacity around the world, even in countries hard-hit by the pandemic that have been waiting for vaccine supplies, she added.</p>
<p id="PWGN3q">The day this vaccine gets approval “is going to be a big day for the future of this pandemic [and] a ticket out of this disease for a larger part of the world,” said Nicholas Lusiani, a senior adviser at Oxfam America. </p>
<h3 id="bnEG1Q">How adenovirus vector vaccines work</h3>
<p id="IQfUn1">Part of the appeal of this vaccine lies in the technology behind it. <a href="https://www.cdc.gov/adenovirus/index.html">Adenoviruses</a> are a family of viruses that can cause a range of illnesses in humans, including the common cold. They’re very efficient at getting their DNA into a cell’s nucleus. Scientists reasoned that if they could snip out the right sections of an adenovirus’s genome and insert another piece of DNA code (in this case, for a fragment of the new coronavirus), they could have a powerful system to deliver instructions to cells.</p>
<p id="BetCdo">For decades, scientists have experimented with adenovirus vectors as a platform for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4507798/">gene therapy and to treat certain cancers</a>, using the virus to modify or replace genes in host cells. More recently, researchers have found success using adenoviruses as vaccines. Already, an adenovirus vector vaccine has been developed for the <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30515-6/fulltext">Ebola virus</a>. </p>
<p id="otHMyj">In addition to Johnson & Johnson and AstraZeneca/Oxford, CanSino Biologics of China is also developing an adenovirus vector Covid-19 vaccine; Russia’s <a href="https://sputnikvaccine.com/">Sputnik V</a> Covid-19 vaccine uses this platform, too. </p>
<p id="tGLE8o">To make one of these vaccines, the adenovirus is modified so that it can’t reproduce but can carry the instructions for making a component of a virus. In the case of Covid-19, most adenovirus vector vaccines code for the spike protein of SARS-CoV-2, the part the virus uses to begin an infection.</p>
<p id="larxQ5">Human cells then read those instructions delivered by the adenovirus and begin manufacturing the spike protein. The immune system recognizes the spike proteins as a threat and begins to build up its defenses. </p>
<p id="Y2fwGf">Since adenoviruses exist naturally, they tend to be more temperature-stable than the synthetic lipid nanoparticles that are used to deliver the mRNA in the Moderna and Pfizer/BioNTech vaccines.</p>
<p id="nRyUnm">“The nice thing about the adenovirus vector vaccines is that they’re a little more tolerant to a longer shelf life, to the conditions of storage,” said <a href="https://ghss.georgetown.edu/people/angela-rasmussen/">Angela Rasmussen</a>, a virologist at Georgetown University. Adenovirus vector vaccines can be stored at refrigerator temperatures, while mRNA vaccines need freezers, with Pfizer/BioNTech’s vaccine requiring temperatures of minus 80 degrees Celsius. </p>
<p id="pDXKOK">This helps lower the cost and complexity of manufacturing, distribution, and administration of adenovirus vector vaccines compared to other platforms. And simply having another vaccine on the market,<strong> </strong>made by a major pharmaceutical company with its own manufacturing infrastructure, is a big step forward. “The more vaccine doses we can have, the better,” Rasmussen said. </p>
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<cite>Jason Redmond/AFP/Getty Images</cite>
<figcaption>An Army National Guard specialist gives directions at one of four mass vaccination sites opened by the Washington state Department of Health on January 26. </figcaption>
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<h3 id="MmC52A">What comes next</h3>
<p id="b3xwwQ">The next challenge for Johnson & Johnson, after getting a green light from the FDA, is actually delivering doses to millions of arms.</p>
<p id="t6g1ey">But with three vaccines eventually on the market, should people hold out for any one vaccine in particular?</p>
<p id="JY7JF4">“Right now when people ask me, which, you know, which vaccine should I get? It’s pretty easy to answer that question because it’s whichever one you get offered,” said <a href="https://physiciandirectory.brighamandwomens.org/details/1354/paul-sax-infectious_disease-internal_medicine-medicine-boston">Paul Sax</a>, a professor of medicine at Harvard Medical School. Vaccine supplies are limited, the transmission of the virus is high, and hospitals are close to capacity, so few people can be picky about what they get. </p>
<p id="wIKdU7">On the other hand, once vaccine supplies stabilize, having multiple vaccines with different characteristics could allow doctors and public health officials to optimize how the shots are distributed. “If the efficacy [of a given vaccine] is lower but still pretty good, there may be a scenario that one vaccine is recommended for low-risk populations and another one is for a high-risk population,” Omer said. </p>
<p id="f95Gyc">Though the Johnson & Johnson vaccine does have some key advantages over its competitors, it could face some of the same distribution snags that have hit other vaccines, like miscommunication between the government and hospitals, and production hurdles.</p>
<aside id="oPwWhl"><div data-anthem-component="readmore" data-anthem-component-data='{"stories":[{"title":"4 reasons we’re seeing these worrying coronavirus variants now","url":"https://www.vox.com/science-and-health/22247525/covid-19-variants-uk-south-africa-brazil-b117-why-now"}]}'></div></aside><p id="YLSHFW">Researchers say that all the manufacturers also need to start working to get vaccines to the rest of the world. The new variants that have emerged in the UK, Brazil, and South Africa and have been detected in other parts of the world are reminders that the virus continues to evolve, and that a partially vaccinated population could exert more selection pressures that accelerate <a href="https://www.vox.com/science-and-health/22247525/covid-19-variants-uk-south-africa-brazil-b117-why-now">these mutations</a>. So vaccination has to happen fast, and globally — and Johnson & Johnson’s vaccine may be a critical tool to do this.</p>
<p id="pMN9D5">“Long term, we need to be thinking about getting vaccines out equitably to the entire world, and having vaccines that are easier to distribute in terms of the cold chain requirements is going to be huge in that regard,” Rasmussen said.</p>
<p id="rC1NxT">But even as these vaccines roll out, there’s still more to learn: how long protection from vaccines last, whether there are any rare complications to consider, whether they prevent transmission as well as disease, and how well these vaccines work against the new variants. There are already some troubling signs of how these variants might eventually be able to <a href="https://www.vox.com/science-and-health/22247525/covid-19-variants-uk-south-africa-brazil-b117-why-now">evade vaccines</a>. Continuing clinical trials will be critical, Sax said.</p>
<p id="t4aitL">“You know, we’ve got millions of people who’ve received these vaccines already, which is exciting,” he added. “We’re on our way.”</p>
https://www.vox.com/2021/1/29/22238591/johnson-and-johnson-jnj-vaccine-effective-safety-one-dose-fdaJulia BelluzUmair Irfan