I’m a pediatrician who cares for transgender kids — here's the truth about their treatment

by Mandy Coles, Boston University

When Charlie, a 10-year-old boy, came in for his first visit, he didn't look at me or my colleague. Angry and crying, he insisted to us that he was cisgender – that he was a boy and had been born male.

A few months before Charlie came into our office, he handed a note to his mother with four simple words, “I am a boy." Up until that point Charlie had been living in the world as female – the sex he was assigned at birth – though that was not how he felt inside. Charlie was suffering from severe gender dysphoria – a sense of distress someone feels when their gender identity doesn't match up with their assigned gender.

I am a pediatrician and adolescent medicine specialist who has been caring for transgender youth for over a decade using what is called a gender-affirmative approach. In this type of care, medical and mental health providers work side by side to provide education to the patient and family, guide people to social support, address mental health issues and discuss medical interventions.

Getting on the same page

The first thing our team does is make sure our patients and families understand what gender care is. We always begin initial visits in the same way. “Our goal is to support you and your family on this journey, whatever that may look like for you. My name is Mandy and I am one of the doctors at CATCH – the Child and Adolescent Trans/Gender Center for Health program. I use she/her pronouns." Sharing pronouns helps transgender people feel seen and validated.

We then ask patients and families to share their gender journey so we can better understand where they are coming from and where they hope to go. Charlie's story is one we often hear. A kid may not think much about gender until puberty but begins to experience worsening gender dysphoria when their body starts changing in what feels like the wrong way.

Social transitions with family help

Transgender and gender-diverse youth (those whose gender identity doesn't conform to the norms expected of their assigned sex) may face transphobia and discrimination, and experience alarmingly higher rates of depression, anxiety, self-harm and suicide than their cisgender peers. One option can be to socially transition to their identified gender, both at home and in the outside world.

An important first step is to help parents become allies and advocates. Connecting parents with one-to-one as well as group support can help facilitate education and acceptance, while helping families process their own experience. Charlie's parents had been attending a local parent group that helped them better understand gender dysphoria.

In addition to being accepted at home, young people often want to live in the world in their identified gender. This could include changing their name and pronouns and coming out to friends and family. It can also include using public spaces like schools and bathrooms, participating on single-gender sports teams and dressing or doing other things like binding breasts or tucking back male genitalia to present more in line with their gender identity. Though more research needs to be done, studies show that youth who socially transition have rates of depression similar to cisgender peers.

Many young people find that making a social transition can be an important step in affirming identity. For those that still struggle with depression, anxiety and managing societal transphobia, seeing a therapist who has knowledge of and experience with gender-diverse identities and gender dysphoria can also be helpful.

However, most young people also need to make physical changes to their bodies as well to feel truly comfortable.

Gender-affirming medical interventions

When I first met Charlie, he had already socially transitioned but was still experiencing dysphoria. Charlie, like many people, wanted his physical body to match his gender identity, and this can be achieved only through medical interventions – namely, puberty blockers, hormonal medications or surgery.

For patients like Charlie who have started experiencing early female or male puberty, hormone blockers are typically the first option. These medications work like a pause button on the physical changes caused by puberty. They are well studied, safe and completely reversible. If a person stops taking hormone blockers, their body will resume going through puberty as it would have. Blockers give people time to further explore gender and to develop social supports. Studies demonstrate that hormone blockers reduce depression, anxiety and risk of suicide among transgender youth.

Once a person has started or completed puberty, taking prescribed hormones can help people match their bodies with their gender identities. One of my patients, Zoe, is an 18-year-old transgender woman who has already completed male puberty. She is taking estrogen and a medication to block the effects of testosterone. Together, these will help Zoe's body develop breasts, reduce hair growth and have an overall more female shape.

Leo, another one of my patients, is a 16-year-old transgender man who is using testosterone. Testosterone will deepen Leo's voice, help him grow facial hair and lead to a more male body shape. In addition to testosterone, transgender men can use an additional short-term medication to stop menstruation. For nonbinary people like my 15-year-old patient Ty, who is not exclusively masculine or feminine, my colleagues and I personalize their treatments to meet their specific need.

The health risks from taking hormones are incredibly small – not significantly different, in fact, than the risks a cisgender person faces from the hormones in their body. Some prescribed hormone effects are partially reversible, but others are more permanent, like voice deepening and growth of facial hair or breasts. Hormones can also impact fertility, so I always make sure that my patients and their families understand the process thoroughly.

The most permanent medical options available are gender-affirming surgeries. These operations can include changes to genitals, chest or breasts and facial structure. Surgeries are not easily reversible, so my colleagues and I always make sure that patients fully understand this decision. Some people think gender-affirming surgeries go too far and that minors are too young to make such a big decision. But based on available research and my own experience, patients who get these surgeries experience improvements in their quality of life through a reduction in dysphoria. I have been told by patients that gender-affirming surgery “literally saved my life. I was free [from dysphoria]."

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Ongoing gender care

In March 2021, nearly five years after our first visit, Charlie walked into my exam room. When we first met, he was struggling with his gender, anxiety and depression. This time, he immediately started talking about playing hockey, hanging out with friends and making the honor roll. He has been on hormone blockers for five years and testosterone for almost a year. With the help of a supportive family and a gender-competent therapist, Charlie is now thriving.

Being transgender is not something that goes away. It is something my patients live with for their entire lives. Our multidisciplinary care team continues to see patients like Charlie on a regular basis, often following them into young adulthood.

While more research is always needed, a gender-affirmative approach and evidence-based medicine allows young transgender people to live in the world as their authentic selves. This improves quality of life and saves lives, as one of our transgender patients said about his experience receiving gender-affirming care. “I honestly don't think I would be here had I not been allowed to transition at that point. I'm not always 100%. But I have hope. I am happy to see tomorrow and I know I will achieve my dreams."The Conversation

Mandy Coles, Clinical Associate Professor of Pediatrics, Boston University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Missouri's biggest newspaper tears into GOP for latest 'irresponsible and heartless' stunt

Props to legislature Republicans, who have found a way to make their dismissal of democracy and refusal to fund the voter-approved Medicaid expansion even worse!

The party's fringe-right, emboldened by the unconstitutional anti-expansion gambit, is now trying to ban regular Medicaid recipients from using the program to purchase contraception. That, however, is a violation of federal law, and while they might be able to get away with disobeying their own voters, Republicans won't be able to avoid the consequences from Washington. If they pass a budget with the anti-contraception amendment intact, the state Medicaid program will likely be stripped of all federal funding, which, even without the major expansion bonus, covers about 2/3rds of the annual bill.

This does not please other, more budget-conscious and maybe slightly more humane Republicans, even if Missouri's program has been unfathomably stingy with benefits — it cuts off families that make above 18% of the federal poverty rate (just $5800 for a family of four!) while dismissing all single, able-bodied adults. As such, the contraception amendment was left out of a budget bill when it hit the floor of the state Senate on Monday, which caused such a furor amongst the vampire fundamentalists that it was pulled soon thereafter.

The whole affair earned the GOP a stinging rebuke from the St. Louis Post-Dispatch, the biggest paper in the state. Here's a juicy tidbit:

It's hard to fathom a more irresponsible and heartless stunt by elected representatives [than not funding expansion], but state Sen. Paul Wieland, R-Imperial, and a majority of his Republican colleagues have managed it. By prohibiting use of Medicaid funds to provide recipients with contraception, Wieland's amendment attempts to overrule federal law with his own extremist views on the topic.

OK, one more:

The episode should stand as one more reason Missouri voters might want to reconsider continually giving power to a party that has repeatedly shown nothing but contempt for the will of the voters, the concept of competent governance and the very lives of their own constituents.

State Senate leaders claim they'll eventually pass it without the puritanical contraception amendment and fund Medicaid expansion, too. What they'll have to compromise on to do so almost too scary to contemplate — they've really dug in on this one with some explosive rhetoric in order to justify denying more than 230,000 working people health care.

"Rural Missouri said no," said Rep. Sara Walsh, a rural Republican, said when the House voted the funding for Medicaid expansion down a few weeks ago, ignoring the more than one-third of rural voters who did vote yes. "I don't believe it is the will of the people to bankrupt our state."

Other GOP representatives have made similar arguments, all of which are enormously dishonest. Gov. Mike Parson's budget anticipates a $1.1 billion surplus and $2.8 billion from the American Rescue Plan. The stimulus also offers Missouri a $1.15 billion windfall for expanding Medicaid, as the federal government will cover 90% of expenses for the first few years.

That it would actually make the state money is irrelevant, of course, when ideology dominates all decisions. Republicans are comfortable defying the will of voters, by the way, because they were able to sneak through a gutting of another previous ballot initiative, which would have taken way the GOP's ability to gerrymander legislative districts.

"Because of term limits and because of the changes within the Republican Party, the fights that we end up having end up not being over policy or even politics," says Shawn D'Abreu, the policy director at the nonprofit advocacy group Missouri Health Care For All. "It's more about this sectarian identity that one party is really fully embracing that says that they have the divine right of kings to rule and governance doesn't matter and any election that they lose doesn't matter."

There's no public outcry against the expansion, either, even though other lawmakers suggest people were "tricked" into approving something that even redder states such as South Dakota and Utah have approved in recent years. D'Abreu suggests that it's likely that even more than 53% of Missourians support the expansion, which was shunted on to a low-turnout primary election day after Republicans failed in a lawsuit to remove it from the ballot altogether. One recent poll has support now at 65%.

And with good reason: Missouri has had some of the stingiest Medicaid qualifications for years now, as I mentioned above. Under the expansion, everyone making up 138% of the federal poverty line would be covered.

D'Abreu remains cautiously optimistic about the budget in the Senate, where he believes there are more Republicans who are more aligned with honoring election results even if they're not philosophically supportive of Medicaid expansion itself. If the Senate winds up also ignoring Medicaid in its own budget, there are a few other options that activists can explore.

"The reality that Medicaid expansion is in the state constitution, and so we have not only the high moral ground, but we have important advantages, both legally and ethically," he says.

Should a final budget pass without expansion, lawsuits would follow almost immediately. There are also supplemental budgets that could be considered later on. The real issue isn't whether those 230,000 Missourians will receive their health care starting on July 1st — the constitution now requires it — but how exactly it'll be paid for.

If the legislature doesn't fund the expansion this time around, the federal government won't kick in that $1.15 billion, which means the state's coffers will be drained much more quickly, giving Republicans cover to cut the program's benefits in the future. It would represent a dastardly subversion of democracy and callous disregard for their poorest constituents, neither of which would be all that surprising at this point.

By the way, Republican State Rep. Rick Boeber is resigning after being accused by his adult children of physical and sexual abuse. His resignation statement, of course, makes no mention of these allegations, which have been under investigation for months. Instead, Boeber says "it has become necessary for me and my soon-to-be wife to relocate out-of-state to be closer to our extended families." These are very upstanding people.

Kansas and Missouri offered $1.6 billion to expand Medicaid — but the GOP does not want the money

Officials at the Health Partnership Clinics (HPC) in Olathe and Paola, Kan. saw their patient load drop by a third last year but the number of patients without insurance spiked by more than 10% and continues to rise.

Similar clinics offering health services to low-income patients in Kansas and Missouri have also noticed similar trends which signal a growing need for Medicaid expansion. In a roundtable discussion on Wednesday, April 7, Health Partnership Clinic CEO Amy Falk expressed concern about the need for Medicaid expansion.

"Without Medicaid expansion, real people, hardworking people, are being hurt," Falk said.

According to, the much-needed expansion would "provide health coverage to hundreds of thousands of people across both states who make too much for Medicaid but not enough for subsidies under the Affordable Care Act."

As part of the Biden administration's $1.9 trillion spending package, states are scheduled to receive hundreds of millions of dollars in federal aid to begin expanding Medicaid and increase the size of state programs. Republican-controlled legislatures in both Kansas and Missouri are said to be "largely ignoring" the funding.

In a statement, Kansas House Majority Leader Dan Hawkins (R-Wichita, Kan.), argued "it's like when a drug dealer offers the first hit of a drug for free knowing that you'll be addicted and coming back for more."

In Missouri's House Budget Committee meeting last month, Rep. Doug Richey, (R-Excelsior Springs, Mo.) noted his concerns about spending.

"I think it is foolish to say that because we have a temporary revenue available because of a very unique situation … that now we can act as though we have money that we can spend," Richey said. "That is not a way to plan and to address long-term issues."

However, Democratic leaders and lawmakers are pushing back against the assertions. On Wednesday, Kansas Gov. Laura Kelly (D) and U.S. Rep. Sharice Davids (D-Kan.) spoke during a visit to HPC as they explained why the expansion package should be put to good use.

"The federal government is making it even dumber than before to not expand," Kelly said.

"We are sending money out to D.C. that absolutely should be coming back here to help the 165,000 people in our state, our neighbors, our loved ones, to get the access to affordable quality health care that they need," Davids said. "And the American Rescue Plan has done just that. There's a way that at the federal level we can incentivize states like Kansas to expand Medicaid."

At HPC, officials have revealed Medicaid expansion would provide a significant financial increase.

New data from 2020 shows just how catastrophic COVID-19 is

COVID-19 was the third leading cause of death in the United States in 2020, a year defined in many ways by the deadly pandemic,

This is the conclusion reached by the Centers for Disease Control and Prevention (CDC) in a report released on Wednesday. (The statistics are provisional, meaning that they are only based on preliminary information provided to the agency from state governments and could later need to be updated.) The CDC estimated that roughly 375,000 people died in the United States within the year 2020 as a result of COVID-19. The only illnesses to cause more fatalities were heart disease, which led to roughly 690,000 deaths, and cancer, which resulted in roughly 598,000 deaths. In the process of rising to the top 10 causes of death, COVID-19 bumped suicide off of the list, which was the 11th most common cause of death in 2020.

The CDC also found that the COVID-19 death rate was highest among Hispanics, while overall death rates were highest among non-Hispanic African Americans and non-Hispanic American Indian or Alaska Native populations. These demographic trends are important, the report argues, because they can provide the agency with useful guidelines about how to address the pandemic going forward.

"Provisional death estimates provide an early indication of shifts in mortality trends," the CDC explained. "Timely and actionable data can guide public health policies and interventions for populations experiencing higher numbers of deaths that are directly or indirectly associated with the COVID-19 pandemic."

In announcing the report, CDC Director Dr. Rochelle Walensky told journalists that "the data should serve again as a catalyst for each of us to continue to do our part to drive down cases and reduce the spread of COVID-19 and get people vaccinated as quickly as possible."

She added that, "Sadly, based on the current state of the pandemic, these impacts have remained in 2021 where we continue to see that communities of color account for an outsize portions of these deaths."

Walensky, and President Joe Biden's administration more generally, have repeatedly expressed concern that Republican-led states are easing COVID-19 restrictions too soon and will prolong the pandemic by doing so. Their fears appear to have been backed up by a report earlier this week that COVID-19 infection rates rose by 16% last week compared to the previous week.

"I am really worried about reports that more states are rolling back the exact public health measures we have recommended to protect people from COVID-19," Walensky told reporters at the time.

Dr. Deborah Birx, who led Trump's coronavirus task force, publicly implied that the coronavirus death toll might have been lower if not for President Trump's public health policies. Birx told CNN on Sunday that she believes the former president's unwillingness to follow consensus public health recommendations could have cost up to 400,000 lives.

Here's the truth about 'vaccine passports' — and the 'dangerous game' the right wing is playing

Marjorie Taylor Greene is characterizing vaccine passports as "Joe Biden's mark of the beast," so they must have some value. But we have to come up with a different name for them if we're going to get the conspiracy nuts…er…Republicans on board.

And that includes right-wing media. The headline in The Washington Post sums up today's health crisis: "The Dangerous Game [Fox News'] Tucker Carlson is Playing on Vaccines."

If our country is going to "open up" again in a way that preserves the lives and liberty of millions of Americans who've stayed virus-free so far, we're going to have to confront the GOP death cult, head-on. "Freedom" shouldn't mean the right to force other people to die all alone in a hospital ICU hooked up to breathing tubes.

Airlines, retail stores, restaurants and bars, workplaces, office buildings, colleges, stadiums, theaters, you-name-it — all will have to start exercising their Supreme Court-certified "right" to the "freedom" to prevent un-vaccinated people from entering their premises.

That sweet new Ad Council "It's Up To You" campaign won't be enough. Too many Republicans have taken in Donald Trump's lies and Qanon's bizarre conspiracy theories to be influenced by sweet pictures and nice words.

Fully 59% of registered Texas Republicans say they have "doubts," and about half of all Republicans in Congress — where the vaccine is, daily, freely and easily available on demand — have chosen not to get vaccinated.

America's venues have to kick some ass to save lives and rebuild our economy. It's going to take both the carrot and the stick.

I got my first vaccine passport in 1979 when I traveled to Kenya, Uganda and had an onward ticket to Somalia on behalf of the Salem international relief organization.

To get on a plane to those countries, and then to get through their own passport control, I had to prove that I was immunized against cholera, yellow fever and typhoid, as I recall, and there might of been a few others; I remember the shots hurt like hell and made me sick as a dog for a day or two.

But that yellow card, with the proof of vaccination stamps in it, periodically updated, sat inside my passport for the next 20 years and not only got me into multiple Third World countries on three continents, but also got me through US border stations and back into the United States from them.

The idea of vaccine passports is nothing new.

Although my kids didn't need them to get into school 40 years ago (the schools just took your word for it), my grandchildren do today. There's pretty much not a school or summer camp in America that'll let a kid in without proof of vaccination against, at least, measles and a few other childhood diseases.

Right now the Biden administration is reportedly working with 17 different organizations and private companies to come up with some sort of vaccine passport that'll work for America, which is apparently why Newsmax's White House Correspondent calls the idea "totalitarian communism."

Want to "own the cons"? Put photos on the passports and require states to allow them as voter ID. But, seriously…

IATA, the International Air Transport Association, which licensed the travel agency Louise and I owned in the 1980s and oversees international travel, is working on one, as is the office of World Tourism with the United Nations. IBM is developing a digital vaccine passport, and Clear, the company that speeds you through airport security lines, has already announced that they, too, will soon have one.

Israel rolled them out last month, and Denmark has announced they'll soon be doing the same.

The way to sell these freedom passports to right-wingers is pretty straightforward: tell them it's the free market, and that it has to do with religious liberty. They love those words even when they don't know what they mean.

These are the same people, of course, who want a business to refuse an LGBTQ person the freedom to patronize that company based on who they are or love. If conservatives believe an American business must legally be able make a decision like that, why shouldn't companies have the freedom to refuse service to someone who may be spreading a deadly disease?

Doesn't "freedom" include the freedom to stay alive in the midst of the worst pandemic in a century?

Freedom is a much misused word. How is it that anybody can say with a straight face that person "A" should have the "freedom" to refuse a vaccine or wear a mask and spread a deadly disease in the direction of person "B," but that person "B" shouldn't have the freedom to remain free of illness?

It's a good argument for calling them "Freedom Passports."

For that matter, vaccine passports are the ultimate statement of belief in the sanctity of human life.

It's truly bizarre that legislators in Arkansas and Texas think a woman who wants to get an abortion should go to prison or even get the death penalty, but if a red-state Republican wants to breathe a deadly disease in your face because they've joined an anti-mask, anti-vaccine cult, that's just fine.

Maybe we should call them "Right To Life Passports."

Crazed Republican conspiracy-mongers aside, the main international objection to vaccine passports comes from groups and organizations concerned about increasing the gap around the world between the haves and the have-nots. One billion people in the world don't even have proof of identity, much less a passport or birth certificate, and this would leave them even farther out of the loop.

On the other hand, those are not generally the folks trying to get into the Super Bowl, your local supermarket or wanting to sit next to you on a flight from Omaha to Cincinnati.

Back in the 1980s, restaurants around the country experimented with being all non-smoking, or having well-spaced smoking sections with separate ventilation. Restaurants today could do something similar.

The taco place down the street might only let you in with a vaccine passport, a modern-day variation on the "no shoes, no shirt, no service" slogan. Farther down the block, the burger joint may opt to ignore the passports and run at 1/3 capacity or even throw caution to the wind and pack the place in.

Nobody, at least so far, is arguing passports should be required by the gummint the way those communist driver's licenses are issued and required to speed down the highway. Although I disagree with President Biden on this issue, it looks like it's going to be entirely up to the "free market."

The NFL has already weighed in, promoting vaccination among their fans so people can show up knowing that Covid isn't floating around inside the stadium.

Meanwhile, Florida's Republican Governor Ron DeSantis, arguably responsible for thousands of unnecessary deaths (that he appears to be hiding), is swearing that he'll never allow a private business in his state to require a vaccine passport for service.

He's fine with Florida businesses refusing to do business with LGBTQ folks, but Republican cult members who refuse to get vaccinated because they're convinced Bill Gates is gonna chip them so they can be tracked? No way! (Don't tell them about that GPS thing in their cell phones, please; they may not be able to handle it.)

As Republican politicians, judges and lawyers constantly repeat, private business should be able to refuse service to people on their "deeply held beliefs." This one's gone all the way up to the Supreme Court, and repeatedly gotten the Republican seal of approval.

And, even for them, Freedom Passports could encompass it all: Freedom! America! The Free Market! Saving innocent lives!

What red-blooded, Nazi-arm-band-wearing, Confederate-flag-waving, Capitol-invading, gun-toting American patriot could possibly object?

Thom Hartmann is a talk-show host and the author of The Hidden History of American Oligarchy and more than 30 other books in print. He is a writing fellow at the Independent Media Institute and his writings are archived at

This article was produced by Economy for All, a project of the Independent Media Institute.

'Her name should live in infamy': Conservative writer slams Dr. Birx for whitewashing her Trump support

During a recent interview with CNN's Dr. Sanjay Gupta, Dr. Deborah Birx discussed some of the difficulties of being on Donald Trump's White House coronavirus task force in 2020 — when she avoided being openly critical of the then-president despite her frustration. Never Trump conservative Jonathan V. Last discusses that interview this week in his column for The Bulwark, arguing that she didn't do the United States any favor by keeping quiet when she wanted to speak out.

Birx, during the CNN interview, recalled a "very uncomfortable conversation" with Trump — who often downplayed the pandemic's severity during his final year in office. And she told Gupta that the COVID-19 death count in the U.S. "could have been mitigated or decreased substantially" if Trump's administration had taken different actions.

Birx's defenders have argued that by not being openly critical of Trump in 2020, she increased her chances of remaining on the task force — as speaking out more forcefully would have gotten her fired. And, the argument goes, Birx's expertise was more useful on the inside than it would have been on the outside. But Last believes that Birx did more harm than good by keeping quiet.

Dr. Birx drops bombshell about US Covid-19 deaths

"I understand the idea that, in an imperfect world, sometimes you have to compromise yourself," Last writes. "Sometimes, you find that you can do more good working within the system. That's the impulse that motivated Jim Mattis and H.R. McMaster and a bunch of other people who took high-level jobs in the Trump administration."

The conservative columnist adds, "I can understand the argument that, by standing his ground and daring Trump to fire him, (Dr. Anthony) Fauci was taking a wise course of action. I get that. But whatever Birx was doing, she was also aiding and abetting Trump."

Last includes some video of Birx from 2020 — and in those clips, Last writes, it's obvious that Birx's efforts to remain in Trump's good graces only had the effect of encouraging his failed COVID-19 response and covering up his blunders.

"Deborah Birx is not a political actor," Last stresses. "She is not a know-nothing TV talking head. She is a scientist and a professional who knew better — who took an oath. Remember Deborah Birx and what she did. Her name should live in infamy."

'These numbers are incredibly encouraging': Vaccines show major success in protecting nursing homes

New Covid-19 cases have plummeted by 96% in nursing homes and other long-term care facilities since late December, a report published Tuesday by the industry group American Health Care Association/National Center for Assisted Living revealed.

AHCA/NCAL reports (pdf) a decline in new U.S. weekly nursing home cases from 33,540 on December 20 to 1,349 on March 7, according to data from the Centers for Medicare and Medicaid Services. Widespread coronavirus vaccinations began in early January, when new nursing home cases dropped precipitously.

The inudstry groups also said there has been a 91% decline in coronavirus-related deaths in nursing homes, dropping from over 6,000 in December to 547 this month.

"We are not out of the woods yet, but these numbers are incredibly encouraging and a major morale booster for frontline caregivers who have been working tirelessly for more than a year to protect our residents," said Mark Parkinson, president and CEO of AHCA/NCAL, in a statement.

"This trend shows that when long-term care is prioritized, as with the national vaccine rollout, we can protect our vulnerable elderly population," Parkinson added. "Now we need Congress to prioritize our nursing homes for the long term by considering the initiatives in the Care For Our Seniors Act to improve the quality of care for our residents."

The Care For Our Seniors Act—written by AHCA and LeadingAge, which represents thousands of nonprofit aging services providers—would enhance critical care in nursing homes, provide increased support to frontline caregivers, improve oversight, and modernize resident dignity and safety, its proponents say.

U.S. nursing homes have been hit particularly hard by the coronavirus pandemic. According to the AARP's nursing home dashboard, more than 174,000 residents and staff at nursing homes and other long-term care facilities have died of Covid-19—nearly a third of all U.S. deaths from the virus, according to figures from Johns Hopkins University.

On Monday, Dr. Rochelle Walensky, head of the U.S. Centers for Disease Control and Prevention, said she felt a sense of "impending doom" over rising coronavirus infections following state leaders' premature moves to relax or completely lift pandemic-related restrictions.

Rand Paul gets schooled by scientists — including one he cited — after lashing out at Anthony Fauci

“Sorry Dr Fauci and other fearmongers, new study shows vaccines and naturally acquired immunity DO effectively neutralize COVID variants. Good news for everyone but bureaucrats and petty tyrants!” — Sen. Rand Paul in a tweet, March 21, 2021 That Sen. Rand Paul of Kentucky often disagrees with infectious-disease expert Dr. Anthony Fauci is well known. This story was produced in partnership with PolitiFact. It can be republished for free. Recently, the pair clashed at a Senate hearing when Paul, a Republican, argued against mask recommendations for people who have had covid-19 or have been vacci...

This historian warns against making the same mistake in a pandemic that we made 100 years ago

by J. Alexander Navarro, University of Michigan

Picture the United States struggling to deal with a deadly pandemic.

State and local officials enact a slate of social-distancing measures, gathering bans, closure orders and mask mandates in an effort to stem the tide of cases and deaths.

The public responds with widespread compliance mixed with more than a hint of grumbling, pushback and even outright defiance. As the days turn into weeks turn into months, the strictures become harder to tolerate.

Theater and dance hall owners complain about their financial losses.

Clergy bemoan church closures while offices, factories and in some cases even saloons are allowed to remain open.

Officials argue whether children are safer in classrooms or at home.

Many citizens refuse to don face masks while in public, some complaining that they're uncomfortable and others arguing that the government has no right to infringe on their civil liberties.

As familiar as it all may sound in 2021, these are real descriptions of the U.S. during the deadly 1918 influenza pandemic. In my research as a historian of medicine, I've seen again and again the many ways our current pandemic has mirrored the one experienced by our forebears a century ago.

As the COVID-19 pandemic enters its second year, many people want to know when life will go back to how it was before the coronavirus. History, of course, isn't an exact template for what the future holds. But the way Americans emerged from the earlier pandemic could suggest what post-pandemic life will be like this time around.

Sick and tired, ready for pandemic's end

Like COVID-19, the 1918 influenza pandemic hit hard and fast, going from a handful of reported cases in a few cities to a nationwide outbreak within a few weeks. Many communities issued several rounds of various closure orders – corresponding to the ebbs and flows of their epidemics – in an attempt to keep the disease in check.

These social-distancing orders worked to reduce cases and deaths. Just as today, however, they often proved difficult to maintain. By the late autumn, just weeks after the social-distancing orders went into effect, the pandemic seemed to be coming to an end as the number of new infections declined.

People clamored to return to their normal lives. Businesses pressed officials to be allowed to reopen. Believing the pandemic was over, state and local authorities began rescinding public health edicts. The nation turned its efforts to addressing the devastation influenza had wrought.

For the friends, families and co-workers of the hundreds of thousands of Americans who had died, post-pandemic life was filled with sadness and grief. Many of those still recovering from their bouts with the malady required support and care as they recuperated.

At a time when there was no federal or state safety net, charitable organizations sprang into action to provide resources for families who had lost their breadwinners, or to take in the countless children left orphaned by the disease.

For the vast majority of Americans, though, life after the pandemic seemed to be a headlong rush to normalcy. Starved for weeks of their nights on the town, sporting events, religious services, classroom interactions and family gatherings, many were eager to return to their old lives.

Taking their cues from officials who had – somewhat prematurely – declared an end to the pandemic, Americans overwhelmingly hurried to return to their pre-pandemic routines. They packed into movie theaters and dance halls, crowded in stores and shops, and gathered with friends and family.

Officials had warned the nation that cases and deaths likely would continue for months to come. The burden of public health, however, now rested not on policy but rather on individual responsibility.

Predictably, the pandemic wore on, stretching into a third deadly wave that lasted through the spring of 1919, with a fourth wave hitting in the winter of 1920. Some officials blamed the resurgence on careless Americans. Others downplayed the new cases or turned their attention to more routine public health matters, including other diseases, restaurant inspections and sanitation.

Despite the persistence of the pandemic, influenza quickly became old news. Once a regular feature of front pages, reportage rapidly dwindled to small, sporadic clippings buried in the backs of the nation's newspapers. The nation carried on, inured to the toll the pandemic had taken and the deaths yet to come. People were largely unwilling to return to socially and economically disruptive public health measures.

It's hard to hang in there

Our predecessors might be forgiven for not staying the course longer. First, the nation was eager to celebrate the recent end of World War I, an event that perhaps loomed larger in the lives of Americans than even the pandemic.

Second, death from disease was a much larger part of life in the early 20th century, and scourges such as diphtheria, measles, tuberculosis, typhoid, whooping cough, scarlet fever and pneumonia each routinely killed tens of thousands of Americans every year. Moreover, neither the cause nor the epidemiology of influenza was well understood, and many experts remained unconvinced that social distancing measures had any measurable impact.

Finally, there were no effective flu vaccines to rescue the world from the ravages of the disease. In fact, the influenza virus would not be discovered for another 15 years, and a safe and effective vaccine was not available for the general population until 1945. Given the limited information they had and the tools at their disposal, Americans perhaps endured the public health restrictions for as long as they reasonably could.

A century later, and a year into the COVID-19 pandemic, it is understandable that people now are all too eager to return to their old lives. The end of this pandemic inevitably will come, as it has with every previous one humankind has experienced.

If we have anything to learn from the history of the 1918 influenza pandemic, as well as our experience thus far with COVID-19, however, it is that a premature return to pre-pandemic life risks more cases and more deaths.

And today's Americans have significant advantages over those of a century ago. We have a much better understanding of virology and epidemiology. We know that social distancing and masking work to help save lives. Most critically, we have multiple safe and effective vaccines that are being deployed, with the pace of vaccinations increasingly weekly.

Sticking with all these coronavirus-fighting factors or easing off on them could mean the difference between a new disease surge and a quicker end to the pandemic. COVID-19 is much more transmissible than influenza, and several troubling SARS-CoV-2 variants are already spreading around the globe. The deadly third wave of influenza in 1919 shows what can happen when people prematurely relax their guard.

[Deep knowledge, daily. Sign up for The Conversation's newsletter.]The Conversation

J. Alexander Navarro, Assistant Director of the Center for the History of Medicine, University of Michigan

This article is republished from The Conversation under a Creative Commons license. Read the original article.

COVID-19 long-haulers are a long-term cost of the pandemic that we've barely started to calculate

The count of COVID-19 cases in the United States has now passed 30 million. It's one of those numbers that seems like it should mark a milestone, but … there have been so many milestones. A year after the start of the pandemic, it's easy at this point to feel as if the whole thing is on the edge of ending. It's spring. There's vaccine. And the nightmare is almost over. Except, of course, for the fact that the rate of new cases and deaths is now right where it was in November 2020, just before it exploded into the largest peak so far.

But even if the race between vaccine and pandemic fatigue falls to the side of not starting another big surge in cases, some people just can't seem to shake off the effects of COVID-19. Right from the start, it was clear from doctors in Wuhan, and then South Korea, and then Italy, and then the United States that while a course of illness lasting less than two weeks might be typical, some patients were being laid low by the SARS-CoV-2 virus for an extended period. Some of this was easy to see in the form of patients who remained on ventilators for day after day. But some of it was a lot more subtle.

A year in, the term "long-hauler" has entered the vocabulary in a way that has nothing to do with trucking. Those exposed to COVID-19 are showing a wide array of symptoms, some of which are genuinely debilitating, or even life-threatening, long after they've supposedly cleared the virus from their systems. And for some patients, serious and long-term problems are occurring even though the disease itself was apparently mild or asymptomatic.

The idea that there may be long-term consequences from COVID-19 is one that doctors were reluctant to accept at first. But it shouldn't have been. Back in 2010, researchers in Hong Kong took a look at people who had come down with SARS during the 2003 outbreak. Almost all of them showed significant impairment of breathing functions seven years later, with an average rate of function over 20% lower than should have been expected. These were not elderly patients, but mostly younger people, and many had not been the most severely affected at the time of infection.

SARS-CoV-2 is closely related to SARS-CoV. Their names alone suggest that close relationship, and genetic analysis has confirmed it many times. So it shouldn't be surprising that both coronaviruses don't depart "cleanly." They leave behind lingering damage that we're only starting to understand. In the case of SARS, the relatively small number of people affected made it possible to overlook the damage this disease had done to their lives. However, with so many people infected by COVID-19, the long-term effects of the disease may represent a huge long-term challenge to both the healthcare system and the economy, as well as the individuals involved.

While the SARS study was limited to looking at lung function, the actual effects of COVID-19 (and likely, of SARS) go far beyond the respiratory system. A new study from Northwestern Medicine found that 85% of COVID-19 long haulers suffered from multiple neurological symptoms. The most common symptom is so-called "brain fog," that includes muddled thinking and forgetfulness. Large number of patients also reported headaches, numbness in parts of their body, muscle pains or weakness, and disorders of taste and smell. That last issue wasn't always a complete loss of those senses. In some cases it was mixed-up signals, with things having unpleasant or simply wrong smells and taste. It was as if COVID-19 had rewired these senses. Badly.

As The New York Times reports, a study from California found almost a third of former COVID-19 patients facing symptoms like shortness of breath, continued coughing, or abdominal pain. This included patients who were supposedly "asymptomatic" during the period where they were actively infected with the SARS-CoV-2 virus. For some patients, symptoms did not begin until well after they should have been "over" any illness.

The wide variety of symptoms post-infection mirrors the baffling array of symptoms and systems affected during active infections. As Americans have learned over the past year, when it comes to COVID-19, everything seems to be a symptom. And even when it seems that nothing is wrong … that could also be a symptom.

The Atlantic began reporting about COVID-19 long-haulers last August, at a time when some officials (and media outlets) seemed scornful of the idea that a disease which was originally thought of as a respiratory infection could cause such a list of lingering illnesses. However, it's become clear that the inflammation and blood clots generated by COVID-19 can affect almost any part of the body. That realization required both a reassessment of what constituted high-risk factors for the disease, and now it's propelling a fresh look at those who are still falling ill weeks or months after infection.

In a follow-up article at the beginning of March, researchers interviewed by The Atlantic offered a new name for what may be wrong with many COVID-19 long-haulers: dysautonomia. This is a condition where systems that regulate the autonomic nervous system have failed, which could explain another cluster of symptoms that some long-haulers are experiencing: high blood pressure, chills, and periods of very rapid heart rate. But even dysautonomia is just a description of an effect. It's not a cause. A real understanding of what's behind the symptoms of COVID-19's lingering effects, and how best to treat them, is still ahead.

What's clear is that the pandemic will leave a lingering social and economic cost that goes beyond just the number of dead. Of those 30 million infected, millions are going to have symptoms that are completely or partially debilitating for a period of months. Some, like SARS patients, may be still be operating at well below their expected capacity years later. Some may never fully recover. That's going to represent both a long-term demand on the healthcare system, and a long-term reduction in productivity, that—like everything else about events of the last year—may be unprecedented.

Though there is one odd sign of hope: As CNN reports, some of those expressing long-term symptoms have apparently improved after receiving a COVID-19 vaccine. It's unclear why waking up the immune system to fight this virus again should have an effect on people whose tests show no active virus … but then, the whole long-hauler issue is poorly understood. And if it works for at least some people, then that's a good thing.

The unusual case of AstraZeneca: Here's the truth about the most controversial Covid vaccine

by Maureen Ferran, Rochester Institute of Technology

On March 22, AstraZeneca released results from its U.S. clinical trial showing that its vaccine is 79% effective and with no serious side effects. Overnight, the National Institutes of Health issued a statement, saying the board charged with ensuring the accuracy of the trial expressed concern that the company may have included “outdated information" in the trial. This unusual announcement is the latest in a series of questions over how effective and how safe the AstraZeneca COVID-19 vaccine is. Maureen Ferran, a virologist at the Rochester Institute of Technology, answers five questions about the AstraZeneca vaccine.

1. How does it work?

The AstraZeneca vaccine is a viral vector vaccine, much like the Johnson & Johnson COVID-19 vaccine. This type of vaccine uses a harmless adenovirus to deliver genetic instructions for a protein from SARS-CoV-2 into your cells. Your cells then make that protein, and your body will recognize the foreign protein and activate an immune response that will protect you from future infection. While the Johnson & Johnson vaccine uses a human adenovirus, the AstraZeneca vaccine uses an adenovirus that normally causes the common cold in chimpanzees. This virus can't replicate in the human body or get you sick.

2. How effective is it?

On March 22, researchers announced the results of the U.S.-based AstraZeneca vaccine clinical trial. They found the vaccine to be 79% effective at preventing symptomatic COVID-19 and 100% effective at preventing severe COVID-19. They also didn't find any serious side effects associated with the vaccine.

Within 24 hours, the NIH said in a statement that an independent data review board had concerns about the trial. The board stated that the data used in the trial was “outdated" and may give an “incomplete" view of results. On March 23, 2021, AstraZeneca agreed to share up-to-date information with the health agency to clarify the results of the trial.

Earlier trials of the AstraZeneca vaccine also showed an overall efficacy of about 70% but had also faced problems. A manufacturing error led to some dosage mistakes during the first phase 3 trial in Brazil and the U.K. These dosage mistakes made calculating the true efficacy rate more complicated than usual.

Despite these missteps, overall, the studies show that the AstraZeneca vaccine is effective at preventing disease caused by the original strain of SARS-CoV-2. However, evidence is emerging that it isn't very good against some of the new variants of the virus.

In a small preprint study that has yet to be peer-reviewed, researchers found that the AstraZeneca vaccine is only 22% effective at preventing mild or moderate illness caused by the variant first discovered in South Africa. As a result, the South African government has decided to no longer use the AstraZeneca vaccine and is instead relying on other ones.

Despite these weaknesses, the World Health Organization continues to recommend the AstraZeneca vaccine in countries where new variants are circulating because the experts believe the vaccine may still protect against severe disease and death.

Although this vaccine is somewhat less effective compared with mRNA-based vaccines, it is cheaper to produce and can be stored at normal refrigerator temperatures, making it a powerful tool in the global immunization effort.

3. Who's using the AstraZeneca vaccine?

As of late March, the AstraZeneca COVID-19 vaccine has been given authorization in 86 countries – first by the U.K. in December and then by the European Union, Canada, India, Argentina, the Dominican Republic, El Salvador, Mexico and Morocco in January. In February, the World Health Organization granted the vaccine emergency use listing, making the vaccine available in low- and middle-income countries.

So far, over 17 million doses have been administered in the European Union and the U.K., but none yet in the U.S.

4. When might the U.S. authorize the vaccine?

Although the AstraZeneca vaccine has been approved for use in many countries, the company has not yet applied for emergency use authorization in the U.S. AstraZeneca is expected to do so in March or early April, and if the Food and Drug Administration gives the vaccine the green light, vaccines could be shipping out by mid- to late April in the U.S. It is hoped that emergency use authorization in the U.S. will bolster global confidence in the vaccine.

5. What's going on with reports of blood clots?

There have been recent reports of people getting certain kinds of blood clots after receiving the AstraZeneca vaccine. In response, the European Medicines Agency began investigating a possible connection. Of the 20 million recipients of the AstraZeneca vaccine, they found 25 instances of those specific blood clots – seven cases of clots in multiple vessels throughout the body and 18 cases of clots forming in people's brains, which can result in a hemorrhage.

On March 18, the agency released a statement saying that the vaccine “is not associated with an increase in the overall risk of thrombotic events or blood clots," but it did acknowledge that there were a “small number of cases of rare and unusual but very serious clotting disorders." The agency said that it could not confirm nor rule out causality, so it recommended that manufacturers add a warning label to the vaccine. They also recommended that recipients be told to seek immediate medical attention if they experience symptoms associated with these types of rare clotting disorders, such as easy bruising or bleeding and persistent or severe headache, particularly more than three days after vaccination.

After considering the evidence, the European Medicines Agency, the World Health Organization and U.K. health authorities concluded that the benefits of the AstraZeneca vaccine far outweigh any risks.

The most recent concerns from the NIH are valid, but once they are addressed, many other experts and I hope that the AstraZeneca vaccine will play a major role in worldwide vaccination.

This is an updated version of an article originally published on March 22, 2020. It was updated to include reflect concerns over the data used in the U.S. clinical trial.The Conversation

Maureen Ferran, Associate Professor of Biology, Rochester Institute of Technology

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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