It goes without saying that all of us are totally sick and tired of even thinking about COVID. Are we better off banishing all thoughts of the dire coronavirus from our fatigued brains? Or can we keep ourselves somewhat informed about the current status of the virus’s doings without driving ourselves nuts? As for me, I am willing to risk being driven mildly nuts in exchange for being at least moderately well-informed.

There was an article in the New York Times (March 27, 2024) with the promising title “Scientists Prepare for the Next Phase of the Coronavirus.” That should tell me something, I thought. But no! It was lengthy, meandering, and mostly inconclusive. That’s not because the author of the article, Apoorva Mandavilli, did not do a good job with the material she had at hand. She interviewed several researchers and reported what they had to say, but what they had to say was, on balance, not very sharply focused.

The article quoted seven immunologists at various institutions. For example, Jesse Bloom, an evolutionary biologist at the Fred Hutchinson Cancer Center in Seattle, said, “We’re not in the acute phases of a pandemic anymore, and I think it’s understandable and probably a good thing. That said, the virus is still evolving – it’s still infecting large numbers of people. We need to keep tracking this.”

Another evolutionary biologist, Sarah Cobey, of the University of Chicago, said, “Intellectually, this virus, to me at least, is only becoming more interesting. In some ways, SARS-COV-2 has been a fabulous reminder of some of the deepest questions in the field, and also how far we have to go in answering a lot of them.”

Katia Koelle, an evolutionary biologist at Emory University did make an interesting and somewhat concerning point, specifically that a chronic infection with the coronavirus, especially in immunocompromised persons, offers the virus an opportunity to experiment with new formats, “allowing it to hit the evolutionary equivalent of a fast-forward button.” She added that viral persistence in the body is thought to play a role in long COVID.

Although other factors doubtless play a role in long COVID, I feel the need to interject at this point that it’s pretty obvious that viral persistence in the body plays a role in long COVID.

The other researchers quoted in that article more or less echoed the same basic premise. There was one single specific mention concerning further research. Akiko Iwasaki (Yale University) and her colleagues are testing whether a 15-day course of Paxlovid might eliminate a slowly-replicating reservoir of coronavirus in the body. The article gave no indication as to how this research might be conducted. Was it to be a clinical trial, in which case how likely would it be that enough trial participants could be found who would agree to that 15-day course of Paxlovid? Or might it be an in vitro experiment?

In any case, the idea that a 15-day course of an antiviral might be more effective at exterminating pathogens than a 5-day course is fairly obvious. As most of us have probably experienced, when our physician prescribes an antibiotic, we are strongly instructed to take the full course of the antibiotic and not stop taking the antibiotic when we start to feel better. The pathogen probably continues to be present in our bodies, especially the pathogens that have some degree of resistance to the antibiotic. It’s those pathogens that are likely to survive an abbreviated course of treatment. And it’s those pathogens that are likely to mutate into antibiotic-resistant variants. The reason for the full course of antibiotic treatment is to eliminate the pathogen completely. As the saying goes, “dead germs don’t mutate.”

The Paxlovid five-day course of treatment was based on the urgent and hurried research that was able to be carried out in the early days of the pandemic. The research currently underway by Dr Iwasaki is consistent with the research that has established the treatment protocols for the antibiotics and antivirals that are in use at present.

On the whole, the seven scientists interviewed by Mandavilli appear to be pursuing research about the coronavirus, but not much about interventions that could benefit us members of the human race, nor are they getting any information about the current state of the pandemic. Perhaps it’s because they are evolutionary biologists, and the focus of their studies is distant from the practice of medicine. As for the New York Times (for which I have a great deal of respect), my guess is that the feeling was that they had to say something about what’s going on with the COVID pandemic, and that’s what one of their writers could come up with.

I guess Doc Gumshoe also felt he had to say something about the current COVID picture. But wait, there’s more.

The Harvard Gazette just published an interview with Professor William Hanage, who is associate director of the Harvard T.H. Chan School of Public Health’s Center for Communicable Disease Dynamics, entitled “Time to Finally Stop Worrying About COVID?” The short answer is “No!” Hanage observes that the CDC changed its isolation policy early in March, reducing the recommended isolation time for those with COVID from five days to one day after a fever breaks or other symptoms start improving. This brings it in line with the recommendations for other respiratory diseases including the flu and RSV.

Hanage did not appear to be entirely in accord with these recommendations. He said, “You should not think that there is no potential for you to transmit after the fever is broken, and if you’d like to be more confident, you can do a rapid test. If you want to be more sure, you can use a mask.”

Hanage was asked that, although the data from the CDC shows that COVID cases are “way down,” isn’t it possible that the CDC data is a great underestimate because nobody’s testing anymore, and a lot of cases are asymptomatic?

His answer:

“If you look at things that are somewhat unbiased, like wastewater monitoring, there’s plainly still a lot of infection and transmission happening in the U.S. We don’t pick up on most of it because most people don’t test and don’t get counted. But we do still see hospitalizations and deaths. Those remain high by pre-2020 standards — though low by everything we’ve seen since then.

The risk is concentrated among those in whom it’s been concentrated all along: older folks, people with comorbidities, and the like. But your average person in the street is not going to be thinking about COVID all the time and frankly, I don’t think they need to.

But I would love it if more folks in that category were conscious of the potential to make somebody sick, someone not as lucky as them.”

Here’s some data from the CDC that is highly likely to be accurate and reliable – the weekly death rates attributable to COVID 19.

Week ending Peak weekly deaths

04/19/2020 — 17,201
01/09/2021 — 25,974
09/04/2021 — 15,493
01/22/2022 — 21,335
01/07/2023 — 3,864
01/13/2024 — 2,553
03/09/2024 — 1,002
03/30/2024 — 271
05/04/2024 — 153

Week over week, all trends are down: most recently, test positivity rates are down 0.6%, emergency room visits are down 14.5%, hospital admissions are down 15.3%, and the overall death rate is down about 20%. The most recent weekly death rates have been less than 1% of the death rates at the peak of the pandemic. That’s week over week, of course, and it’s always possible for another surge to take place, as happened between September of 2021 and January of 2022.

A matter of some concern is that the coronavirus keeps mutating at an unusually quick pace. Here’s a list of the variants that have emerged since the evil coronavirus was first detected:

• B.1.1.7 UK, September 2020
• B.1.357 South Africa, shortly thereafter
• B.1 Brazil, November 2020
• B.1.427 Southern California, US, July 2020
• B.617.1 India, fall 2020
• C. 37 Peru, December 2020
• B.1.525 UK, Nigeria, December 2020
• B.1.621 Colorado, US, January 2021
• B.1.526 New York City, US, February 2021 (high mortality)
• P.2.0 Brazil, February 2021
• B.1.617.2 The Delta variant became the dominant world-wide variant in spring 2021, causing 70% of infections in fully vaccinated persons
• B.1.1.529 The Omicron variant became dominant in November 2021; highly transmissible, but causing milder symptoms
• BA.1 & BA.2 Subvariants requiring updating of the COVID vaccine
• BA.2.12.1 Caused the majority of new cases worldwide by May 2022
• BQ.1 & BQ.1.1 As of 10/21/22 caused 16% of US cases
• BA.4 & BA.5 Emerged 05/22, evaded immune defenses
• B.1.1640.2 Spring 2022, France, caused very few cases
• XBB & XBB.1 Began circulating Spring 2022
• XBB.1.5 Emerged in March 2023
• XBB.1.16 April 2023, one of the fastest spreading variants
• EG.5 August 2023, another fast-spreading variant
• BA.2.86 August 2023, in the US, Denmark, and India; produced many mutations
• BA.2.75.2 & FL.1.5.1 Late September, 2023
• JN.1 December 2023, closely related to BA.2.86, evades immunity
• KP.2 As of May 2024, an Omicron variant, is the cause of 28.2% of new cases

Viruses do, of course, mutate, but the coronavirus that causes COVID 19 mutates at an exceptionally rapid rate. It’s worth remembering that from the perspective of the virus, causing death or serious illness is not a survival characteristic. What the virus wants is to infect as many hosts as possible, so that it can go on reproducing. Viruses cannot reproduce on their own; they need to invade the host cells and borrow material from which they create their own cells. The virus particles emerge from the host’s cells, and the host then releases the virus to infect other hosts. This process works less well if the host is seriously ill, because the host is less likely to have close contact with other potential hosts. The seriously ill host keeps to his/her bed, and also other potential hosts try to keep away from the sick host. It’s even worse for viral reproduction if the host is dead.

The HIV virus is just about ideal, from the point of view of viral reproduction. The host can go about for years without having the faintest notion that he/she is infected, during which time HIV can get passed on to lots and lots of other potential hosts.

As the coronavirus has reproduced and mutated, the variants appear to be causing milder disease and fewer deaths. Of course, a major part of the reduction in hospitalizations and deaths is due to the increase in immunity, both from having had the infection and from vaccination. No, COVID 19 is not over, but in spite of the amazingly large number of mutations and variants, the impact of the epidemic has greatly diminished, and we can all feel grateful.

An innovation that helps us avoid being blinded by headlights

I am drawn to this subject because my dear wife is especially sensitive to bright headlights shining in her eyes. This is especially problematic when, coming in the opposite direction is a bozo who won’t dim his lights when you flick your high-beams. No, the bozo keeps the high-beams on, right in your face. This is not only rude, but dangerous.

Many new cars in Europe, China, and Canada (but not in the US) offer a technology called “adaptive high beams” (ADB) which can actually shape the light coming from headlights rather than scattering it all over the road. If there’s a car coming in the other direction, or one driving ahead in the same lane ahead of your car, the light stays precisely away from that vehicle. The rest of the road is still covered in bright light with just a pocket of dimmer light around the other vehicles. This way a deer, pedestrian or bicyclist by the side of the road can still be seen clearly while other drivers sharing the road aren’t blinded.

(I use the term “blinded” figuratively, but in my experience glancing for even a fraction of a second at those oncoming high-beams prevents me from clearly seeing things like the center line or the edge of the road.)

In the US, the closest we can get to that today are automatic high beams, a feature available on many new cars that automatically flicks off the high beams if another vehicle is detected ahead.

US auto safety regulations enacted in 2022 were supposed to finally allow ADB headlight, something for which the auto industry and safety groups had long been asking for. But, according to automakers and safety advocates, the new rules make it difficult for automakers to add the feature. That means it will probably be years before ADB headlights are widely available in the US.

Until two years ago, US auto safety regulations, written for traditional headlights, simply didn’t allow for adaptive headlight technology at all. Light beams wrapping around other vehicles just wasn’t something the regulations could encompass, so the technology wasn’t allowed here by default.

That changed in early 2022 when, after a decade of work on it, America’s National Highway Traffic Safety Administration (NHTSA) finalized regulations for adaptive beam headlights. But because the US regulations are so different from those in other countries, with requirements so difficult to meet, automakers still can’t offer it here. It will be years before they can offer new, redesigned ADB headlights that meet the standards, auto industry sources say.

The NHTSA regulations prioritize reducing any potential to cause glare for other drivers. Glare has been a particular concern for many years since new vehicles have brighter headlights that can sometimes cause discomfort or even temporarily blind other drivers. Many in the industry say the regulations overemphasize that concern, though, holding adaptive beam headlights to even higher standards than regular headlights when it comes to glare reduction.

NHTSA also states that other standards put forth by the industry don’t do enough to prevent the systems from sometimes putting too much light into the eyes of other drivers. Eventually, ADB will come to the American roads but, assuming there’s no change to the regulations, it will take awhile. One day, let’s hope, Americans will be able to use high-tech headlights that can do more than just make light shows.

…and one more thing about our light environment

The US Department of Energy (DOE) has just issued a rule that as of June 25, 2028, all LED light bulbs must be of the blue-pump class. Blue-pump LEDs emit light, as the name suggests, only at the blue end of the spectrum.

This is a very, very bad idea.

The DOE has based that ruling purely on the grounds that the blue-pump LEDs put out more lumens per unit of electrical energy than other LEDs. Therefore, they are more “environmentally friendly,” because they use less energy than the warmer-tone LEDs.

But blue-pump LEDs are not human-friendly. The DOE entirely ignores the elemental fact that we humans, who live our lives in a circadian rhythm, do not adjust well to blue light as we shift from daylight hours to evening. Blue light tends to keep us awake. We need light at the warmer end of the spectrum.

Moreover, many people simply cannot tolerate those intense purple-blue LEDs. It is not a matter of personal preference. Those LEDs can bring on migraines and in some cases trigger epileptic seizures. It has been suggested that the light emitted by those LEDs can damage eyesight. This would be difficult to demonstrate definitively. Obviously, there is not going to be a clinical trial in which one cohort is subjected to the purple-blue LEDs while another is exposed to the warmer LEDs. But it’s clear, to this observer at least, that we humans have evolved in a light environment that is markedly different from the environment created by blue-pump LEDs.

When LEDs began to supplant old-time incandescent light bulbs, I was somewhat skeptical. Yes, I acknowledge the urgency of doing whatever possible to slow the effects of climate change, and energy efficiency was a move in that direction. I thought that the earliest LEDs were rather nasty, but then I began to see warmer-tone LEDs, and I thought that things were moving in the right direction.

The DOEs pronouncement that LEDs would, in a scant four years, shift exclusively to blue-light emitting bulbs, clearly favors saving a very small amount of electrical power over the living conditions and health of human beings.
I can only hope that opposition to that ruling takes hold and stops it from taking effect.

Might some patients do better treated at home than in the hospital?

This was based on a study in 5,132 patients treated at home for conditions such as heart failure, respiratory infections, sepsis, kidney and urinary tract infections, and cellulitis. Many of those cases were medically complex, with underlying conditions like cancer, dementia, chronic obstructive pulmonary disease, and heart failure. The patients in the study were seriously ill, with complex conditions which would usually have required hospitalization. However, at-home treatment was allowed under a temporary Medicare/Medicaid waiver that will expire this year. The study was conducted at Mass General Brigham Healthcare at Home, which is the home-hospital-care model of Brigham and Women’s Hospital and Massachusetts General Hospital, and published in Annals of Internal Medicine in January, 2024.

Researchers found that the average period during which home hospital services were required was 6.3 days. Of the 5,132 patients in the study, 6.2 percent needed to enter a brick-and-mortar hospital for care. The mortality rate during home hospitalization was 0.5 percent. Thirty days after the home care period ended, statistics were also favorable, with a mortality rate of 3.2 percent, the need for a skilled nursing facility 2.6 percent, and a readmission rate of 15.6 percent.
Dr Stephen Dorner, a Harvard Medical School instructor in emergency medicine and chief clinical and innovation officer at Mass General Brigham Healthcare at Home, said home care may represent the next major shift in the U.S. medical landscape. He said, “We know there are huge disparities in outcomes of hospital care right now in America. Yet, in home hospital care we’re not seeing that.”

Scaling up such treatment nationally can offset forces that have relentlessly pushed healthcare costs upward, Dorner said. Avoiding construction of new facilities alone has the potential to save millions, even billions each year, he said.
“This care delivery model can help course correct for a lot of trends that we see with healthcare costs,” Dorner said. “If it costs less to deliver care in this format while improving quality, improving experience, and overall outcomes, then instead of building X number of additional hospitals across the country to meet rising demand, if we expand home hospital services, can we flatten that curve of growing cost trends? Can we improve the overall quality of care in the country? That’s a really exciting and invigorating prospect for me and for the whole team.”

It’s not feasible to compare home-care outcomes with hospital outcomes, because hospital outcomes include a much wider range of patients, and many of those patients are by definition in a much more precarious state of health than the home-care cohort. The home-care cohort is specifically chosen in consideration of their need, or absence of need, for acute hospital-based care.

From Doc Gumshoe’s point of view, expanding home hospital services is not apt to have much impact on improving quality or overall outcomes. It certainly might improve the experience for many patients. Personally (all things being equal), I would much rather be treated at home in my own bed than in the hospital, but I’m not in the least convinced that the outcome, in terms of my health, would be significantly better.

The greatest likely impact would be on the economics, as Dorner pointed out. And, if some rising healthcare costs could be addressed, the result could be a bit of breathing room for other healthcare expenses, which in turn could have some favorable impact on outcomes. At least in theory, spend less on new brick-and-mortar hospitals and more on improved treatment options, and the benefit will accrue to patients.

What’s in the Mediterranean diet besides olive oil and wine?

It’s a rare person that hasn’t heard about how the Mediterranean diet is good for us, leads to longevity and to a reduced incidence of the diseases that plague us and shorten our life-spans. The quick take-aways seem to be that we should live on vegetables and fruits; that whatever carbohydrates we get in our diets should come from whole grains; and that instead of butter and animal fats, we should use olive oil. And yes, it’s okay to accompany those meals with a glass or so of wine.

The methodologies used for assessing the nutritional and health benefits of the Mediterranean diet are far from perfect. Dietary scores supposedly determining the nutritional content of the Mediterranean diet don’t generally consider the total daily calorie intake or the proportions of macronutrients. My source for this is a recent article in the Journal of Translational Medicine (Godos J., 2024 https:// translational-medicine.biomedcentral.com/articles/10.1186/s12967-024-05095-w).

Trying to capture the beneficial features of the Mediterranean diet by means of quick a quantitative index doesn’t really capture what it is about this diet that produced healthy lives in the individuals actually living in Mediterranean parts of the world. There are many cultural and behavioral elements that don’t get addressed.

But there are also foods in the Mediterranean diet that get scant attention.

Eggs

Dietary indices assessing the level of adherence to the Mediterranean diet do not generally include egg consumption. Eggs are widely perceived as a major source of cholesterol and a risk factor for cardiovascular disease. But in reality, an egg is an inexpensive and nutritious source of proteins, vitamins, and minerals.

Egg proteins are easily digested and provide many essential amino acids. Eggs are a rich source of bioactive peptides with antioxidant and anti-inflammatory properties. Yes, eggs contain cholesterol, but eggs also contain phospholipids, mono- and poly-saturated fatty acids, lutein, lecithin, choline, and a number of vitamins and minerals which contribute to our overall health status.

On balance, egg consumption is associated with many health benefits. Folks in the Mediterranean parts of the world certainly do not shun eggs.

Dairy products

Milk and its products, such as butter, yogurt, curd, and buttermilk, have been part of a typical diet in Mediterranean regions for at least 9,000 years. However, more recently, saturated fatty acids in dairy products have led some persons to restrict their consumption because of the possibility of increasing low-density lipoprotein (LDL) cholesterol in the blood.
Dairy product-derived saturated fatty acids do to some degree increase circulating LDL cholesterol levels. But these fatty acids also have many beneficial effects, including raising high-density lipoprotein (HDL) levels, improving metabolic function, and preventing microbiota dysbiosis, which is a condition characterized by a harmful decrease in the diversity of the microbial population in our digestive system.

No doubt, increased circulating LDL cholesterol is not a good thing, since it causes the deposition of atherosclerotic plaque in our arteries and leads to heart disease. But we need to remember that the main source is red meat. Dairy products are a distinctly secondary source.

There is also some evidence suggesting that milk and milk product consumption is associated with a lower risk of cardiovascular complications, including hypertension, as well as a lower risk of colorectal cancer.

Nuts and seeds

Certain types of nuts, such as almonds, walnuts, pistachios and pine nuts, as well as seeds such as flaxseeds and pumpkin and sunflower seeds, have been part of the typical diet in Mediterranean regions for thousands of years. A large pool of evidence indicates that nut consumption is associated with a lower risk of heart diseases.

Nutritional analysis of these energy-rich foods indicates the presence of essential fatty acids, chemicals with antioxidant and anti-inflammatory properties, and phytosterols with cholesterol-lowering properties.

Herbs and spices

Herbs and spices have been commonly used in Mediterranean regions for a long, long time. As we all know, these plant-derived components are used to enhance the flavor and aroma of foods. However, these components have hardly been found in any Mediterranean diet adherence measure.

There is some evidence suggesting that herbs and spices can reduce the risk of some non-communicable diseases. They are rich in chemicals with antioxidant, anti-inflammatory, anticancer, lipid-lowering, and blood pressure-lowering properties. They can improve digestion and have positive effects on our neuronal system.

Wine

Drinking wine, in moderation, is an integral part of a traditional Mediterranean diet. However, some current dietary guidelines advise excluding alcohol from the diet because of potential carcinogenic and other detrimental health effects.
Many observational studies clearly indicate that moderate alcohol intake can significantly reduce the risks of cardiovascular disease and all-cause mortality. In particular, a so-called J-curve has been observed linking overall mortality and alcohol consumption. The lowest mortality rate was in persons who consumed around one and a half alcoholic drinks per day – lower than the mortality rate in teetotalers.

The Godos article did not mention things like seafood or poultry as being associated with the Mediterranean diet, nor yet a scarcity of red meat. I suspect that eating fish or chicken instead of beefsteak is a characteristic of what folks in those parts have for lunch or dinner. Whether that should be considered part of the Mediterranean diet, I know not.

* * * * * * *

I had several other topics in mind for this Doc Gumshoe spiel, but the current COVID news took up more room than I had anticipated. Therefore, I have an abundant handful of current healthcare developments to ruminate about, and I will send you the news and my ruminations.

By the way, there was another NY Times piece about COVID, by the same writer, Apoorva Mandavilli who did the piece that led off this installment. It was similarly lengthy, meandering, and inconclusive. The title was “Could the Covid-19 Vaccines Have Caused Some People Harm?” It focused on the human interest angle with very little factual information. But the subject is interesting and concerning, and will require Doc Gumshoe to do a fair amount of digging.

Many thanks for all comments and questions. I will do my best to address whatever needs addressing.

Best to all, Michael Jorrin (aka Doc Gumshoe)

[ed note: Michael Jorrin, who I dubbed “Doc Gumshoe” many years ago, is a longtime medical writer (not a doctor) and shares his commentary with Gumshoe readers once or twice a month. He does not generally write about the investment prospects of topics he covers, but has agreed to our trading restrictions.  Past Doc Gumshoe columns are available here.]