El año pasado se reportaron alrededor de por dengue en Estados Unidos, frente a las 2.050 de 2023, según los Centros para el Control y Prevención de Enfermedades (CDC). Todos los casos de 2024 se adquirieron en el extranjero, excepto 105 contraídos en California, Florida o Texas. Los CDC emitieron una alerta sanitaria en marzo advirtiendo sobre el riesgo continuo de infección por dengue.

"Creo que el dengue ha llegado para quedarse", declaró , especialista en enfermedades infecciosas y director médico asociado de epidemiología hospitalaria del de Los Ángeles, sobre la posibilidad de que el dengue se convierta en la nueva normalidad en el país. "Estos mosquitos no se irán a ninguna parte".

El dengue es endémico 鈥攗na etiqueta que las autoridades de salud pública asignan cuando las enfermedades aparecen de forma constante en una región鈥� en del mundo, como Latinoamérica, India y el sudeste asiático. Los casos de dengue el año pasado en muchos de esos lugares, especialmente en Centro y Sur América.

La enfermedad, que puede propagarse por la que portan el virus, no fue común en Estados Unidos continental durante gran parte del siglo pasado. Actualmente, la mayoría de los casos de dengue adquiridos localmente (es decir, no relacionados con viajes) en el país se registran en Puerto Rico, donde se registró un , lo que desencadenó una emergencia de salud pública local.

La mayoría de las personas que desarrollan dengue . Sin embargo, en algunas, los síntomas son graves: sangrado por la nariz o la boca, dolor de estómago intenso, vómitos e hinchazón. En ocasiones, el dengue causa la muerte.

California ofrece un caso centinela sobre la propagación del dengue en el país. Hace 25 años, la presencia de los mosquitos Aedes aegypti y Aedes albopictus, que transmiten el dengue, en el estado. Actualmente, se , principalmente en el sur de California y en el Valle Central.

La propagación de los mosquitos es preocupante porque su presencia aumenta la probabilidad de transmisión de enfermedades, afirmó Steve Abshier, presidente de la .

Entre 2016 y 2022, se registró un promedio de 136 nuevos casos de dengue al año en California, cada uno de los cuales probablemente traído al estado por alguien que viajó y se infectó en otro lugar. En 2023, se registraron alrededor de 250 casos nuevos, incluyendo dos adquiridos localmente.

En 2024, California registró 725 nuevos casos de dengue, incluyendo 18 adquiridos localmente, según .

El cambio climático podría contribuir al aumento de la población de mosquitos Aedes, afirmó Ben-Aderet. Estos mosquitos sobreviven mejor en zonas urbanas cálidas, y suelen picar durante el día. Las infecciones de transmisión local suelen ocurrir cuando alguien contrae dengue durante un viaje, regresa a casa y lo pica un mosquito Aedes que, a su vez, pica e infecta a otra persona.

"Se han propagado rápidamente por toda California", explicó Ben-Aderet.

El dengue representa un desafío para muchos médicos de atención primaria que nunca lo han visto. Ben-Aderet dijo que los médicos que sospechan dengue deben obtener un historial de viaje detallado de sus pacientes, pero confirmar el diagnóstico no siempre es rápido.

"No existe una prueba sencilla para detectarlo", afirmó. "La única prueba que tenemos para el dengue son las pruebas de anticuerpos". Agregó que "la mayoría de los laboratorios probablemente no lo estén comercializando, por lo que suele ser una prueba que se debe analizar en otra instalación. Por lo tanto, es fundamental sospechar que alguien tiene dengue".

Las mejores prácticas para evitar el dengue incluyen eliminar cualquier agua estancada en una propiedad, aunque sea poca, y usar repelente de mosquitos, dijo Abshier. Limitar la actividad al atardecer y al amanecer, cuando los mosquitos pican con mayor frecuencia, también puede ayudar.

Los esfuerzos para combatir el dengue en California se complicaron aún más este año después de que los incendios forestales arrasaran Los Ángeles.

Los incendios ocurrieron en una zona de alta incidencia de enfermedades transmitidas por mosquitos. Funcionarios del San Gabriel Valley Mosquito and Vector Control District han trabajado durante meses para tratar más de 1.400 piscinas sin mantenimiento que quedaron tras el incendio, eliminando así posibles criaderos de mosquitos.

Estos oficiales han utilizado recursos locales y estatales para tratar las piscinas, dijo Anais Medina Díaz, vocera del distrito. Han solicitado un reembolso a la Agencia Federal para el Manejo de Emergencias (FEMA), que históricamente no ha financiado las iniciativas de control de vectores luego de incendios forestales.

En California, las agencias de control de vectores suelen financiarse principalmente con impuestos y tasas locales que pagan los propietarios.

Algunos funcionarios están implementando el novedoso método de para reducir el problema. Eso puede resultar eficaz, pero implementar el método en un gran número de áreas sería costoso y requeriría un esfuerzo masivo a nivel estatal, dijo Abshier.

Mientras tanto, el gobierno federal está reduciendo sus intervenciones: varios medios han informado que los Institutos Nacionales de Salud nuevas investigaciones relacionadas con el cambio climático, que podrían incluir trabajos sobre el dengue.

Este año, las tasas de dengue reportadas en gran parte del continente americano . Sin embargo, es probable que la tendencia en Estados Unidos no se esclarezca hasta finales de año, después que termine la temporada de mosquitos de verano.

Los investigadores de salud y control de vectores no están seguros de la gravedad de la situación en California.

Algunos afirman que podría haber brotes limitados, mientras que otros predicen que el dengue podría empeorar mucho. , profesor e investigador de enfermedades infecciosas en el Instituto de Inmunología de La Jolla, señaló que otros lugares, como Nepal, experimentaron relativamente pocos casos de dengue en el pasado reciente, pero ahora se registran brotes grandes con regularidad.

Existe una vacuna para niños, pero debido a la falta de demanda mundial. Otras dos vacunas no están disponibles en Estados Unidos. El laboratorio de Shresta trabaja arduamente en una contra el dengue. Espera publicar los resultados de las pruebas en animales en aproximadamente un año; si son positivos, los ensayos en humanos podrían ser posibles en unos dos años.

"Si no hay una buena vacuna ni buenos antivirales, este será un país endémico para dengue", afirmó.

Phillip Reese es especialista en reportaje de datos y profesor asociado de Periodismo en la Universidad Estatal de California-Sacramento.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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Congress has mostly stood by as the Trump administration 鈥� spurred by Elon Musk and his Department of Government Efficiency, named and created by President Donald Trump 听鈥� takes a chainsaw to a broad array of government programs. But now the courts are stepping in to slow or stop some efforts that critics claim are illegal, unconstitutional, or both.

Funding freezes and contract cancellations are already having a chilling effect on health programs, such as biomedical research grants for the National Institutes of Health, humanitarian and health aid provided overseas by the U.S. Agency for International Development, and federal funding owed to community health centers and other domestic agencies.

This week’s panelists are Julie Rovner of 麻豆女优 Health News, Jessie Hellmann of CQ Roll Call, Shefali Luthra of The 19th, and Maya Goldman of Axios.

Panelists

Among the takeaways from this week’s episode:

• Universities are reconsidering hiring and other forward-looking actions after the Trump administration imposed an abrupt, immediate cap on indirect costs, which help cover overhead and related expenses that aren’t included in federal research grants. A slowdown at research institutions could undermine the prospects for innovation generally 鈥� and the nation’s economy specifically, as the United States relies quite a bit on those jobs and the developments they produce.
• The Trump administration’s decision to apply the cap on indirect costs to not only future but also current federal grants specifically violates the terms of spending legislation passed by Congress. Meanwhile, the health impacts of the sudden shuttering of USAID are becoming clear, including concerns about how unprepared the nation could be for a health threat that emerges abroad.
• Congress still hasn’t approved a full funding package for this year, and Republicans don’t seem to be in a hurry to do more than extend the current extension 鈥� and pass a budget resolution to fund Trump’s priorities and defund his chosen targets.
• The House GOP budget resolution package released this week includes a call for $880 billion in spending cuts that is expected to hit Medicaid hard. House Republican leaders say they’re weighing imposing work requirements, but only a small percentage of Medicaid beneficiaries would be subject to that change, as most would be exempt due to disability or other reasons 鈥� or are already working. Cuts to Medicaid could have cascading consequences, including for the national problem of maternal mortality.

Also this week, Rovner interviews Mark McClellan 鈥� director of the Duke-Margolis Institute for Health Policy who led the FDA and the Centers for Medicare & Medicaid Services during the George W. Bush administration 鈥� about the impact of cutting funding to research universities. And Rovner reads the winner of the annual 麻豆女优 Health News’ “health policy valentines” contest.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:听

Julie Rovner: Axios’ “,” by Maya Goldman.听

Shefali Luthra: Politico’s “” by Jonathan Martin.听

Maya Goldman: 麻豆女优 Health News’ “,” by Daniel Chang.

Jessie Hellmann: NPR’s “,” by Selena Simmons-Duffin.听

Also mentioned in this week’s podcast:

• Reuters’ “,” by Jonathan Landay and Humeyra Pamuk.
• Newsweek’s “,” by Theo Burman.

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]听

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 13, at 10 a.m. As always, news happens fast and things might’ve changed by the time you hear this. So, here we go.听

Today we are joined via videoconference by Shefali Luthra of The 19th.听

Shefali Luthra: Hello.听

Rovner: Jessie Hellmann of CQ Roll Call.听

Jessie Hellmann: Hi.听

Rovner: And we welcome to the podcast our first of two new panelists you’ll be hearing in the coming weeks, Maya Goldman of Axios news.听

Maya Goldman: Hi, great to be here.听

Rovner: Later in this episode we’ll have my interview with doctor and economist Mark McClellan, former commissioner of the Food and Drug Administration and administrator of the Centers for Medicare & Medicaid Services under President George W. Bush 鈥� though not at the same time. Mark now heads a research institute at Duke University, and he will try to explain what’s happening with NIH [National Institutes of Health] grants. We also have the winner of our annual 麻豆女优 Health News Health Policy Valentine Contest, but first this week’s health news.听

So by the time you hear this, Robert F. Kennedy Jr. is almost certain to have been confirmed by the Senate as the next secretary of health and human services. But even before he gets sworn in, as we have been chronicling these past few weeks, things are changing fast and furious over at HHS [the Department of Health and Human Services], and, increasingly, courts are trying to stop or at least slow some of those changes.听

The thread running through all of these, which we will talk about, is growing doubt about whether this administration will comply with those court orders or touch off a constitutional crisis. So I admit I had to make myself a chart to keep track of all of these lawsuits challenging all of the actions the administration has taken just in its first three weeks. We’ll start with what’s going on 鈥� or not 鈥� at the National Institutes of Health, where last Friday night the agency announced that, henceforth, indirect costs as part of agency grants would be capped at 15%, including for current grants. We’ll have more on this and what it might mean in my chat with Mark McClellan later in this episode. But suffice it to say that I am old enough to remember when NIH was an untouchable jewel for both Republicans and Democrats. What the heck happened here?听

Hellmann: I think Elon Musk, in his crusade to find government waste, decided to hone in on NIH next. And this has been something that the conservative think tanks have been talking about for a little bit, that they think some of these universities are just ripping off the government with these indirect costs on NIH grants. Some of the universities get up to 60% or higher on their NIH grants to cover administrative costs, staffing, stuff like that. But it’s just become a target. [President Donald] Trump also tried to do something similar in 2017, but Congress said, No, we do not want to do that, and actually put a rider in appropriations bills to stop it. And that was kind of the end of it. But it seems like the strategy in this version of the Trump administration is to do something anyway and then take it through the courts.听

Rovner: Don’t skip over that too fast. There’s actual language in the spending bill that says you can’t do this.听

Hellmann: Yeah, there just doesn’t seem to be a lot of concern about this, even from people who have historically supported NIH, and Republicans are just kind of going along with what Elon Musk has been saying about, This is wasteful. We think 15% is fair. So it’s definitely been a big shift.听

Goldman: There have been some Republicans that have spoken out, though. I think Sen. Katie Britt from Alabama was one of the first voices to 鈥� I don’t know if you could necessarily say she spoke out against it so strongly, but she said, I value the research that the universities in my state do, and I’m talking to RFK Jr. I think, well, it’s not the same kind of response that we might’ve seen seven, eight years ago. There is a little bit of pushback, which is I think different than some other health changes that we’ve seen.听

Rovner: I did notice that [Sen.] Susan Collins had a strongly worded statement in which she buried the news that she was going to vote for RFK Jr., too, as HHS secretary but also saying that Jackson Labs, big biomedical research facility in Maine, thinks this is really important. I have sort of a broader question. This usually comes up in the context of Medicare. We talk about whether or not the federal government is a good or a bad business partner. Because if they keep changing the rules, you don’t want to rely on their word if it can change. I mean it’s one thing to say, Yes, going forward we’re going to cap indirect costs of 15% and you can decide whether to take it or leave it, but they’re doing this for current grant. They’re just saying: OK, that’s it. We’re not going to pay you this money that we gave you a grant and agreed to pay you for five years. One would think that could have longer-term consequences even if this is eventually reversed. And as I just said, there is language in the spending bill that says they can’t do this.听

Luthra: The other thing that I think is worth noting is that there is this sort of uncertainty that it has created at a lot of universities, similar to what we’re seeing in basically any institution that’s been touched by some sort of very sudden funding freeze or funding cut. A lot of universities really rely on these funds, and they don’t know whether they will come back, whether they’ll be losing tens of millions of dollars each year. And they’re trying to plan their budgets, and that means in some cases I’ve heard about universities canceling existing hiring cycles because they don’t think they can necessarily afford to pay for employees that two weeks ago they thought they’d be able to. And what we have seen in other institutions, which we’ll talk about later in the podcast, is coming up here in academia as well, and this will just have vast ripple effects throughout our country and our economy, given what a big role universities play.听

Rovner: And also, in the young scientist pipeline, that’s always been a concern that, who’s going to be the next generation. If graduate students and even undergraduate students see all of this uncertainty and people being suddenly laid off, are they going to think, Well, maybe I should go learn coding or do something else? Maya, you’re nodding.听

Goldman: Yeah, I talked to somebody yesterday who said she’s hearing from students that she mentors 鈥� she’s a professor 鈥� she’s hearing from students that she mentors that they’re, like, Maybe I should just go to the private sector and make some money. Which I think is actually maybe one of the underlying goals of DOGE [the Department of Government Efficiency] and Elon Musk, to get people to go to the private sector.听

Rovner: Although as we discover, and we will talk more about this, the private sector gets a lot of money from the federal government.听

Goldman: Absolutely.听

Rovner: That’s been kind of the Republican mantra for many generations, of Let’s partner more with the private sectors. Therefore, there’s a lot of partnerships between the public and private sectors.听

Hellmann: It’s also interesting because there’s been a lot of distrust from RFK Jr. about health research done in the private sector by pharmaceutical companies. So if you’re not doing this research or funding it through NIH and you don’t trust pharmaceutical companies to do it, either, then where does that leave you?听

Rovner: Well, moving on to the broader funding freeze that the Office of Management and Budget tried to impose, then tried to rescind, but apparently didn’t in many cases. A U.S. district judge ordered the administration to resume payments, and when officials didn’t, another judge in a second lawsuit ordered the resumption in much angrier terms and led Elon Musk and Vice President JD Vance, the latter of whom is a graduate of Yale Law School, to question whether judges even have the authority to tell the executive branch what it can and can’t do. I have not been to law school, but, I don’t know, I’ve been doing this for a long time, and my perception has always been that’s courts’ jobs, to tell the executive branch and Congress what it can and can’t do. Is it not?听

Luthra: It is, and any of us who has taken civics or American history could tell you that. But I do think it’s worth noting that this actually isn’t a new talking point for, in particular, the vice president, who frequently references Andrew Jackson, the president who famously said: “The courts have made their order. Let’s see them enforce it.” And to what you alluded to earlier, Julie, that is the question about whether we find ourselves hurtling toward some kind of very serious constitutional, if not crisis, then very serious concern about whether the separation of equal powers remains tantamount.听

Rovner: I think you can call it a constitutional crisis. I mean we’re not there yet鈥斕�

Luthra: Yes, but we could be hurtling toward one.听

Rovner: Yes. I think that’s very, very fair.听

Luthra: Excellent.听

Rovner: Well, also among the early Trump actions getting shot down by federal judges are the removal of various webpages and datasets at HHS, including a two-week delay of the release of the CDC’s [Centers for Disease Control and Prevention’s] Morbidity and Mortality Weekly Report, with a couple of key studies of bird flu, which by the way continues to spread from birds to cows to people in a growing number of states, most lately Nevada. In a case filed by the liberal groups Doctors for America and Public Citizen, a judge has given HHS until this Friday to restore the websites to the state they were in before they were taken down. I checked this morning, and the CDC website still says it’s being, quote, “modified” to comply with the president’s executive orders. Is this another of those judicial orders the administration considers optional to obey?听

Goldman: I am very curious to see that. I think it’s also hard to wrap my head around exactly what was taken down and changed, because there’s just so much information on the CDC’s website, on federal health websites. So I think it’ll be really hard to know unless you’re looking on a case-by-case basis to see if something has been restored or changed.听

Rovner: I did see, I think this was in , a researcher who said she had a paper on using mobile vans to distribute fruit and vegetables and healthier foods in remote areas and it was taken down because it had the word “diverse” populations in it. I can’t remember whether it was back up or not. But I mean, yes, the president gets to say, We’re not going to do DEI [diversity, equality, and inclusion] again, but this is like the NIH grant. It’s one thing to say we’re not going to do this going forward, and it’s another thing to say everybody who’s ever said this is now fired, which basically they’re saying in a lot of departments.听

Luthra: And that words have very vast meanings. You mentioned diverse populations. “Biodiversity,” a scientific term that may not be used in a lot of these papers anymore, just sort of creates a real chilling effect and makes it in some cases impossible to do accurate science.听

Rovner: Yes. And if you missed it in last week’s episode, I read out part of the list of the words that can no longer be used in federally funded research. Well, outside of HHS, but still inside of health care, the fight continues over the fate of the U.S. Agency for International Development, which Elon Musk has all but obliterated. This may be an example of court relief coming too late. We’re getting stories of rotting food in warehouses with no one to deliver it, from Myanmar dying because the hospital that had been providing her oxygen in Thailand closed suddenly, and suddenly finding themselves ordered to change continents while in their third trimester of pregnancy. Is there a point to this? There’s so far been no real evidence of fraud in the program. It’s only spending that the new administration doesn’t agree with.听

Luthra: I think we could go even further than spending they don’t agree with. It’s hard to see that they’ve even reviewed it. A lot of the reporting coming out shows that people who work at USAID haven’t gotten any questions from the administration about, What work are you doing? There’s been process initiated to review all the grants that they have frozen, which suggests that maybe they won’t actually do that. This seems very arbitrary, very broad, and to your point, Julie, the health implications will be and are very immediate and very sweeping and risk setting Americans, but also people across the globe, back in terms of health progress by I don’t even know how much.听

Rovner: One presumes that USAID is a target because Americans in general don’t like foreign aid. This is foreign aid. Most people haven’t heard of it. It’s an easy target, if you will, and they can sort of, like, If we can do this with USAID, then we can go on and do it with things that might be a little more politically sensitive. Is that a fair interpretation? Maya, you’re nodding.听

Goldman: Yeah. I mean I think so, but it’s also a matter of national security in a lot of ways, and foreign aid, at least global health foreign aid, is a pretty small fraction of the federal budget. But I’ve been talking to some virologists who are really worried that the collapse of U.S. involvement in global health efforts, there’s going to be viruses that mutate and then come back to the U.S., and who knows if we’ll have the public health infrastructure in our country to fight them anymore. But it’s also just a good investment to fight these viruses, prevent these viruses abroad before they even get to the U.S.听

Rovner: Yeah, it’s better to control Ebola in Africa before somebody with it gets on an airplane.听

Goldman: Exactly, yeah. And there’s also the question that we’ve been talking about on my team of the collapse of U.S. soft power in some ways. You’re leaving a vacuum for another country like China, perhaps, to come in and exert influence in other countries. And I think that you could also see that in biomedical research if NIH funding continues to be cut.听

Rovner: So moving over to Capitol Hill, we’ll talk about efforts to launch the fiscal 2026 budget process and legislate President Trump’s agenda in a moment. But first, our weekly reminder that Congress hasn’t yet finished the fiscal 2025 spending bills, even though the fiscal year began last Oct. 1. And the temporary funding that Congress passed in December runs out March 14. So the new Congress must be about to get that all tied up in a bow, right?听

Hellmann: Yeah, it doesn’t seem to be a lot of urgency about that right now. House Republicans are now pushing for a full-year CR [continuing resolution]. Some Democrats are talking about potentially using a potential shutdown as leverage as they fight back against some of these unilateral spending cuts by Elon Musk. But yeah, most of the focus right now seems to be on the budget reconciliation package that Donald Trump wants to extend his tax cuts and do border spending and things like that. And the government doesn’t shut down for a month, which is a million years in Congress time. So鈥斕�

Rovner: It’s like the opposite of dog years. But still, when you say a, quote-unquote, “full-year CR,” that’s really a seven-month CR. That’s really just, Let’s continue what we’ve been doing and move on to fight the next battle.听

Hellmann: Yeah.听

Rovner: Which of course they could have done in December, but they didn’t want to, because I think they were going to come in and do exciting things for the rest of fiscal 2025. But Congress being Congress, they’re going to kick the can down the road. And while we’re on news from Congress, as I mentioned at the top, RFK Jr. will become the next health and human services secretary any minute, if it hasn’t already happened. They are literally voting as we tape this morning. This was a huge controversy 鈥� until it wasn’t. What happened to Republicans who were so worried about his anti-vax and potentially pro-abortion-rights views? It just all kind of melted away?听

Luthra: I think what happened is what’s happened with every Cabinet nominee with the exception of Matt Gaetz, which is that the resistance from Senate Republicans is simply not there anymore. I’ve been pretty surprised personally to see some of the lawmakers who are typically considered more moderate, the Susan Collinses of the world, Lisa Murkowskis, who in Trump 1 would vote against some of these types of picks but appear to have changed their perspective this time around. There was so much attention on [Sen.] Bill Cassidy during last week’s hearings, and he made a very public conversation about whether RFK Jr.’s views on vaccines would be deeply detrimental.听

And then he came back and said, I have gotten real reassurances that everything will be fine. And all of these lawmakers are citing these private conversations they’ve had and these commitments that they say they received, and at the same time you have Democrats like [Sen.] Patty Murray saying they have never had more disturbing conversations with a nominee than they had with this particular one. And it just really shows how stark the contrast is. You have the Republican Party largely saying yes to everything Donald Trump is proposing, and Democrats may be critical in cases like this one, but without really the power to stop it.听

Rovner: As we pointed out on the podcast, Kennedy showed an almost alarming lack of knowledge about the programs that he’s going to be overseeing as secretary. I mean, not just didn’t know but apparently just didn’t bother to do the basic homework that one would assume that a Cabinet nominee would do before coming before the Senate. Perhaps he knew that it didn’t matter, that Republicans are going to basically fall in line for whoever Trump wants, because that seems to be what’s going on right now.听

Hellmann: Yeah, he was asked about Medicare and Medicaid in his first hearing and didn’t have a very good answer, and then was asked about it in his second hearing and I think somehow gave a worse answer. So it’s like he didn’t go home and do any studying on it. And maybe he has since.听

Rovner: Yeah, we will see.听

Hellmann: Hopefully.听

Rovner: All right. Well, now onto next year’s budget. It’s not hard to see why President Trump is trying to do so much using his executive power, because the Republican Congress is so far looking unlikely to do anything approaching the president’s, quote, “big, beautiful bill” anytime soon. Just a reminder that in 2017 the Republican Congress just barely got its big tax bill over the finish line before Christmas, so it took them an entire year back then. Jessie, I know you’re following this, or trying to. First, why are the House and the Senate seemingly on different tracks? If they’re going to plunge ahead with the president’s agenda, shouldn’t they be trying to do the same thing at the same time?听

Hellmann: I think Trump just wants to let both sides go at it and see who gets it done fastest and who comes up with the best outcome, kind of like pitting them against each other a little bit. But I think Senate Republicans have a lot of doubt about how quickly the House can get this done. There’s been a lot of pushback on the House side from members of the Freedom Caucus, the really conservative members who would like to see deeper spending cuts. And I think House leadership knows that that’s going to necessitate some cuts that are going to be really unpopular for some moderate Republicans in competitive districts. So I think the Senate sees a sense of urgency. Ross Vought, the OMB director, was on the Hill today basically saying they’re running out of money to do some of these immigration things that they want to do, and [Sen.] Lindsey Graham is saying: We need to be more urgent about this. We need to get this done quickly. So I think that that’s why they’re trying to move.听

Rovner: Just to be clear: The Senate is trying to do a smaller bill first with a single budget resolution, and then they’ll do the tax bill later, and the House is trying to do all of it together. Is that basically where we are in the 15-second wrap-up?听

Hellmann: Yes.听

Rovner: Well, President Trump rather famously on the campaign trail said he would not cut Social Security or Medicare benefits, and just two weeks ago he said he wouldn’t cut Medicaid, either, except for fraud and abuse. How on Earth is either chamber going to pay for $4 trillion in tax cuts without cutting Medicare, Medicaid, or Social Security?听

Goldman: I think it’s important to note that Trump said that he’s going to love and cherish Medicaid and only make changes in fraud, waste, and abuse categories. But what does that mean? We don’t really know. There are a lot of ways that that could be interpreted. So I definitely don’t think that Medicaid and, possibly, I haven’t heard chatter about Medicare, but if you apply the same logic, possibly Medicare and Social Security as well are on the table.听

Rovner: Yeah. And Medicaid, I know that certainly everybody seems to be getting all excited about Medicaid work requirements. They seem to have forgotten what we learned before, which is that most people on Medicaid already work, and if they don’t, it’s because they can’t. They’re either disabled themselves, caring for someone who’s disabled, or for other legitimate reasons cannot work. And that when you do work requirements, generally what we discovered in Arkansas is that you knock eligible people off the rolls, not because they’re not working but because they’ve not been able to properly report that they are working. So we saw lots of people who were eligible and working who were still cut 鈥� which maybe that’s the idea of how you cut Medicaid and call it waste, fraud, and abuse?听

Goldman: Definitely possible.听

Rovner: Shefali, what’s the impact of a really big cut to Medicaid, besides the fact that it would save a lot of money?听

Luthra: I think it’s something that we don’t talk about enough, because Medicaid is such a tremendous payer for so many people’s health insurance. We’ve seen really meaningful efforts to expand Medicaid’s reach in the past. Even just a few years, I’m thinking about its role in covering pregnancy, in particular. About half of all pregnancies are paid for through Medicaid. A lot of people qualify for the program specifically when they become pregnant, because the income threshold is different. And we’ve seen a lot of states extend eligibility so that you can hold on to your Medicaid for six months postpartum, the period when you’re most vulnerable, in an effort to reduce pregnancy-related mortality. And obviously insurance is not the sole silver bullet toward improving health, but it makes a very big difference. And so when we talk about cuts toward Medicaid, we talk about cuts toward very vulnerable people. We also do talk about backtracking in an effort to undo one of our most significant reproductive health problems, which is that we really trail other wealthy nations when it comes to maternal mortality, and jeopardizing Medicaid means that we could continue to do that.听

Rovner: An administration that pushes not just the pro-life position, but the pro-family position and the pro-natal, the Let’s have more children position, that seems to be something that gets lost, I think, in a lot of this fiscal discussion of, Let’s cut Medicaid to save money so we can have tax cuts. But obviously we will be talking more about this, because this is just the very beginning of it.听

All right. That is the news this week, or at least as much as we have time for. Now we will play my interview with Mark McClellan, and then we will come back and do our extra credits.听

I am so pleased to welcome to the podcast health economist and doctor Mark McClellan, who is the only person to have led both the Food and Drug Administration and the Centers for Medicare & Medicaid Services, both in the George W. Bush administration. Mark now leads the Duke-Margolis Institute for Health [Policy], which conducts interdisciplinary health policy research across Duke University and its affiliated health care system. Mark, welcome to “What the Health?”听

Mark McClellan: Julie, great to be with you. That was a mouthful and nice to be talking about. There’s so much to discuss on these kinds of topics right now.听

Rovner: I know. You’re really in the right place. So I listened to a podcast that you taped all the way back in January talking about some of the policy changes you were expecting in a second Trump administration. Is it safe to say that what’s happening now over at HHS is not what you were expecting?听

McClellan: Well, maybe it’s a matter of degree and timing, but I think the Trump Version 2 here is, they said themselves, it’s different than Version 1. There are some common themes 鈥� tax cuts, deregulation 鈥� and some new themes, though, as well 鈥� “Make America Healthy Again,” bigger emphasis on finding ways to prevent chronic disease and reduce disease burden than deal frankly with a big frustration of Americans. The first Trump administration was more about repealing the ACA [Affordable Care Act]. This is a different approach here. And also the president promised not to cut Medicare benefits. But then, Julie, I think you’re referring to the third part, which may be the DOGE part, which is a more aggressive approach. As President Trump said, “I’ve learned a lot” over the last eight years. I think he and the people who are advising him have come away from that thinking they can be more aggressive if they want to get more changes done in the direction that they feel like they were elected to pursue.听

Rovner: Well, my main reason in asking you to join us today was to explain this big fight going on at the National Institutes of Health, one of the few major agencies at HHS that you have not led, at least not yet. I assume that many of the researchers you work with have NIH grants, right?听

McClellan: Yeah. So at Duke University, very heavily dependent on federal function, a big federal grant support for its research functions, lots of programs, from gene therapies to cutting-edge AI. All of the efforts to translate that from basic science to impacts on making Americans healthier depends on the NIH.听

Rovner: So how’s the grant process supposed to work? I live near NIH, and I think most people think, Oh, it all goes on there. It’s like the vast majority of it does not go on there.听

McClellan: No, the vast majority is grants that go out to academic institutions and other researchers. And that goes back to the post-World War II era when the United States was trying to figure out what kind of biomedical science policy would work best. And the decision then was we’re not going to have just government institutes run and executed under direct government oversight. We’re going to do this as a public-private partnership with the federal government providing a lot of support, especially for the basic research, what us economists call a public good. Something that benefits everybody is therefore kind of harder for an individual company to support by itself. We’re going to support private academic institutions, nonprofits, sometimes state-affiliated, and we’re going to do that through the grants themselves and also for the infrastructure that’s needed to sustain that research base and grow it out and strengthen it over time.听

Rovner: And that’s what these indirect costs are, right?听

McClellan: Yeah, the indirect costs also date back to the early days, and over time, just like everything else that where federal funding is involved, you’ve got to be careful about how to do it. So in order to do research, you not only need cutting-edge technology and equipment, the funding for the researchers who are the best trained in the world and have the most promising ideas out there, but also funding for increasingly advanced and sophisticated medical equipment, gene sequencers, advanced microscopes.听

And not only the equipment themselves, but maintaining all of this. I work with a lot of these labs and researchers in them. They are also having to spend a lot of resources and time and effort making sure that they’re handling data and samples securely and appropriately, that they’re maintaining all this equipment and the buildings and the other infrastructure supports that they need. And also making sure they’re documenting and complying with all the requirements for what you can and can’t do with federal grant money. That’s where all the overhead goes, and there’ve been, over years, a lot of agreements worked out that have a whole process for figuring out what’s an appropriate cost and what’s not that factors into the resulting overhead rates that academic institutions get for their grants.听

Rovner: So the Trump administration says that, Why should the federal government be paying these indirect costs, particularly to big institutions like Duke that have big endowments? Why can’t Duke just use its endowment to pay for these indirect costs?听

McClellan: Well, Duke does have an endowment, but most of the organizations that are conducting research don’t have an endowment that would cover the kinds of costs that we’re talking about here. We’re talking about, like, biosecure materials, sensitive patient information, very complex equipment put together at scale for major research projects. And that’s something that historically has been part of what governments do best, just like paying for the development of the good research ideas to see if they really pan out and can be advanced to be used effectively in humans. Also, the supports for those increasingly complex research projects that are needed. And the private foundations, Julie, that pay for some additional projects and things, they’re really operating off of this base publicly supported infrastructure that’s had tremendous contributions 鈥� you look at the data 鈥� tremendous contributions in terms of value for money for the research spending, including the overhead spending that goes into it.听

I should say that that’s not to say that we’ve got all this right. These programs get established and you need to keep looking at them. So do we really need as many NIH institutes as we have today? We’ve learned that a lot of underlying biological processes work across different diseases, not only different types of cancer, but say, as we’ve seen with some of the obesity drugs, obesity and cardiometabolic diseases also have implications for heart and kidney disease, maybe even cancer. Are we doing enough big moonshots on these, kind of understanding fundamental biologic processes? Are we set up to do that? And are these really the most efficient ways to set overhead to support modern technology and research where AI and cloud-based data infrastructure are a much more important part? So it’s important to keep looking at these questions, but they are important issues to deal with if you want to have effective research infrastructure.听

Rovner: What happens, though? At the moment, this is on hold. Judges ordered it stopped. I believe NIH had said they will go back to issuing grants. But if this were to happen 鈥� I mean, you’re an economist, also 鈥� this would have an enormous economic effect, and in addition to the impact that it would have just on鈥斕�

McClellan: Yeah. And I’ll leave it to the universities and the research advocates who have made a very clear case about 鈥� these are billions of dollars in funding, collectively. It would have a big impact on the biomedical research infrastructure. And I think, Julie, that’s why you’ve seen two things have happened since this proposal went out. The first was the proposals faced judicial restrictions, temporary restraining orders, both on the ground. This was a very broad decision that might not be consistent with the congressional requirements to spend money on these research priorities. But second, what they call in government regulatory speak an arbitrary and capricious government decision, one that wasn’t tied to a look at. And the NIH does have the authority to set and adjust rates, but it has a well-established set of processes for figuring out what is an appropriate rate. It can update those processes, but it has to go through the effort, essentially what the temporary restraining orders on these cases have put in place. So those are not moving forward right now.听

The other thing that’s happened has been a lot of these research advocates and others, patient groups, affected cancer patients, etc., have talked to their members of Congress, and you’ve seen a bipartisan swell of concern about this. This is not a new thing under the sun. The Trump administration in 2018 actually proposed in its legislative budget proposals to limit overhead costs. The response to that in Congress was not only continuing the NIH budget where it was, but restricting reductions in overhead rates without a due-process approach. So we’re seeing some of the same thing playing out here.听

Rovner: Last question. This is really for you. You’ve worked as a high-level HHS official in a Republican administration. What advice would you give those who are about to walk into the jobs that you once had?听

McClellan: Well, I would advise them to, and I hope would advise the administration, to help those people get there soon. So these kinds of policy approaches, some further proposals for NIH and, for that matter, FDA and CDC reforms, are on the books, but we don’t have confirmed leaders in any of those agencies right now, and also some very thin staff. Julie, often in addition to the Senate-confirmed leader of the organization, there’ll be some other senior leaders who can carry out the administration’s policy agenda, but also have a lot of experience with the agency or with the organizations that the agency is dealing with.听

And the NIH, the FDA are pretty thin on those people right now. I’d contrast that with CMS, where my other successor, Dr. [Mehmet] Oz, is not there yet. He hasn’t been confirmed, but he has a whole team of seasoned political appointees and actually some really good career appointees who have come back who are trying to implement policies effectively there. That’s what I’d really encourage, getting a team on board so we can look at these issues, find ways to do research more efficiently and effectively. Those are the kinds of goals that I think a lot of people would share.听

Rovner: Well, we will all be watching. Mark McClellan, thank you so much.听

McClellan: Great to talk with you.听

Rovner: OK, we’re back. It’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Jessie, why don’t you go first this week?听

Hellmann: My story is from NPR. It’s called “.” It’s about an executive order basically ordering hospitals not to provide gender-affirming care if they want to continue receiving Medicare and Medicaid funding and other kinds of federal funding. Obviously, Medicare and Medicaid are huge revenue sources for hospitals, and so they really feel like they have no other option but to comply with his executive order. And the story looks at the impact that that has. Hospitals have been canceling appointments that people have already made to receive this care. And then on the other hand, you have states telling hospitals that they can’t stop providing this care if they’ve been doing it already. And it just really shows how there’s no playbook for this and hospitals and patients are left in a really tenuous position.听

Rovner: Shefali.听

Luthra: My piece is from Politico, by Jonathan Martin. The headline is “.” And it’s a really great Q&A that he’s done with a longtime USAID worker whose name he withholds for privacy concerns. And they talk about how this employee feels and how he’s processed the past several days of USAID being virtually abandoned by the federal government. What I love about this is how frank the conversation is and how I think it does a really important job of putting a very human face on the kind of people that we have heard really criticized by Elon Musk and by Donald Trump, described as fraudsters and disloyal and criminals.听

And what we see in this piece is that the people who work for USAID and work in this industry, they could be making more money elsewhere, but they are risking their lives and often facing threats of kidnapping, of violence in their work because they think it means something and they really care about doing this work. I just hope that more people read pieces like this to understand who exactly is being hurt, workers and also the people whom they help, the lives they save every day, when we talk about the decimation of USAID that we are currently experiencing.听

Rovner: Yeah, it’s quite a moving piece. Maya.听

Goldman: My extra credit is a story published by 麻豆女优 Health News on CBS’ website called “.” And I think it’s important for a couple reasons. One, it’s a good reminder that while there is so much chaos happening in Washington, there are other issues that have been going on since long before the election, like health care worker shortages and primary care shortages that are still really important to pay attention to. But I also love that this takes a really big issue, provider shortages in rural areas, and humanizes it, like Shefali said, and shows a really poignant example. There’s this small town. They had one doctor for many years, and that doctor retired. And now, what do you do? It’s just, I think, a good look at that problem.听

Rovner: It is. Right, my extra credit is actually by Maya, and it’s called “.” So between those ads for movies and Dunkin’ Donuts and new cars and beer was one for NYU Langone Health, a giant academic medical center in New York City. It’s not the first hospital ad to air during the Super Bowl, and it’s not even NYU’s first. But a supposedly nonprofit system dropping a cool $8 million while the long knives are out for health spending, as we’ve been discussing for the last half an hour, is maybe not the best look. I don’t know. I personally prefer the Budweiser Clydesdales.听

OK, so before we go, as promised, I am honored to announce the winner of this year’s 麻豆女优 Health News Health Policy Valentine Contest. It’s from Sally Nix of North Carolina, and it goes like this. “Roses are red, our system is flawed. Surprise bills and denials leave us all feeling odd. They promise us care, yet profits come first, leaving patients to suffer and wallets to burst. But know that voices stand by your side, doctors and advocates who won’t let this slide. Love should mean coverage that’s honest and kind, not loopholes and jargon designed to blind. This Valentine’s Day, let’s champion care, and demand a system that’s honest and fair.”听

Congratulations, Sally. I hope the rest of you also have a very happy Valentine’s Day. OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always, to our producer and editor, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me occasionally at X, , and increasingly at Bluesky, . Where are you guys hanging on social media these days? Maya?听

Goldman: I’m on [X] and , @Maya_Goldman_, I believe. And been a little more active on recently, so find me there.听

Rovner: I’m hearing that a lot. Shefali, where are you?听

Luthra: I am on Bluesky, at , and that’s about it.听

Rovner: Jessie?听

Hellmann: I am and , @jessiehellmann.听

Rovner: Great. We will be back in your feed next week. Until then, be healthy.听

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Trump’s from the World Health Organization means the U.S. will probably not be at the table in February when the WHO executive board next convenes. The WHO is shaped by its members: 194 countries that set health priorities and make agreements about how to share critical data, treatments, and vaccines during international emergencies. With the U.S. missing, it would cede power to others.

“It’s just stupid,” said Kenneth Bernard, a visiting fellow at the Hoover Institution at Stanford University who served as a top biodefense official during the George W. Bush administration. “Withdrawing from the WHO leaves a gap in global health leadership that will be filled by China,” he said, “which is clearly not in America’s best interests.”

Executive orders to withdraw from the WHO and to reassess America’s cite the WHO’s “mishandling of the COVID-19 pandemic” and say that U.S. aid serves “to destabilize world peace.” In action, they echo priorities established in ’s “Mandate for Leadership,” a conservative policy blueprint from the Heritage Foundation.

The 922-page report says the U.S. “must be prepared” to withdraw from the WHO, citing its “manifest failure,” and advises an overhaul to international aid at the State Department. “The Biden Administration has deformed the agency by treating it as a global platform to pursue overseas a divisive political and cultural agenda that promotes abortion, climate extremism, gender radicalism, and interventions against perceived systemic racism,” it says.

As one of the world’s largest funders of global health 鈥� through both international and national agencies, such as the WHO and the U.S. Agency for International Development 鈥� America’s step back may curtail efforts to provide lifesaving health care and combat deadly outbreaks, especially in lower-income countries without the means to do so alone.

“This not only makes Americans less safe, it makes the citizens of other nations less safe,” said Tom Bollyky, director of global health at the Council on Foreign Relations.

“The U.S. cannot wall itself off from transnational health threats,” he added, referring to policies that block travelers from countries with disease outbreaks. “Most of the indicates that they provide a false sense of security and distract nations from taking the actions they need to take domestically to ensure their safety.”

Less Than 1%

Technically, countries cannot withdraw from the WHO until a year after official notice. But Trump’s executive order cites his termination notice from 2020. If Congress or the public , the administration can argue that more than a year has elapsed.

Trump suspended funds to the WHO in 2020, a measure that doesn’t require congressional approval. U.S. contributions to the agency hit a low of during that first year of covid, falling behind Germany and the Gates Foundation. Former President Joe Biden restored U.S. membership and payments. In 2023, the country gave the WHO .

As for 2024, Suerie Moon, a co-director of the global health center at the Geneva Graduate Institute, said the Biden administration paid for 2024-25 early, which will cover some of this year’s payments.

“Unfairly onerous payments” are cited in the executive order as a reason for WHO withdrawal. Countries’ dues are a percentage of their gross domestic product, meaning that as the world’s richest nation, the United States has generally paid more than other countries.

Funds for the WHO represent about 4% of America’s , which in turn is less than 0.1% of U.S. federal expenditures each year. At about $3.4 billion, the WHO’s entire budget is roughly a third of the budget for the Centers for Disease Control and Prevention, which got $9.3 billion in core funding in 2023.

The WHO’s funds support programs to prevent and treat polio, tuberculosis, HIV, malaria, measles, and other diseases, especially in countries that struggle to provide health care domestically. The organization also responds to health emergencies in conflict zones, including places where the U.S. government doesn’t operate 鈥� in parts of Gaza, Sudan, and the Democratic Republic of the Congo, among others.

In January 2020, the WHO alerted the world to the danger of the covid outbreak by sounding its highest alarm: a public health emergency of international concern. Over the next two years, it vetted diagnostic tests and potential drugs for covid, regularly updated the public, and advised countries on steps to keep citizens safe.

Experts have cited missteps at the agency, but that internal problems account for the United States’ having one of the world’s highest rates of death due to covid. “All nations received the WHO’s alert of a public health emergency of international concern on Jan. 30,” Bollyky said. “South Korea, Taiwan, and others responded aggressively to that 鈥� the U.S. did not.”

鈥業t’s a Red Herring’

Nonetheless, Trump’s executive order accuses the WHO of “mishandling” the pandemic and failing “to adopt urgently needed reforms.” In fact, the WHO has made some changes through bureaucratic processes that involve input from the countries belonging to it. Last year, for example, the organization to its regulations on health emergencies. These include provisions on transparent reporting and coordinated financing.

“If the Trump administration tried to push for particular reforms for a year and then they were frustrated, I might find the reform line credible,” Moon said. “But to me, it’s a red herring.”

“I don’t buy the explanations,” Bernard said. “This is not an issue of money,” he added. “There is no rationale to withdraw from the WHO that makes sense, including our problems with China.”

Trump has accused the WHO of being complicit in China’s failure to openly investigate covid’s origin, which he alludes to in the executive order as “inappropriate political influence.”

“The World Health Organization disgracefully covered the tracks of the Chinese Communist Party every single step of the way,” Trump said in posted to social media in 2023.

On multiple occasions, the WHO has from China. The agency doesn’t have the legal authority to force China, or any other country, to do what it says. This fact also repudiates Trump’s warnings that a pandemic treaty under negotiation at the WHO impinges on American sovereignty. Rather, the accord aims to lay out how countries can better cooperate in the next pandemic.

Trump’s executive order calls for the U.S. to “cease negotiations” on the pandemic agreement. This means the pharmaceutical industry may lose one of its staunchest defenders as discussions move forward.

In the negotiations so far, the U.S. and the European Union have sided with lobbying from the to uphold strict patent rights on drugs and vaccines. They have from middle-income countries in Asia, Africa, and Latin America to include licensing agreements that would allow more companies to produce drugs and vaccines when supplies are short in a crisis. A estimated that more than a million lives would have been saved had covid vaccines been available around the world in 2021.

“Once the U.S. is absent 鈥� for better and for worse 鈥� there will be less pressure on certain positions,” Moon said. “In the pandemic agreement negotiations, we may see weakening opposition towards more public-health-oriented approaches to intellectual property.”

“This is a moment of geopolitical shift because the U.S. is making itself less relevant,” said Ayoade Alakija, chair of the Africa Union’s Vaccine Delivery Alliance. Alakija said countries in Asia and Africa with emerging economies might now put more money into the WHO, change policies, and set agendas that were previously opposed by the U.S. and European countries that are grappling with the war in Ukraine. “Power is shifting hands,” Alakija said. “Maybe that will give us a more equitable and fairer world in the long term.”

Echoes of Project 2025

In the near term, however, the WHO is unlikely to recoup its losses entirely, Moon said. Funds from the U.S. typically account for about 15% of its budget. Together with Trump’s that pauses international aid for 90 days, a lack of money may keep many people from getting lifesaving treatments for HIV, malaria, and other diseases.

Another loss is the scientific collaboration that occurs via the WHO and at about 70 centers it hosts at U.S. institutions such as Columbia University and Johns Hopkins University. Through these networks, scientists share findings despite political feuds between countries.

A commands the secretary of state to ensure the department’s programs are “in line with an America First foreign policy.” It follows on the order to pause international aid while reviewing it for “consistency with United States foreign policy.” That order says that U.S. aid has served “to destabilize world peace by promoting ideas in foreign countries that are directly inverse to harmonious and stable relations.”

These and executive orders on climate policies track with policy agendas expressed by Project 2025. Although Trump and his new administration have distanced themselves from the Heritage Foundation playbook, the work histories of the 38 named primary authors of听Project 2025听and found that at least 28 of them worked in Trump’s first administration.听One of Project 2025’s chief architects was Russell Vought, who served as director of the Office of Management and Budget during Trump’s first term and has been nominated for it again. Multiple contributors to Project 2025 are from the America First Legal Foundation, a group headed by Trump adviser Stephen Miller that’s filed complaints against “woke corporations.”

Project 2025 recommends cutting international aid for programs and organizations focused on climate change and reproductive health care, and steering resources toward “strengthening the fundamentals of free markets,” lowering taxes, and deregulating businesses as a path to economic stability.

Several experts said the executive orders appear to be about ideological rather than strategic positioning.

The White House did not respond to questions about its executive orders on global health. Regarding the executive order saying U.S. aid serves “to destabilize world peace,” a spokesperson at USAID wrote in an email: “We refer you to the White House.”

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La salud de los estadounidenses ha sido desigual durante mucho tiempo, pero muestra que la disparidad entre las expectativas de vida de diferentes grupos poblacionales casi se ha duplicado desde el año 2000. “Esto es como comparar países muy distintos”, dijo Tom Bollyky, director del programa de Salud Global en el Council of Foreign Relations, y autor del estudio.

El análisis, llamado “Ten Americas” (10 Américas), publicado a fines del año pasado en The Lancet, halló que “la expectativa de vida de una persona varía drásticamente dependiendo de en dónde vive, las condiciones económicas en ese lugar y la identidad racial y étnica de la persona”.

Que la salud de algunas poblaciones específicas haya empeorado es una razón clave por la que la del país (75 años para los hombres y 80 para las mujeres) sea la más corta entre las naciones ricas.

Para cumplir con las promesas de la nueva administración Trump de que Estados Unidos vuelva a ser saludable, los responsables de las políticas tendrán que solucionar los problemas que socavan la expectativa de vida en todas las poblaciones.

“Mientras tengamos estas disparidades realmente graves, tendremos una expectativa de vida muy baja”, dijo Kathleen Harris, socióloga de la Universidad de Carolina del Norte. “No debería ser así para un país tan rico como Estados Unidos”.

Desde el año 2000, la expectativa de vida promedio de muchos indígenas americanos y nativos de Alaska ha estado disminuyendo de manera constante. Lo mismo ha sucedido desde 2014 con las personas negras en los condados de bajos ingresos del sureste del país.

“Algunos grupos en Estados Unidos enfrentan una crisis de salud”, dijo Bollyky, “y debemos responder porque está empeorando”.

Las enfermedades cardíacas, los accidentes de tránsito, la diabetes, covid-19 y otras causas comunes de muerte son responsables directos. Pero las investigaciones muestran que , sus comportamientos y sus entornos influyen en gran medida para que algunas poblaciones corran un mayor riesgo que otras.

Los nativos americanos del oeste (región que en el estudio “Ten Americas” abarca más de una docena de estados, excluyendo California, Washington y Oregon) estuvieron entre los más pobres del análisis, viviendo en condados donde el ingreso anual promedio de un individuo es inferior a los $20.000. Los economistas han demostrado que las personas con bajos ingresos .

Estudios también han vinculado el estrés de la pobreza, el y la con conductas de riesgo para confrontarlos como el y las . Y las reservas a menudo no tienen mercados y , lo que dificulta comprar y cocinar alimentos saludables.

Aproximadamente uno de cada 5 nativos americanos del suroeste no tiene seguro médico, según . Aunque el Servicio de Salud Indígena ofrece cobertura, el informe indica que el programa es frágil debido a la falta crónica de fondos. Esto significa que las personas pueden retrasar o saltearse tratamientos para afecciones crónicas. El posponer la atención médica contribuyó al enorme número de víctimas de covid entre los nativos americanos: aproximadamente murió de la enfermedad en el pico de la pandemia.

“La combinación de un acceso limitado a la atención médica y mayores riesgos para la salud ha sido devastadora”, dijo Bollyky.

En el otro extremo del espectro, la categoría de estadounidenses de origen asiático en el estudio mantuvo la expectativa de vida más larga desde el año 2000. En 2021, era de 84 años.

La educación puede ser en parte la base de las razones por las que ciertos grupos viven más.

“Las personas con más educación tienen más probabilidades de pedir, y seguir, consejos de salud”, dijo Ali Mokdad, epidemiólogo del Instituto de Métricas y Evaluación de la Salud de la Universidad Washington y autor del artículo. La educación también ofrece más oportunidades de empleo a tiempo completo con beneficios de salud. “El dinero te permite tomar medidas para cuidarte”, dijo Mokdad.

El grupo con los ingresos más altos en la mayoría de los años del análisis estuvo compuesto de manera predominante por personas blancas, seguido por el grupo principalmente asiático. Este último, sin embargo, mantuvo, por lejos, las tasas más altas de graduación universitaria. Aproximadamente la mitad terminó la universidad, en comparación con menos de un tercio en otras poblaciones.

El estudio sugiere que la educación explica en parte las diferencias entre las personas blancas que viven en condados de bajos ingresos, donde el ingreso individual promedio fue inferior a $32.363. Desde el año 2000, las personas blancas de los condados de bajos ingresos de los estados del sureste (definidos como los de Appalachia y el valle inferior del Mississippi) tuvieron una esperanza de vida mucho más baja que la de los estados del medio oeste superior, como Montana, Nebraska y Iowa. (Los autores proporcionan detalles sobre cómo se definieron y delimitaron los grupos ).

El consumo de opioides y las tasas de VIH no explicaron la disparidad entre estos grupos blancos de bajos ingresos, dijo Bollyky. Pero desde 2010, más del 90% de las personas blancas del grupo del norte se graduaron de la escuela secundaria, en comparación con alrededor del 80% en el sureste de Estados Unidos.

Comparado con otros, el efecto de la educación no se mantuvo en los grupos latinos. Los latinos tuvieron tasas más bajas de graduación de la escuela secundaria que los blancos, pero vivieron más tiempo en promedio. Esta tendencia de larga data cambió recientemente entre los latinos del suroeste debido a covid. Las personas hispanas o latinas y negras tenían casi el a causa de la enfermedad.

En promedio, los negros han experimentado durante mucho tiempo peor salud que otras razas y etnias en Estados Unidos, excepto los nativos americanos. Pero este análisis revela una mejora constante en la esperanza de vida de los negros desde el año 2000 hasta aproximadamente 2012. Durante este período, la brecha entre la esperanza de vida de los negros y los blancos se redujo.

Esto es así para los tres grupos de negros en el análisis: aquellos que viven en condados de bajos ingresos en estados del sudeste como Mississippi, Louisiana y Alabama; aquellos en condados altamente segregados y metropolitanos, como Queens, Nueva York y Wayne, Michigan, donde muchos vecindarios son casi completamente negros o completamente blancos; y los negros en todas partes.

Mejores medicamentos para tratar la hipertensión y el VIH ayudan a explicar estas mejoras que han experimentado muchos estadounidenses entre 2000 y 2010. Y las personas negras, en particular, han visto un marcado aumento de la graduación de secundaria, y avances en la educación universitaria en ese período.

Sin embargo, para las poblaciones negras el progreso se estancó en 2016. Las disparidades en materia de riqueza aumentaron. En 2021, los estadounidenses asiáticos y muchos blancos tenían los ingresos más altos del estudio, y vivían en condados con ingresos per cápita de alrededor de $50.000. Los tres grupos de negros del análisis se mantuvieron por debajo de los $30.000.

La brecha de riqueza entre los negros y los blancos tiene raíces históricas que se remontan a la época de la esclavitud, las leyes de Jim Crow y las políticas que impedían a los negros ser dueños de propiedades en vecindarios con mejores servicios de escuelas públicas, entre otros. En el caso de los nativos americanos, la brecha histórica de riqueza se puede rastrear hasta la casi aniquilación de la población y el desplazamiento masivo en los siglos XIX y XX.

La desigualdad ha seguido aumentando por varias razones, como la entre los líderes corporativos predominantemente blancos y los trabajadores con salarios bajos, que son, de manera desproporcionada, personas de color. Artículos de 麻豆女优 Health News muestran que la decisión de algunos estados de no expandir Medicaid ha puesto en peligro la salud de cientos de miles de personas que viven en la pobreza.

Investigadores han estudiado los posibles beneficios para la salud de los pagos de reparación para abordar las injusticias históricas que llevaron a las brechas raciales de riqueza. Un estima que estos pagos podrían reducir la muerte prematura entre los estadounidenses negros en un 29%.

Menos controversiales son las intervenciones adaptadas a las comunidades. Por ejemplo, la obesidad a menudo comienza en la infancia, por lo que los responsables de las políticas podrían invertir en programas después de la escuela que brinden a los niños un lugar para socializar, estar activos y comer alimentos saludables, dijo Harris. Estos programas tendrían que ser gratuitos para los niños cuyos padres no pueden pagarlos, y ofrecer transporte.

Pero si no se introducen cambios en las políticas que aumenten los salarios bajos, reduzcan los costos médicos, pongan a disposición viviendas seguras y una educación pública sólida, y garanticen el acceso a la atención de salud reproductiva, incluido el aborto, Harris dijo que la expectativa de vida general del país puede empeorar.

“Si el gobierno federal está realmente interesado en la salud de Estados Unidos”, agregó, “podría calificar a los estados en función de sus indicadores de salud y darles incentivos para que mejoren”.

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In 1997, I watched as chickens were slaughtered in Hong Kong to combat the first major global outbreak of the disease. Eighteen people were sickened by the virus and, all of whom had close contact with the birds. They were the first deaths in humans.

Though officials in Hong Kong and at the Centers for Disease Control and Prevention were pretty sure H5N1 was unlikely to spread from person to person (and still are), there were mysteries surrounding this flu strain that had suddenly acquired the ability to infect people. Among them: Some workers in Hong Kong’s poultry markets had antibodies to the virus but didn’t fall ill.

It fell off my radar until late 2005, when birds started dying in biblical numbers in remote eastern Turkey, where residents live in proximity to their animals. When bird flu is detected in an area, best practice is to promptly kill all domesticated fowl to prevent spread of the disease. The government was slow to react and farmers in the area only reluctantly culled their birds, often their main source of income. More than a dozen people were sickened and about a third died, of Zeki and Marifet Kocyigit’s four children.

I visited the family in their simple cement home during a frigid January and asked if the children had had contact with the birds. “Of course my children played with our chickens; they are children,” he said.

Shortly thereafter birds started dying of H5N1 in Greece and Nigeria. It was popping up all over Europe and Africa. Scientists determined that the virus was spreading from landing among domesticated flocks, making it hard to control by culls.

As wild fowl continued to threaten outbreaks in Europe, several countries mandated that chickens be if dead wild birds were found in an area. In 2015, a variant of the H5N1 virus , sparking outbreaks and culls on Midwest farms 鈥� though no human deaths.

Last year it .

“This has been a 20-year process,” said Peter Hotez, an infectious-disease expert at Baylor College of Medicine. “The first red flag was birds dropping from the sky. The second was harbor seals. The third is, now, cattle.”

Cows in at least in nine states have tested positive for the flu, though the full extent of the U.S. outbreak is unclear in part due to reluctance by farmers and farmworkers to cooperate with health officials. 鈥� a dairy worker who suffered conjunctivitis.

There are important differences between the Hong Kong outbreak of more than 25 years ago and the current U.S. outbreak. H5N1 today is better understood; health authorities say that in the event of more human cases it should respond to antivirals like Tamiflu, and the CDC says the United States could produce and ship 100 million doses of a vaccine 鈥� already developed 鈥� within months.

But experts like Hotez still worry. “Surveillance testing has been very fragmented 鈥� I don’t think cattle was on anyone’s radar.”

He likens the virus’s appearance in herds to a modest earthquake in San Francisco: “You know something bigger is likely coming, but you don’t know if it’ll be one year or 100.”

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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Motivada por graves errores durante la pandemia, la OMS convocó a unos 50 expertos en virología, epidemiología, ciencia de aerosoles e ingeniería biológica, entre otras especialidades, que pasaron dos años revisando evidencia sobre cómo se propagan los virus y bacterias por el aire.

El informe de la OMS no recomienda acciones a los gobiernos, hospitales o al público en general. Queda por ver si los Centros para el Control y Prevención de Enfermedades (CDC) utilizarán esta información en su propia orientación sobre el control de infecciones en entornos de atención médica.

La OMS concluyó que la transmisión aérea ocurre cuando las personas enfermas exhalan patógenos que quedan suspendidos en el aire, contenidos en pequeñas partículas de saliva y moco que, a su vez, son inhaladas por otros.

Aunque pueda parecer obvio, y algunos investigadores han abogado por este reconocimiento durante más de una década, el que perduró es un dogma alternativo que impidió a las autoridades sanitarias decir que el covid se transmitía por vía aérea hasta muchos meses entrada la pandemia.

Específicamente, se basaron en la noción tradicional de que los virus respiratorios se propagan principalmente a través de gotas expulsadas por la nariz o la boca de una persona infectada. Estas gotas infectan a otros al caer directamente en su boca, nariz u ojos, o entran en estos orificios por los dedos contaminados con estas gotas.

Aunque estas vías de transmisión siguen ocurriendo, especialmente entre niños pequeños, expertos han concluido que muchas infecciones respiratorias se propagan simplemente al inhalar aire contaminado con virus.

“Esto es un cambio radical”, dijo Julian Tang, virólogo clínico de la Universidad de Leicester en el Reino Unido, quien asesoró a la OMS para el informe. También ayudó a la agencia a crear para evaluar el riesgo de transmisión aérea en interiores.

Peg Seminario, especialista en salud y seguridad ocupacional en Bethesda, Maryland, aplaudió el cambio después que las autoridades sanitarias se resistieran por años. “El dogma de que las gotas son una forma principal de transmisión es ahora la posición de la 鈥楾ierra plana'”, dijo. “隆Viva! Finalmente estamos reconociendo que la Tierra es redonda”.

El cambio pone un nuevo énfasis en la necesidad de mejorar la ventilación en interiores y almacenar máscaras de calidad antes que se desate la próxima enfermedad transmitida por vía aérea. Lejos de ser una posibilidad remota, el sarampión está y la se está propagando entre el ganado en varios estados.

Los científicos temen que a medida que el virus H5N1 pase más tiempo en mamíferos, podría más fácilmente a las personas y propagarse entre ellas por el aire.

Las creencias tradicionales sobre la transmisión por gotas ayudan a explicar por qué la OMS y los CDC se centraron tanto en lavarse las manos y en limpiar las superficies al comienzo de la pandemia. Estos consejos eclipsaron las recomendaciones para el uso de máscaras N95 que filtran la mayoría de las partículas de virus suspendidas en el aire.

Los empleadores negaron a muchos trabajadores de salud el acceso a las N95, insistiendo en que solo aquellos que trabajaban rutinariamente a pocos metros de pacientes con covid las necesitaban. Más de 3,600 trabajadores de salud murieron en el primer año de la pandemia, muchos debido a la falta de protección.

Sin embargo, un comité asesor de los CDC parecen estar dispuesto a ignorar la actualización científica cuando se trata de su propia orientación pendiente sobre las instalaciones de atención médica.

Lisa Brosseau, experta en aerosoles y consultora del Centro de Investigación y Política de Enfermedades Infecciosas en Minnesota, advierte sobre volver a vivir el 2020 si eso sucede.

“El momento de la verdad llega cuando se toman decisiones sobre cómo proteger a las personas”, dijo Brosseau. “Los científicos de aerosoles pueden ver este informe como una gran victoria porque piensan que a partir de ahora todo seguirá a la ciencia. Pero esto no funciona así y todavía hay barreras importantes”.

El dinero es una de ellas.

Si una enfermedad respiratoria se propaga por inhalación, significa que las personas pueden reducir su riesgo de infección en interiores a través de métodos a veces costosos para limpiar el aire, como la ventilación mecánica o los purificadores de aire, y usando una máscara N95.

Hasta ahora, los CDC han sido reacios a presionar por tales acciones, mientras actualiza las directrices fundamentales para frenar las infecciones transmitidas por el aire en hospitales, hogares de adultos mayores, prisiones y otras instalaciones que brindan atención médica.

Este año, un comité asesor de los CDC publicó el que difiere significativamente del informe de la OMS. Mientras que el informe de la OMS no caracteriza a los virus y bacterias transmitidos por vía aérea como “viajeros” de distancias cortas o largas, el borrador de los CDC mantiene esas categorías tradicionales. Recomienda máscaras quirúrgicas menos ajustadas, en lugar de las N95 para patógenos que “se propagan predominantemente por distancias cortas”.

Las máscaras quirúrgicas bloquean muchas menos partículas de virus en el aire que las N95, que cuestan aproximadamente 10 veces más.

Los investigadores y trabajadores de salud han reaccionado con indignación al borrador del comité, y han enviado cartas y peticiones a los CDC. Dicen que tergiversa la ciencia y que pone en peligro la salud. “Una separación entre distancias cortas y largas es totalmente artificial”, dijo Tang.

Los virus transmitidos por aire viajan de manera similar al humo del cigarrillo, explicó. El olor será más fuerte junto a un fumador, pero los que están más lejos inhalarán más y más humo si permanecen en la habitación, especialmente cuando no hay ventilación.

De la misma manera, las personas abren ventanas cuando queman tostadas para que el humo se disipe antes de llenar la cocina y activar una alarma. “驴Creen que los virus se detienen después de 3 pies y caen al suelo?”, dijo Tang sobre la noción clásica de distancia. “Eso es absurdo”.

El comité asesor de los CDC está compuesto principalmente por investigadores de control de infecciones en grandes sistemas hospitalarios, mientras que la OMS consultó a un grupo diverso de científicos que examinaron muchos tipos diferentes de estudios.

Por ejemplo, de la OMS examinó las nubes de vapor expulsadas por cantantes y músicos que tocaban clarinetes, trombones, saxofones y trompetas. Otro sobre brotes de covid en restaurantes, un gimnasio, una fábrica de procesamiento de alimentos y otros lugares, encontrando que una ventilación insuficiente probablemente empeoró el problema sanitario.

En respuesta a la protesta, los CDC devolvieron el borrador a su comité para su revisión, pidiéndole que reconsiderara sus consejos. Desde entonces, se han realizado reuniones privadas con un grupo de trabajo ampliado. Pero el sindicato National Nurses United obtuvo notas de las conversaciones a través de una solicitud de registros públicos a la agencia.

Los registros sugieren una presión para una protección más relajada. “Puede ser difícil en cuanto a la conformidad no tener las mascarillas quirúrgicas como una opción”, dijo un miembro no identificado, según las . Otro advirtió que “el suministro y el cumplimiento serían difíciles”.

El sindicato de enfermeras : “El Grupo de Trabajo ha priorizado los costos y ganancias del empleador (a menudo bajo el paraguas de 鈥榲iabilidad’ y 鈥榝lexibilidad’) por sobre las protecciones sólidas”.

Jane Thomason, higienista industrial principal del sindicato, dijo que los registros de la reunión sugieren que el grupo de los CDC está trabajando al revés: moldeando sus definiciones de transmisión aérea para que se ajusten al resultado que prefiere.

Tang espera resistencia al informe de la OMS. “Las personas de control de infecciones que han construido sus carreras en esto se opondrán”, dijo. “Se necesita mucho tiempo para cambiar la forma de pensar de las personas”.

Los CDC se negaron a hacer comentarios sobre cómo el cambio de la OMS podría influir en sus políticas finales sobre el control de infecciones en instalaciones de salud, normas que podrían no completarse este año.

Formular políticas para proteger a las personas de inhalar virus transmitidos por el aire es algo complejo por la cantidad de factores que influyen en cómo se propagan en interiores, como la ventilación, la temperatura y el tamaño del espacio.

Agrega complejidad que los responsables de formularlas deben sopesar el costo de varias dolencias, desde el covid hasta los resfriados y la tuberculosis, contra la carga de la protección. Y los costos a menudo dependen del contexto: si un brote ocurre en una escuela o en una sala oncológica.

“驴Cuál es el nivel de mortalidad que las personas aceptarán sin precauciones?”, dijo Tang. “Esa es otra pregunta”.

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For nearly two decades, activists there have been organizing for patent reform. Host Dan Weissmann and producer Emily Pisacreta speak with one of them, drug patent expert Tahir Amin, about how legal victories in India (and some extra pressure from John Green’s online community of fans) have set the stage for generic manufacturing and lower-priced TB drugs.听听

Now, those same patent-reform activists are turning their attention to the U.S. in hopes of lowering prices here and influencing global standards.听

Credits

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there 鈥� This is part two of a two-part story, and although I think it’s great on its own, I also think you’re gonna enjoy it a LOT more if you listen to the first part. I’m just saying.

Here’s where we left off last time: The writer John Green 鈥� author of the mega-seller The Fault in Our Stars and unbeknownst to a whole lot of people, an absolute LEGEND on YouTube, which will become a big part of this story before we’re done 鈥� was feeling something like despair.

About drug prices. Especially the price of a particular drug 鈥� one that’s needed to treat tuberculosis in other countries, a drug that’s literally life and death for millions of people, made by 鈥� and priced out of reach by 鈥� Johnson & Johnson.

He knew that 8 out of 9 people who need this drug don’t get it.

A little while ago, I got to talk with this widely beloved dude.听

John Green: This is all I was thinking about: How did we end up in a world where the world’s deadliest infectious disease is largely ignored in the richest parts of the world? But I felt powerless before it.

Dan: The drug was under patent protection. So Johnson & Johnson had a legal monopoly, and they could set the price. Even so, John Green knew there were people trying to find a way.

John Green: I would look at these, um, activists and I would say, this is amazing what they’re doing. This is incredible. Like, I don’t understand how they have the energy to fight these fights where the chance of winning is so, so, so slim.

Dan: But he was about to find out 鈥� thanks to a successful patent challenge in India.

That patent challenge built on 20 years of legal and political work to craft the drug patent system in India.

And NOT ONLY did that challenge open the door to unlocking cheaper prices for that TB drug John Green is obsessed with.

But the people who fought for those changes in India 鈥� have turned their attention to the United States for the past few years.

They think they’ve got a shot at helping us reform our own drug patent system. And boy, do we need their help.

You might have heard 鈥� like in our last episode: One thing that makes drugs in the U.S. so expensive is the way pharma companies here work the patent system. Extending their monopolies way past 20 years, sometimes by decades.

But you know, it’s not like these global activists are here in the U.S. on a charitable mission.

They know if we don’t get our patent act together, they’re screwed too.

Here’s the story of what they’ve won so far. How they busted John Green out of his despair, and what it could mean for us.

This is “An Arm and a Leg.” A show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life and to bring you something entertaining, empowering, and useful.

And the person who has really been running down this part of the story is our producer Emily Pisacreta.

Emily: So, here’s something I learned: Twenty years ago, in India, they didn’t actually recognize any patents on medicine. In fact, that’s what allowed India to build a big generic drug industry. People called it the Pharmacy of the World 鈥� cranking out cheap generic drugs.

But all that was about to change.

The World Trade Organization was tightening the screws on intellectual property, like patents. If India wanted to be part of the big global trade club, it had to agree to enforce the same patent protections as places like the U.S. and Europe 鈥� including for drugs.

It was an interesting time to be a patent lawyer. Tahir Amin, whom we met last episode, was a young one at the time, living in London 鈥� on a partnership track at a law firm.

But that wasn’t what he’d hoped for.

Tahir Amin: You know, you practice law because you feel you have a legal case and you’re using your brain to kind of find the right arguments and the best arguments.

Emily: But working for big corporate clients, with deep pockets to hire lawyers, meant arguments were 鈥� less relevant.

Tahir Amin: It wasn’t really an argument, it was just that I’ve got more money and I’m just gonna sort of, you know, railroad you into a submission.

Emily: As a patent attorney, he wanted to be on the other side of that fight 鈥� maybe in a place like India, where they were creating a new patent system for drugs. By 2004, he had a new job, in Bangalore, with a group called the Alternative Law Forum.

One big issue was how India’s new patent laws would affect people with HIV. It was the height of the epidemic in India. The new laws threatened to make anti-retrovirals more expensive and out of reach for a lot of people who needed them. Tahir was outraged. Just listen to him talking to a reporter back then.

Tahir Amin: You’re telling me that actually preventing such an epidemic occurring in India is not as important as maintaining the pharmaceutical industry and giving out patents on essential medicines and drugs.

Emily: So the stakes were high! And India wasn’t going to back out of its commitment to enforcing drug patents. But activists in Tahir’s circle managed to get an important concession written into the law. It’s called Section 3D. “D” as in standing for “Don’t try to double-dip on a drug patent in India.” ’Cuz what Section 3D says is basically this: If you’re gonna try and patent a new formulation of an already existing drug, then you have to prove it increases the drug’s efficacy 鈥� makes it more effective.

Tahir Amin: The burden became much heavier on the patent holder or the applicant to show that it had better efficacy, and that was the bridge that a lot of the, the pharmaceutical companies really did not like in India’s law. And they still don’t like to this day.

Emily: And here’s why. People started using it. India passed its new patent law in 2005. The very next year, Tahir and another lawyer founded IMAK 鈥� I-M-A-K: the Initiative for Medicines, Access and Knowledge. And in [its] very first year of existence, IMAK successfully challenged seven patents on HIV medicines in India. In some cases, drug companies even withdrew their patents once the challenges were filed, knowing they wouldn’t hold up.

Dan: So, for sure: Getting Section 3D was a big victory, in India, 15, 20 years ago. And let’s talk about how different it is from our patent deal in the U.S., and what that means.

Because here, like we talked about last time, drug companies file all kinds of extra patents on existing drugs 鈥� often dozens and dozens of them. A single patent lasts 20 years, but those extra patents can add years and years of patent protection 鈥� even decades. Which allows those companies to keep their monopolies, keep prices high.

Tahir Amin calls this sort of thing “over-patenting.” Other experts call it evergreening. Pharma companies have their own term: “Life-cycle management.”

And India’s patent law, Section 3D, set a limit on this kind of thing. Your “new” add-on to your existing drug doesn’t make the drug work better? Sorry. No additional patent for you. You get your 20 years, then you’re done.

And TB advocates have been watching that 20-year clock tick down on a really important drug called 鈥� you might remember from last time 鈥� bedaquiline. There are extra patents on it 鈥� that they hoped to use Section 3D to challenge. And they wanted TB survivors to be the faces of that patent challenge.

Emily: Someone like the TB survivor I spoke to recently on Zoom听

Phumeza Tisile: OK, so my name is Phumeza Tisile.

Emily: Phumeza’s in Cape Town, South Africa, and our Zoom connection wasn’t fabulous.

Phumeza Tisile: Can we turn the video off because i think there’s a glitch?

Emily: So I’m going to relay what she told me. Phumeza first got sick with TB in 2010, when she was 19. It took a long time for doctors to realize what she had. And once they did, she had to quit university and move into the hospital for treatment for drug-resistant tuberculosis. And the treatment was rough. There were literally thousands of pills, plus lots of injections. And then one day she woke up and a nurse came by.

Phumeza Tisile: I know she was speaking. I know this because her lips were moving.

Emily: Phumeza could see her lips moving 鈥� but couldn’t hear her voice.听

Phumeza Tisile: It felt like a dream.

Emily: Like about half the people given this treatment, she had lost her hearing 鈥� for good. In some ways, she was lucky. She recovered from TB. And when she did, she got involved in TB advocacy, and wrote a blog for Doctors Without Borders 鈥� also known as MSF. That’s how she learned about a newer drug called bedaquiline 鈥� a drug that didn’t cause hearing loss and a drug that had the potential to save millions of lives. Growing numbers of people have multidrug-resistant forms of TB that can’t be cured without bedaquiline. And in 2019, MSF invited her to team up on a project to make bedaquiline more available

Dan: 鈥� by using Section 3D of India’s patent law! Because they knew: The initial patent on bedaquiline was set to expire in 2023. And Johnson & Johnson had filed one of those extra patents 鈥� a patent that would maintain their monopoly on bedaquiline for another four years.

Emily: But in India, that EXTRA patent hadn’t yet been granted. MSF saw an opportunity to challenge it based on Section 3D. MSF asked Phumeza to be the public face of that challenge, along with another TB survivor from India named Nandita Venkatesen, to make this case against the secondary patent.

That case went on for years 鈥� until March of this year. When Phumeza’s side totally won.

Based on Section 3D, India rejected Johnson & Johnson’s secondary patent on bedaquiline.

Dan: And in the U.S. and around the world, John Green and other TB advocates were watching closely. They saw some big opportunities beyond India. That’s next.

This episode of “An Arm and a Leg” is produced in partnership with 麻豆女优 Health News. That’s a nonprofit newsroom covering health care in America. Their work is terrific 鈥� wins all kinds of awards every year 鈥� and I am so proud to work with them.

AND if this story about the effort to wipe out TB speaks to you at all, you might enjoy the latest podcast from 麻豆女优: In a new season of “Epidemic,” Dr. Céline Gounder looks at the effort to eradicate smallpox. Which a lot of people thought couldn’t be done. And which wasn’t easy.

Yogesh Parashar: Any outbreak was an emergency because if you don’t move within hours and contain it, you do not know how many contacts will be there, how much it would spread, and your work would increase exponentially.

Dan: But guess what? They did it. Céline Gounder talked to some of the people who actually made it happen, on the ground. Look for “Epidemic” Season 2, wherever you get podcasts.

So back in the U.S., John Green sees the victory that Phumeza and Nandita have won, and what it can mean. For one thing, there’s an immediate practical effect.

John Green: From that moment, that meant that Indian generic medication manufacturers, of whom there are a lot, could start to develop their, their own generic versions of bedaquiline almost immediately so that, like, almost immediately after this patent expired in India, there would be generic bedaquiline available in India.

Dan: And if generic bedaquiline 鈥� cheaper bedaquiline 鈥� can be MADE in India, then maybe it could be DISTRIBUTED in other countries. Johnson & Johnson would still, somehow, have to get pressured into allowing that distribution, which would not be a small thing.

But the legal victory in India had just expanded John Green’s idea of what advocacy could accomplish.

John Green: And I was like, that is incredible. Like, maybe it is possible, you know, seeing these two young women who didn’t have the audience that I had or the power that I have or any of that succeed. I was like, OK, well, maybe working the system and being patient and, and, and, and, you know, fighting for incremental progress matters.

And that’s when I started to think, well, let’s see what I can do, or let’s see what we can do.

Dan: He says, “What we can do,” because, you know, we mentioned this last time: John Green and his brother Hank have millions of YouTube subscribers. And a lot of these folks are not casual viewers.

The Green brothers have spent more than 15 years cultivating an active community. They call themselves “nerdfighters.”

So Phumeza and Nandita won their case in March of 2023. And the original patent on bedaquiline 鈥� in India, the ONLY important patent on bedaquiline 鈥� was set to expire just a few months later, in July.

Exactly a week before that deadline, John Green posted a video that began, as lots of his videos do, in the form of an address to his brother Hank.

John Green: Good morning, Hank, it’s Tuesday. So a week from today marks a huge moment of progress for human health as the patent on the drug bedaquiline expires, allowing less expensive generic versions to be produced that can cure far more people living with multidrug-resistant tuberculosis.

Dan: And then he does a quick double-take, like someone’s whispered to him from off-camera.

John Green: Wait, what’s that? Oh, well, that’s unfortunate.

What will actually happen next Tuesday is that the company Johnson & Johnson will begin enforcing a secondary patent, thus denying access to bedaquiline to around 6 million people over the next four years.

Dan: The video is called “Barely Contained Rage: An Open Letter to Johnson & Johnson.”

And, in it, John Green lays out how Johnson & Johnson’s secondary patent on bedaquiline could keep generics off the market for four more years.

Keeping bedaquiline too expensive for an estimated 1.4 million people who would likely die without it.

John Green: So if it sounds like I’m angry, that’s because I’m angry, but I think we can make change here. Thanks to lawsuits filed by TB survivors led by two extraordinary young women, there are, right now, generic manufacturers, ready to go, making bedaquiline.

Dan: And he urges everybody watching 鈥� and that’s a lot of people 鈥� to start making some noise. Lots of nerdfighters did exactly that.

And before the week was over, Johnson & Johnson seemed to blink. The company announced that they were striking a deal with global-health agencies, to make generic bedaquiline more widely available, beyond India.

It was a cool moment for the nerdfighters 鈥� but John Green will tell you, they weren’t the whole story.

John Green: The heroes of this story are not me or the people who watched that video, although I think our contribution was important. The heroes of the story are the people who worked for the last years to make it happen.

Dan: And, as John Green says: It’s not the END of the story. For one thing, this deal excluded 11 countries 鈥� including ironically, South Africa, where Phumeza is from. All of them have high rates of TB.

John Green: The deal is good news. Um, it’s just not the news that we need yet. And everybody who it leaves out, it’s unacceptable. It’s unacceptable to leave anyone out.

Dan: A few weeks after the initial deal was announced, Johnson & Johnson made a new announcement: They were cutting their own price on bedaquiline in ALL low- and middle-income countries by more than half. Which meant even more people would have access to bedaquiline.

Emily: Which we love! But Tahir Amin says a deeper problem just doesn’t get addressed this way: It’s still Johnson & Johnson that gets to dictate virtually everything about bedaquiline 鈥� who makes it, who distributes it, and how much it should cost. That’s because, except in India, all their patent rights still stand.

Tahir Amin: Yes, they’re trying to make a voluntary arrangement that can help patients get TB drugs, but the key is, is who keeps the power? And J&J keeps the power, and that’s what the real issue should be about in this conversation.

Emily: Which sort of brings us to what he’s up to now.

Tahir Amin: As an organization we’ve pivoted, um, a little bit because we, for the best part of 16 years, we, we did challenges country by country, drug by drug. And while we felt that it was very important because it, it helped tell the story and we notched some victories.

Emily: 鈥� for the last few years they’ve taken a different approach: He says 80% of IMAK’s work is now focused here.

Dan: This is that really interesting turn we talked about right at the top of this episode: The global activists who have been fighting patent challenges around the world have focused their attention, their work, here in the United States. And it’s not because they feel bad for us, because drug prices in the U.S. are so wildly high, which they are.

Emily: Right. It’s because of what policies in the U.S. mean for people around the world. The U.S. is the heart of the global patent regime. U.S. drug companies shaped the World Trade Organization policies regarding drug patents 鈥� the policies that forced places like India to recognize patents on drugs in the first place. And it’s U.S. patent officers who train examiners around the world. How we think about and award patents here has global implications. That’s why IMAK is here now.

Tahir Amin: What we felt was we need to educate people and policymakers, other stakeholders, other groups who are interested in these issues, basically popularize the issue.

Emily: He wants to popularize the case against over-patenting, evergreening, life-cycle management, whatever you want to call stretching a 20-year patent into, say, a 38-year patent.

Tahir Amin: There’s an interesting graph that I sometimes use in my presentations. It’s like, um, you know, the duration of a patent, the social benefit actually goes up when you get the initial sort of a certain period of protection. But once you start stretching it out, the social benefit goes down.

Emily: He says not only does over-patenting keep prices super-high, it actually prevents the thing that patents are supposed to do 鈥� promote innovation: getting newer, better drugs to market faster. Because why bother making something newer and better when you have a lock on what’s selling now?

Dan: Yeah. There was a horrifying example of this in a recent New York Times story. Back in 2004, the drugmaker Gilead knew it had discovered a promising improvement to one of its HIV drugs 鈥� this new version that was less likely to damage patients’ kidneys and bones. But Gilead decided to shelve it until the patents had run dry on the old version 鈥� as part of what executives explicitly called a “patent extension strategy.”

Emily: So Tahir thinks we should rethink our patent system for drugs.

Tahir Amin: No one’s denying that people shouldn’t be rewarded for whatever investment and capital they put in. But I think the returns are just way greater than we are led to believe that they’re investing in them.

Dan: So, of course we reached out to Johnson & Johnson to ask them their opinion of these arguments. They didn’t respond, but pharmaceutical companies will often say our ability to enforce our patent rights 鈥� the big profits those monopolies make us 鈥� is what gives us the resources to innovate, to create new medicines.

Emily: And, of course, there are a lot of reasons to be skeptical of that rhetoric. For one, lots of people will point to the fact that much of the research that goes into making new medicines is actually funded by the public.

Dan: Yeah, including bedaquiline. But look, getting into that debate would take a whole ’nother episode. Or five.

Emily: Totally. And encouraging that debate 鈥� popularizing the issue 鈥� is why Tahir’s sticking around in the United States.

Dan: Yeah 鈥� and, you know, he’s fighting a GIANT battle. The scope of these battles is something I think about a lot making this show. The systems we’re up against 鈥� and pharma is just one of them 鈥� are really big. And the solutions we need are really sweeping.

I brought that up with John Green, actually. He told me about a conversation he’d had with his brother Hank.

John Green: I remember years ago, my brother was doing something stupid like he always is. He was up to some, you know, big world-changing plan. And I was like, this just isn’t gonna work, man. Like, it’s like you’re trying to move the ocean, and you have a little bucket. And you fill up the bucket, and you walk like a hundred feet.

And then you pour it in a ditch. And then you walk back. And then you fill up the bucket again. And it’s the ocean, Hank. Like, we’re not gonna move the ocean. And he was like, all right, well 鈥� OK, but I am going to go ahead and fill up this bucket and walk 100 feet and pour it in the ditch, and then I’m going to walk back to the ocean. And I’m going to do that. And that’s just what I’m going to do. And I find a lot of beauty in that. I think a lot of times we can only see how much of the ocean we’ve moved when we look back. And for now, we go on, and we go on together.

Dan: And what we’re talking about in this story is not Sisyphean. It’s not random activity. It’s strategic and purposeful, even if it’s slow.

About 20 years ago, Tahir Amin was in India, joining the fight to influence that country’s drug-patent laws.

And because he and his colleagues succeeded, those laws became the basis for Phumeza and Nandita’s successful challenge 鈥� which created leverage for advocates [and John Green’s nerdfighters] to use in actually pushing Johnson & Johnson to make generic bedaquiline more widely available.

That fight’s not over, but guess what? The updates are not discouraging.

The pressure campaign against Johnson & Johnson happened in July 2023. As we write this, it’s September 2023, and here are three things happening this actual month:

One: The South African government launched an investigation into Johnson & Johnson for price-gouging on bedaquiline and for gaming the patent system to unfairly maintain its rights to the drug.

Two: John Green and the nerdfighters teamed up with global health agencies again to blast the internet with demands that a company called Danaher lower the price of its diagnostic tests for tuberculosis.

They were like: Make this test $5. And within a week 鈥� literally, just in time for John Green to post his next weekly video to YouTube 鈥� Danaher said, um, how about $7.97?

John Green: Which isn’t the 50% reduction we hoped for, but is extremely, extremely significant. And it’s significant in part because Danaher has committed to making no profit in poor countries from their standard TB cartridge.

Dan: And three: The Federal Trade Commission threatened to crack down on pharma companies for some abuses of patent system rules.

And you know who was there, egging them on? Tahir Amin.

Tahir Amin: This allows branded drugmakers to pocket extra revenue, often in the billions at the expense of Americans.

Dan: Again, all these updates are, as I’m writing this, just in the last month. Could be worse.

I’ll catch you in a few weeks. Till then, take care of yourself.

This episode of “An Arm and a Leg” was produced by Emily Pisacreta and me, Dan Weissmann 鈥� with help from Bella Cjazkowski 鈥� and edited by Ellen Weiss.

Daisy Rosario is our consulting managing producer.听

Adam Raymonda is our audio wizard. Our music is by Dave Winer and Blue Dot Sessions.

Gabrielle Healy is our managing editor for audience. She edits the First Aid Kit Newsletter.

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Sarah Ballema is our operations manager.

“An Arm and a Leg” is produced in partnership with 麻豆女优 Health News 鈥� formerly known as Kaiser Health News. That’s a national newsroom producing in-depth journalism about health care in America, and a core program at 麻豆女优 鈥� an independent source of health policy research, polling, and journalism.

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Pero después de dejar el cargo, lanzó una guerra contra las llamadas enfermedades olvidadas, males de tierras lejanas que la mayoría de los estadounidenses nunca sufrirán y de las que tal vez ni siquiera hayan oído hablar.

Enfermedades como la filariasis linfática, el tracoma, la ceguera del río, la esquistosomiasis鈥� y una particular causada por un bichito desagradable llamado gusano de Guinea.

Los gusanos de Guinea se propagan a través del agua potable contaminada y al comer pescado poco cocido. Los gusanos hembra, que pueden medir hasta 3 pies de largo una vez que maduran, causan ampollas abiertas increíblemente dolorosas, en general en la parte inferior de las piernas y los pies de la persona infectada, a través de las cuales emergen los gusanos.

Puede permanecer en el cuerpo durante semanas o meses, y a veces de forma permanente, dejando a algunas personas incapaces de trabajar y mantener a sus familias.

Si alguien con gusano de Guinea tiene contacto con el agua, tal vez para aliviar el dolor ardiente causado por la aparición de un gusano, el gusano puede liberar decenas de miles de gusanos bebés, contaminando todo el curso de agua.

El esfuerzo por acabar con esta enfermedad no se basó en métodos de alta tecnología. “La enfermedad del gusano de Guinea no tiene cura, no hay vacunación, básicamente todo el esfuerzo de erradicación se basa en el cambio de comportamiento”, dijo Kelly Callahan, trabajadora de salud pública que pasó años luchando contra la enfermedad del gusano de Guinea en el sur de Sudán con el Centro Carter, la organización benéfica que el ex presidente y su esposa crearon junto con la Universidad Emory.

Eso ha significado enseñar a las personas en áreas vulnerables a filtrar el agua y brindarles las herramientas de bajo costo para hacerlo.

Otras estrategias incluyen brindar acceso a suministros de agua potable, una mejor detección de casos humanos y animales, limpiar y vendar heridas, evitar que las personas y los animales infectados entren al agua y usar larvicidas para matar a los gusanos.

Gracias a Carter, el mundo ha estado increíblemente cerca de acabar con el gusano de Guinea.

“Me gustaría ver al gusano de Guinea completamente erradicado antes de morir”, dijo Carter en una conferencia de prensa en 2015. “Me gustaría que el último gusano de Guinea muera antes que yo. Creo que ahora mismo tenemos 11 casos. Empezamos con 3,6 millones”.

Parecía que el último gusano de Guinea iba a morir antes que el presidente número 39 de los Estados Unidos. Luego, hace unos años, científicos descubrieron que el parásito se estaba propagando entre los perros callejeros en Chad, y que los babuinos en Etiopía también portaban el parásito.

Este reservorio de gusanos que se pasó por alto durante mucho tiempo fue un revés para el programa de erradicación global y demostró que matar al último gusano de Guinea sería más difícil de lo que se pensaba.

Además, a medida que el número de casos ha disminuido, han surgido nuevos desafíos. En 2018, se detectó la , un país en donde no se habían registrado casos en el pasado.

Como resultado, en 2019, la Organización Mundial de la Salud (OMS) retrasó su fecha prevista de erradicación de la enfermedad una década completa, de 2020 a 2030.

Los investigadores ahora están buscando un tratamiento para los perros infectados, y los trabajadores de salud pública han recurrido a nuevas intervenciones, como pagar a las personas para que informen sobre los animales infectados. No obstante, la campaña de Carter ha tenido un éxito notable.

En una entrevista con NPR en 2015, Carter recordó los orígenes de su cruzada. El ex zar antidrogas de Carter, Peter Borne, estaba trabajando en una iniciativa de las Naciones Unidas (ONU) llamada “Década del agua dulce”. Borne fue al Centro Carter para hablar sobre enfermedades olvidadas que se propagan por “beber agua en mal estado”. Una de ellas fue el gusano de Guinea.

“La razón principal por la que [Borne] vino al Centro Carter fue porque no podía conseguir que nadie más abordara este problema”, recordó Carter. “Es una enfermedad despreciable. Y se presentaba en pueblos tan remotos que nadie quería asumir la tarea. Entonces, decidimos asumirla”. Eso fue en 1986.

El doctor Paul Farmer, fundador de Partners in Health y defensor de causas mundiales de salud que murió el año pasado, habló con NPR en 2019 sobre los esfuerzos de Carter. Farmer dijo que el ex presidente merece gran parte del crédito por llevar al gusano de Guinea al borde de la extinción.

La viruela, dijo Farmer, es “la única enfermedad humana [que ha] sido erradicada. Y si鈥� el gusano de Guinea está justo detrás, será gracias a Carter. Quiero decir, hubo millones de casos en los que se involucró鈥� después de su presidencia a mediados de los años 80. Y ahora tenemos menos de 100 el año pasado”.

El Centro Carter informó que en 2022, solo hubo 13 casos humanos registrados de la enfermedad, un número provisional que se confirmará oficialmente, probablemente este mes.

“Cuando te enfrentas a un problema como este, como el gusano de Guinea, tienes que hablar con persuasión a los funcionarios del ministerio, las figuras políticas, las enfermeras, los médicos, los activistas comunitarios, los agricultores, las personas que están鈥� en mayor riesgo. Carter ha tenido que hablar con persuasión a todas esas personas. Y eso es algo que ha sido muy inspirador para muchos de nosotros”, dijo Farmer.

, profesor adjunto de medicina en la Facultad de Medicina de la Universidad de Maryland, está de acuerdo en que la defensa de Carter ha ayudado a los gobiernos y las agencias de salud pública de todo el mundo a mantenerse enfocados en erradicar la enfermedad del gusano de Guinea. El , invirtiendo alrededor de $500 millones desde 1986.

“Creo que deberíamos ser optimistas de que es algo factible”, dijo Plowe. “Creo que no deberíamos ser demasiado optimistas sobre lo rápido que ocurrirá”.

El gusano de Guinea fue solo uno de los objetivos de la guerra de Carter. La oncocercosis, también conocida , ha sido eliminada de la mayor parte de las Américas y reducida drásticamente en África gracias al trabajo de Carter y el Centro Carter. También se han hecho avances importantes contra otras enfermedades desatendidas, como la , que provoca una horrible inflamación de las piernas y los genitales.

Aquellos que conocen bien a Carter dijeron que fue su educación en una zona empobrecida del sur lo que lo hizo tener un fuerte sentido de autosuficiencia y sacrificio, y el deber de ayudar a los demás.

Nacido en Plains, Georgia, en 1924, se mantuvo cerca de sus raíces y regresó a casa después de su carrera en la Marina para administrar la granja de maní de la familia. La iglesia fue una parte central de su vida en Plains 鈥攅nseñó en la escuela dominical hasta los 90 años鈥� y sus amigos dijeron que su fe cristiana lo impulsaba.

“Hizo lo que hizo por amor a la humanidad”, dijo , cofundadora de Habitat for Humanity, que ha contado a Jimmy y Rosalynn Carter entre sus muchos voluntarios, clavando clavos durante el día y durmiendo en literas durante la noche. Los Carter trabajaron en proyectos de Hábitat en 14 países.

En febrero, Carter ingresó a cuidados paliativos, renunciando a un tratamiento médico adicional para prolongar su vida. Pero su muerte no significará el fin de su obra. En un comunicado, el Centro Carter se comprometió a continuar la lucha para erradicar al gusano de Guinea.

Cuando la enfermedad llegue a su fin, se convertirá en uno de los logros característicos de Carter, un logro extraordinario que refleja un principio simple pero profundo de su filosofía personal: “tratar de ayudarse unos a otros en lugar de estar dispuestos a ir a la guerra uno contra otro”.

Este artículo fue producido como parte de una alianza entre KHN y NPR.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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Guinea worms are spread through contaminated drinking water and eating undercooked fish. The female worms, which can be up to 3 feet long once mature, cause incredibly painful, open blisters usually on the infected person’s lower legs and feet 鈥� through which the worms emerge. It can take a toll for weeks or months, and sometimes permanently, leaving some people unable to support a family.

If someone with Guinea worm has contact with water 鈥� perhaps to cool the burning pain caused by a worm’s emergence 鈥� the worm may release tens of thousands of baby worms, contaminating the whole body of water.

The effort to end this disease did not rely on high-tech methods. “Guinea worm disease has no cure, no vaccination, basically the entire eradication effort is built on behavior change,” said Kelly Callahan, a public health worker who spent years fighting Guinea worm disease in southern Sudan with the Carter Center, the charity the ex-president and his wife created in partnership with Emory University.

That has meant teaching people in vulnerable areas to filter their water and giving them the low-cost tools to do so.

Other strategies include providing access to safe water supplies, better detection of human and animal cases, cleaning and bandaging wounds, preventing infected people and animals from wading into water, and using larvicide to kill the worms.

Because of Carter, the world has come incredibly close to wiping out Guinea worm.

“I would like to see Guinea worm completely eradicated before I die,” Carter said at a press conference in 2015. “I’d like for the last Guinea worm to die before I do. I think right now we have 11 cases. We started out with 3.6 million cases.”

It did look as if the last Guinea worm was going to die before the 39th U.S. president. Then, a few years ago, scientists discovered that the parasite was spreading among stray dogs in Chad 鈥� and that baboons in Ethiopia were also carrying the parasite. This long-overlooked reservoir of the worms was a setback for the global eradication program and showed that killing the last Guinea worm would be harder than previously thought.

What’s more, as the number of cases has dwindled, new challenges have emerged. In 2018, Guinea worm disease was , a country not known to have had cases in the past.

As a result, in 2019 the World Health Organization pushed back its expected eradication date for the disease a full decade 鈥� from 2020 to 2030.

Researchers are now looking for a treatment for infected dogs, and public health workers have turned to new interventions, like paying people to report infected animals. Nonetheless, Carter’s campaign has been remarkably successful.

In an interview with NPR in 2015, Carter recalled the origins of his crusade. Carter’s former drug czar, Peter Borne, was working on a U.N. initiative called the “Freshwater Decade.” Borne came to the Carter Center to talk about overlooked diseases spread by “drinking bad water.” One of them was Guinea worm.

“The main reason [Borne] came to the Carter Center was because he couldn’t get anyone else to tackle this problem,” Carter recalled. “It’s a despicable disease. And it was in such remote villages that no one wanted to take on the task. So, we decided to take it on.” That was in 1986.

Dr. Paul Farmer, the founder of Partners in Health and a champion of global health causes who died last year, spoke to NPR in 2019 about Carter’s efforts. Farmer said the former president deserves much of the credit for pushing Guinea worm to the brink of extinction.

Smallpox, Farmer said, is “the only human disease [that’s] ever been eradicated. And if 鈥� Guinea worm is right behind, that’s going to be thanks to Carter. I mean, there were millions of cases when he got involved 鈥� after his presidency in the mid-’80s. And now we are down to fewer than a hundred last year.” In 2022, the Carter Center reported, there were only 13 recorded human cases of the disease, a provisional number that will be officially confirmed, likely this month.

“When you take on a problem like this, like Guinea worm, you have to sweet-talk the ministry officials, the political figures, the nurses, the doctors, the community activists, the farmers, the people who are 鈥� most at risk. Carter’s had to sweet-talk all those people. And that’s something that’s been very inspiring to many of us,” Farmer said.

, adjunct professor of medicine at the University of Maryland School of Medicine, agrees that Carter’s advocacy has helped governments and public health agencies around the world stay focused on eradicating Guinea worm disease. , too, investing about $500 million since 1986.

“I think we should be optimistic that it is achievable,” said Plowe. “I think we shouldn’t be overly optimistic about how quick it’s gonna be.”

Guinea worm was just one of the targets of Carter’s war. Onchocerciasis, also known as , has been eliminated from most of the Americas and dramatically reduced in Africa due to the work of Carter and the Carter Center. Major inroads have also been made against other neglected diseases including which causes horrific swelling of the legs and genitals.

Those who know Carter well said it was his upbringing in an impoverished part of the South that left him with a strong sense of self-reliance and self-sacrifice, and a duty to help others.

Born in Plains, Georgia, in 1924, he stayed close to his roots, returning home after his Navy career to run the family’s peanut farm. Church was a central part of his life in Plains 鈥� he taught Sunday school there into his 90s 鈥� and friends said his Christian faith drove him.

“He did what he did out of a love for mankind,” said , a co-founder of Habitat for Humanity, which has counted Jimmy and Rosalynn Carter among their many volunteers, hammering nails by day and sleeping in bunk beds by night. The Carters worked on Habitat projects in 14 countries.

In February, Carter entered hospice care, forgoing additional medical treatment to extend his life. But his death will not mean the end of his work. In a statement, the Carter Center has pledged to continue the fight to wipe out Guinea worm.

When the disease does come to an end, it will become one of Carter’s signature achievements 鈥� an extraordinary accomplishment that reflects a simple yet profound tenet of his personal philosophy: “to try to help one another instead of being willing to go to war with one another.”

This article is from a partnership that includes and KHN.

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Behind those questions are concerns about stigma and how best to allocate scarce resources. But they also reflect an individualistic understanding of public health. Rather than asking what the monkeypox outbreak means for them now, the public could be asking how the monkeypox outbreak could affect them in the future and why and how it could be contained now.

The longer monkeypox transmission goes unchecked, the more likely it is to spill over into other populations. There have already been a handful of cases among women and a couple of cases in children because of household transmission. In otherwise healthy people, monkeypox can be extremely painful and disfiguring. But in pregnant women, newborns, young children, and immunocompromised people, monkeypox can be deadly. Those groups would all be in danger if monkeypox became entrenched in this country.

Stopping transmission among men who have sex with men will protect them in the here and now and more vulnerable populations in the future. But with a limited supply of monkeypox vaccine available, how can public health officials best target vaccines equitably for impact?

It won’t be enough to vaccinate close contacts of people with monkeypox to stop the spread. Public health officials have been unable to follow all chains of transmission, which means many cases are going undiagnosed. Meanwhile, the risk of monkeypox (and other sexually transmissible diseases) isn’t evenly distributed among gay and bisexual men and trans women, and targeting all of them would outstrip supply. Such a strategy also risks stigmatizing these groups.

The Centers for Disease Control and Prevention recently for monkeypox vaccination to include people who know that a sexual partner in the past 14 days was diagnosed with monkeypox or who had multiple sexual partners in the past 14 days in a jurisdiction with known monkeypox cases. But this approach depends on people having access to testing. Clinicians are testing much more in some jurisdictions than in others.

Alternatively, public health officials could target monkeypox vaccinations to gay and bisexual men and trans women who have HIV or are considered at high risk for HIV and are eligible for , or PrEP (medication to prevent HIV infection). After all, there’s a lot of overlap between these populations and those at risk for monkeypox. But only 25% of people eligible for PrEP in the U.S. , and that proportion drops to 16% and 9% among Hispanic and Black people, respectively. This approach risks missing many people who are at risk and exacerbating racial and ethnic disparities.

This is why some LGBTQ+ activists are advocating for more aggressive outreach. “We talk about two kinds of surveillance,” said Gregg Gonsalves, an epidemiologist at the Yale School of Public Health and a longtime AIDS activist. “Passive surveillance, where I show up to my doctor’s office. Active surveillance is where we go out and we seek cases actively by going where people are at. There are parties, social venues, sex clubs where we could be doing monkeypox testing.”

This will be especially critical , where both patients and providers may be less informed and gay sex more stigmatized.

In New York City, the epicenter of monkeypox in the U.S., disparities in access to monkeypox vaccines have already emerged. The city’s health department offered appointments for first doses of the vaccine through an online portal and promoted them on Twitter. Those initial doses were administered at a sexual health clinic in the well-to-do Chelsea neighborhood.

“It was in the middle of the day,” Gonsalves said. “It was in a predominantly gay white neighborhood. 鈥� It really was targeted at a demographic that will be first in line for everything. This is the problem with relying on passive surveillance and people coming to you.”

Michael LeVasseur, an epidemiologist at Drexel University, said, “The demographics of that population may not actually reflect the highest-risk group. I’m not even sure that we know the highest-risk group in New York City at the moment.”

Granted, of the city’s cases had been reported in Chelsea, a neighborhood known for its large LGBTQ+ community, but that’s also a reflection of awareness and access to testing. Although are offering monkeypox testing, are still unaware of monkeypox or unwilling to test patients for it. You have to be a strong advocate for yourself to get tested, which disadvantages already marginalized populations.

The health department opened a second vaccination site, in Harlem, to better reach communities of color, but most of those accessing monkeypox vaccines there have been . And then New York City launched in the Bronx, Queens, and Brooklyn, which were open for one day only. To get the vaccine, you had to be in the know, have the day off, and be willing and able to stand in line in public.

How can public health officials do the active surveillance that Gonsalves is talking about to target monkeypox vaccination equitably and to those at highest risk? Part of the answer may lie in efforts to map sexual networks and the spread of monkeypox, like the Rapid Epidemiologic Study of Prevalence, Networks, and Demographics of Monkeypox Infection, or . Your risk of exposure to monkeypox depends on the probability of someone in your sexual network having monkeypox. The study may, for example, help clarify the relative importance of group sex at parties and large events versus dating apps in the spread of monkeypox across sexual networks.

“A network map can tell us, given that vaccine is so scarce, the most important demographics of folk who need to get vaccine first, not just to protect themselves, but actually to slow the spread,” said Joe Osmundson, a molecular microbiologist at New York University and co-principal investigator of the RESPND-MI study.

During the initial phase of covid-19 vaccine rollout, when vaccines were given at pharmacies and mass vaccination centers, a racial gap emerged in vaccination rates. Public health officials closed that gap by meeting people where they were, in approachable, community-based settings and through mobile vans, for example. They worked hard with trusted messengers to reach people of color who may be wary of the health care system.

Similarly, sexual health clinics may not be a one-size-fits-all solution for monkeypox testing and vaccination. Although sexual health clinics may feel welcoming to some, others may fear being seen there. Others may not be able to go to sexual health clinics because of their , on weekdays only.

It isn’t new for public health officials to meet members of the LGBTQ+ community where they are. During a 2013 outbreak of meningitis among gay and bisexual men and trans women, health departments across the country with community-based LGBTQ+ organizations to distribute meningitis vaccines. Unlike New York, Chicago is now leveraging those relationships to vaccinate people at highest risk for monkeypox.

Massimo Pacilli, Chicago’s deputy commissioner for disease control, said, “The vaccine isn’t indicated for the general public nor, at this point, for any [man who has sex with men].” Chicago is distributing monkeypox vaccines through venues like and bars to target those at highest risk. “We’re not having to screen out when people present because we’re doing so upstream by doing the outreach in a different way,” Pacilli said.

Monkeypox vaccination “is intentionally decentralized,” he said. “And because of that, the modes by which any individual comes to vaccine is also very diverse.”

Another reason to partner with LGBTQ+ community organizations is to expand capacity. The New York City Department of Health and Mental Hygiene is one of the biggest and best-funded health departments in the country, and even it is to the monkeypox outbreak.

“Covid has overwhelmed many public health departments, and they could use the help, frankly, of LGBTQ and HIV/AIDS organizations” in controlling monkeypox, Gonsalves said.

But even as public health officials try to control the transmission of monkeypox among gay and bisexual men and trans women in this country, it’s important not to forget that monkeypox has been spreading in West and Central Africa for years. Not all of that transmission has been occurring among men who have sex with men. Strategies for controlling monkeypox will need to be informed by the local epidemiology. Social and sexual mapping will be even more critical but challenging in countries, like Nigeria, where gay sex is illegal. Sadly, wealthier nations are already hoarding monkeypox vaccine supply as they did covid vaccines. If access to monkeypox vaccine remains inequitable, it will leave all countries vulnerable to resurgences in the future.

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