• Should someone my age get another MMR shot?

• What the hell is “presumptive immunity?”

• I was born after 1967 (and therefore got the modern MMR shot), but I only see one MMR on my childhood vaccine record? What’s up with that?

• Should I get my measles antibody levels checked?

• What if my titers are not good? Does that mean I’m going to catch measles?

I wrote a long post about this a year and a half ago when this measles outbreak started. Can you believe it’s still spreading? I sure can, unfortunately.

Anyway. For serious people, with sincere questions and genuine concerns, I’ve made five tables to answer the most common questions I get about measles from parents and adults alike.

I’VE ALSO CODED MY VERY FIRST APP EVER! It walks you through a few key questions and then spits out the CDC/IDSA guidance for someone of your age/situation. This information is not medical advice from me to you, but rather can be used as evidence-based, guideline-informed intelligence to discuss with your doctor regarding needing an MMR boost, an antibody check, etc! I have to thank that genius professor (from Germany, with the blue hair, whom I talked with at my daughter’s friend’s birthday party about writing apps to go along with my content sometimes). Amazing! Consider this another token of my appreciation for folks supporting my work here:

Plus, a list of references can be found at the end of this post. Most are from CDC (legit version) and Infectious Disease Society of America (IDSA).

I hope this helps!

Question #1 — Should I get another MMR shot?

• 2 doses in an outbreak situation for adults 1957 or later means 2 total doses, including the one you got as a kid… unless you’re in the 1963-1967 cohort, in which case follow those boxes and legit CDC says get the modern, live attenuated MMR!

• “Presumptive evidence” that we’re supposed to have during outbreaks is explained below.

~

Question #2 — What the hell is “presumptive immunity?”

~

Question #3 — I was born after 1967 (and therefore got the modern MMR shot), but I only see one MMR on my childhood vaccine record? What’s up with that? Why didn't I get two? Should I get another one now in this outbreak?

~

Question #4 — Should I get my measles antibody levels checked?

~

Question #5 — What if my titers are not good? Does that mean I’m going to catch measles?

Conclusion

I hope this is helpful — nuanced and very challenging as it is.

Now you know how we often feel answering these questions!

It’s not easy, but tables make it easier, so just take your time, and you know, talk to your doc. Quiz them even!

Here’s the simple app I made in case you missed it:

References

• Centers for Disease Control and Prevention. (2025a). Clinical Overview of Measles: Vaccination Guidelines. https://www.cdc.gov/measles/hcp/clinical-overview/questions.html

• Centers for Disease Control and Prevention. (2025b). Measles Vaccine Recommendations: For Healthcare Professionals. https://www.cdc.gov/measles/hcp/vaccine-considerations/index.html

• Immunize.org. (2026). Ask the Experts: MMR (Measles, Mumps, and Rubella) for Healthcare Personnel. https://www.immunize.org/ask-experts/topic/mmr/for-healthcare-personnel-mmr/

• Infectious Diseases Society of America. (2025). Measles: Know the Facts. https://www.idsociety.org/ID-topics/infectious-disease/measles/

That’s the point.

That’s the whole game.

Here’s what happened. I used Claude and Perplexity to help me document this across the internet, and to draft as accurate a version of this post as I could. On August 25, Pennsylvania’s health department announced two “measles-associated” deaths in Lancaster County (a short drive from here in Philly), both in unvaccinated residents. These were the first measles deaths in PA in 35 years. Citing privacy, few other details were released.

Within a day, Lancaster County’s coroner told reporters his office had no measles deaths on its books. Without context or knowledge of how information flows between county health and coroner, that might naturally raise suspicion.

One of the two deceased turned out to be a newborn who died August 14 at a birthing center of a “traumatic” laceration of the spleen. He tested positive for measles by PCR on lung tissue. By definition this would be an infection acquired before birth, not just maternal antibodies being detected. The coroner and the forensic pathologist concluded measles was not a contributing cause, though measles was listed under Part II of the death certificate, the section for conditions that contribute to a death without totally causing it. Were the coroner and pathologist correct? Or did they not go there with a plausible connection between measles infection, splenic enlargement and heightened risk of splenic rupture?

This is a good time to assert the following refrain:

Measles is a vaccine-preventable disease that hospitalizes about one in five unvaccinated children, kills one to three of every thousand it infects, and strips survivors of immune memory they had already built against other infections. In babies infected before their first birthday roughly one-in-600 will develop SSPE, a brain disease that surfaces years later and is always fatal. We have had a vaccine since 1963, and the United States declared measles eliminated in 2000.

There are no politics informing these numbers, and this is what a typical case looks like.

Back to Pennsylvania, and the different messages coming from two offices charged with different tasks. A coroner’s office determines cause of death for a legal certificate. A state health office counts deaths under outbreak surveillance definitions - a necessary and faster standard designed to flag a death plausibly connected to an outbreak. That allows the state to respond in real time rather than wait days/weeks for a final certificate. As Dr. Amesh Adalja of Johns Hopkins observed, the state did not tell people in their announcement that two systems were running, so a coroner’s log showing zero next to a state count of two was ripe for controversy.

What happened next seems opportunistic and motivated to create that controversy. Within 48 hours Secretary of Health and Human Services RFK Jr. was suggesting on X that the deaths “may even have been altogether fabricated by one of the Governor’s hopeful staffers,” and telling reporters that nobody could find any measles deaths in Lancaster County.

See the sleight of hand? It is worth reminding folks who the accuser is. Days earlier, the Associated Press and the Guardian published documents (including a letter to Samoa’s prime minister that used the word vaccine or vaccination eight times) indicating that RFK Jr’s sworn confirmation testimony that his 2019 Samoa trip had “nothing to do with vaccines” was false. Senator Ron Wyden has called for a Justice Department referral for possible criminal investigation. HHS says the suggestion is defamatory. But we can’t forget that trip preceded a measles outbreak in Samoa that killed 83 people, most of them children under five.

According to Governor Shapiro, in a phone call about this Pennsylvania matter, Secretary Kennedy said it would be better if we went back to "natural measles."

Note that the Pennsylvania pattern is familiar: a procedural quirk or delay in how a death is classified gets converted into a claim that the death didn’t happen, or didn’t count. We saw the same weak but effective maneuvers employed on Covid mortality statistics, and even on the two Texas children who died of measles complications last year.

This is also a good time to assert the following refrain:

Measles is a vaccine-preventable disease that hospitalizes about one in five unvaccinated children, kills one to three of every thousand it infects, and strips survivors of immune memory they had already built against other infections. In babies infected before their first birthday roughly one-in-600 will develop SSPE, a brain disease that surfaces years later and is always fatal. We have had a vaccine since 1963, and the United States declared measles eliminated in 2000.

There are no politics informing these numbers, and this is what a typical case looks like.

Let’s revisit the tragic infant death as reported. I am not an OB/GYN (though I’ve delivered babies), nor am I a neonatologist or medical encyclopedia. But I can look stuff up. Neonatal splenic rupture is not merely rare — fewer than 50 cases had been reported in the world literature as of this review from 2017. Another 2021 review found 39 cases across five decades of published reports.

The clinical literature also draws a specific distinction: a newborn’s spleen ruptures either because it was abnormally enlarged, or because the delivery was unusually traumatic. If the spleen in this case was indeed normal, something very traumatic happened during birth to explain it, and no such account has been offered that I can find. I scoured the public records using Perplexity just now. It has not been publicly disclosed whether the labor was uncomplicated, prolonged, precipitous, malpresenting, or otherwise difficult, nor whether resuscitation, delivery maneuvers, an unrecognized in-utero event, or some other process caused splenic trauma.

Don’t forget the infant had measles detected in the lungs. Measles enlarges the spleen and thins its capsule, which is why Dr. considers rupture during birth the likely mechanism. The coroner reported no enlargement, but enlargement would be genuinely hard to assess in a spleen that has already burst. Congenital measles is vanishingly uncommon in the United States.

So, to hold that these two very rare events, congenital measles infection and splenic rupture, landed in the same delivery independently is to claim a coincidence of a kind almost no one would accept in any other context. And yet this coincidence seems to underpin the entire distraction, and redirects us away from the real problem of measles in America.

Pennsylvania has confirmed 460 cases, nearly half in Lancaster County, with 70 people having been hospitalized. Being hospitalized means you are really sick and suffering. Nationally there have been more than 2,700 cases, more than any year since 1991 when the Soviet Union collapsed, the World Wide Web went online, and Michael Jordan won his first ring. Plus, we still have four months and back-to-school on the 2026 calendar. And then there is 2027.

MMR coverage in Lancaster County fell from 95.5% in 2017 to 87.6% in 2025. That is below what is needed for herd immunity. Nationwide, 4.2% of kindergartners, roughly 155,000 children, now carry at least one vaccine exemption. A panel is reviewing whether the United States has lost measles elimination status after 26 years. Semantics.

The infant at the center of the argument did not have an opportunity to get vaccinated. The first MMR dose is given at 12 months of age. The only things protecting a baby that young are a mother with immunity and a community that hasn’t fallen below the threshold for herd protection.

So, zoom out when this argument zooms in. The criticism that Pennsylvania created an information vacuum is sound. There are structural reasons why this happened, but that’s still a poor excuse for sloppy communication. And yet the real stinking fish here is the red herring: whether one newborn's spleen was enlarged at autopsy. Answering that will still not change much of anything with respect to what’s going down with vaccination, measles, and the health of the American public in 2026.

The logical fallacy of the red herring introduces a tangential issue to divert attention from the actual question, so that arguing about the tangent substitutes for fixing the actual problem.

Cue refrain:

Measles is a vaccine-preventable disease that hospitalizes about one in five unvaccinated children, kills one to three of every thousand it infects, and strips survivors of immune memory they had already built against other infections. In babies infected before their first birthday roughly one-in-600 will develop SSPE, a brain disease that surfaces years later and is always fatal. We have had a vaccine since 1963, and the United States declared measles eliminated in 2000.

There are no politics informing these numbers, and this is what a typical case looks like.

By now you’ve heard that Covid rates are on their way up here in the US. For example I saw two older people in my office yesterday who tested positive. Last week a partner diagnosed four. A wave is typical for this time of year, with another usually rolling in from Thanksgiving through New Year’s. Fall shots are hopefully coming soon for those who want them, and I’ve clipped a few articles and studies from this summer that I’d like to highlight.

By now you’ve also heard that Dolly Parton has left us. Among the many, many cherished things about Dolly Parton were her contagious enthusiasm, engaging humor, and confident kindness. Her incredible voice endures as one of our all time favorites. She also put it to service early in the pandemic, along with a million dollars donated to Vanderbilt as they worked feverishly hard on the Moderna Covid shot, which she got in her left arm:

God bless.

~

For two years I dropped these Covidlandia posts on a monthly basis. Now I have decided to stretch them out a bit. I want to keep this proportionate with the pace at which any paradigm-shifting studies, treatments, or prevention strategies are discovered/reported, and timely when Covid rates bump upward.

The basic tenets remain the same. In Covidlandia we believe:

Covid rates right now

It is estimated that about 1 in every 136 people in America has infectious Covid right now… but the variation is huge going from state to state, county to county. For example, based on sewage analysis, some areas of Texas are as high right now as the peak of the BA-1 Omicron wave. Put another way, in some Texan counties 1 out of every 20 people has active Covid right now.

Other hot spots include Mississippi, Hawaii, and Puerto Rico, with California, Washington, and Alaska picking up steam on the west coast.

The two patients I saw yesterday with Covid had just returned from trips to Florida, where some counties look Very High.

The heat map is from Pandemic Mitigation Collaborative. The tireless effort headed by Dr. Mike Hoerger seems to be a better source of reporting/analysis/heads up than the CDC these days. Dr. Hoerger recently explained how the captured CDC moved the goalposts, minimizing Covid rates with new categories that make everything seem like low prevalence.

I keep a KN95 mask on in the office. When someone comes in with Covid symptoms (even mild like sore throat), I upgrade to an N95. My health system requires all physicians to be fit tested annually. The 3M Aura N95 mask is a good, validated, well-fitting option for me. Often people test positive for Covid and are surprised, and have exposed lots of other people including their families. Rapid antigen testing at home is still worthwhile, and costs about $10/test.

Given the realities of maintaining a social life, the overall reduced severity of Covid illnesses, the many competing existential catastrophes in the world right now… I can’t pretend that Covid is the worst thing out there. But I still try not to catch a case when I can. See modalities and ideas hyperlinked in the shaded box above under “prevention” if you want a review!

Here’s the near term national forecast:

Fall updated shots

From everything I’ve read, these shots targeting the XFG variant should be out in early September. This seems like a good match providing more precise target practice against the stuff going around right now. I’ll keep you posted when I learn more from the sources I follow. I called Sanofi (the company in charge of the Novavax shots now) and I couldn’t score any more information than the public, vague, “soon” timeline.

It would make sense to have these updated shots available by August, since year after year the first wave hits towards end-of-summer/back-to-school, right? Alas, not much makes sense in 2026.

My own strategy? Assuming I don’t get Covid between now and when the shots come out, I’m planning to get Nuvaxovid for the second year in a row. It’s now a Sanofi product, but was developed by Novavax. It’s a protein nanoparticle vaccine platform. I have nothing against mRNA shots, and I tolerate them just fine. But I like and wrote about the wonky logic of reigning in IgG antibody class switching by mixing it up. And a head-to-head study recently found that Nuvaxovid does indeed produce less side effects than Moderna’s newish mNexspike option.

Why stay up to date? I’m hoping for a reduction in my risk of contracting Covid for a while. If I do catch a case, I’ll be counting on less severe symptoms, less risk of transmitting it to others, and likely a bit less chance of developing long Covid and other downstream sequelae of infection. I’ve painstakingly documented how previous years’ shots have done all this, and I’ll keep dropping some studies as they roll in. I’m also used to the annual flu shot paradigm that has served me well as a primary care doc around people who are often sick.

The FDA issued recommendations for Covid shots, but the CDC/ACIP skipped its usual March and June meetings, perhaps because they are in a state of disarray, limbo, and zombie-like existence. We used to have the nicest things. Fortunately, medical societies including IDSA, AAP, ACOG, and AAFP issued their own guidance, and health insurers pledged Covid vaccine coverage through 2027. But the confusion will still depress uptake. Sad.

Are a bunch of viruses activated with Covid infections?!

Speaking of zombies, this study published in the journal Nature caused a good deal of concern this summer. Researchers looked at ~1K patients hospitalized with Covid and found that some of the dormant viruses most of us carry around (think Epstein-Barr, cytomegalovirus, herpes simplex, and the lesser-known Anelloviridae) can reactivate during infection. This happened even in people with healthy immune systems… but this study comes from unvaccinated hospitalized patients, early in the pandemic, with older Covid strains.

I think this study provides more under-the-radar intelligence about why it’s good to take Covid seriously and acknowledge how much we still do not know. But it’s also important to realize that reactivation of viruses happens with many other serious illnesses in general, too. This is not completely novel.

Right now there's nothing here to act on. Blood tests for Epstein-Barr and CMV already exist, and logically we might think of using antivirals like Valtrex when these viruses are found to be reactivating… but previous trials in critically ill patients found no benefit and possible harm with similar approaches. Plus, the virus most tied to lingering Covid symptoms has no treatment at all.

Interesting, but not actionable, and not widely applicable.

How to stop household transmission when someone has Covid

This is the first season that people in the US will have access to Xocova, a newly approved antiviral that reduces household spread of Covid illness by about 70%.

I’m guessing that very few people will take this. It’s expensive (about $1,000 for a 5 day course), insurance has been mixed in covering it when I’ve tried so far, it can interact with some medications, and most people understandably don’t want to take a medicine for 5 days to prevent something that is generally not as severe as it was back in the day. But many do. I expect many folks from Covidlandia will. Some patients have asked me for prescriptions already, just in case.

For household contacts of influenza cases, people often ask for/I recommend Tamiflu/oseltamivir 75 mg once daily for 10 days. That cuts household flu transmission by like 80-90%. So let it be with Covid.

Here was my deepish dive on Xocova. Don’t forget that getting updated shots, providing good ventilation, camping out for a while in a separate part of the house, and mutually masking when sick and in necessary proximity can also reduce spread.

Early antiviral treatment and long Covid

As anyone who has read Examined over the past 5 years knows, I have been long on knocking down viral loads early. I kept writing about that when it wasn’t cool (it still isn’t), and I’ll keep writing about it until I’m proven wrong. It just makes sense that a tenfold reduction in viruses polluting our systems has to make cleanup easier.

Two observational studies of ~8K Covid outpatients — nearly all mildly ill, 90% vaccinated — found that starting an oral antiviral within five days was associated with less long Covid: 21.5% versus 25.1%, a 14% relative reduction, number needed to treat 24. Not mind-bending, but statistically significant especially since late-comers at day 5 were included. Best to start early when the viral load is peaking. Benefits held across subgroups, including younger patients without risk factors. In a companion analysis, 25% of antiviral recipients hadn't returned to usual health by 28 days versus 34% without, a number needed to treat for complete recovery by one month of 11. Ensitrelvir and molnupiravir drove most findings, as these analyses took place in Japan. Are findings similar for Paxlovid?

I wrote about why Paxlovid still deserves a place at the treatment table, even in low risk patients dealing with Covid illness in whom we are not just trying to prevent grim hospitalization and rare death. Dr. Daniel Griffin agreed with me. I appreciate those guys.

The federally suppressed study about last year’s Covid shot effectiveness

CDC-led researchers using the VISION network analyzed data from 253 emergency departments and 179 hospitals across seven states from September to December 2025. That was last year:

• Among immunocompetent adults, last year’s updated shots were about 50% effective against Covid-related emergency and urgent care visits

• 55% effective against hospitalization, measured at a median 47 days after vaccination.

• Adults 65 and older fared similarly, at 48% and 53%.

• Critically, these figures represent added protection on top of substantial immunity people already carried from prior infection or vaccination

Remember this study? Probably not. The study never ran in CDC’s own journal. A senior official blocked it before publication. A co-author called the move an attack on transparency. It reached the public through a leaked copy, and remains unpublished and unreviewed as far as I know. It uses a test-negative design, a standard but imperfect method whose limitations the authors themselves discuss. Voltaire wrote “Le mieux est l’ennemi du bien”, that is, “the best is the enemy of the good,” often simplified to “never let perfection be the enemy of good.” I left both the French and English words for any French Canadians upset by their suddenly crummy neighbors. And finally, Dolly Parton once stated: “I never have considered myself a perfectionist, but I do think of myself as a ‘professionalist’… I always strive simply to be my very best.”

Did you also miss this? They hoped you would…

“No child deaths definitively linked to Covid shots, FDA says”

It needs to be stated publicly, again and again. Recall that Dr. Vinay Prasad, now the former FDA vaccine chief, sent an official memo 6 months ago to staff stating quite the opposite.

• “No fewer than 10” childhood deaths were “related” to the Covid vaccines according to Prasad’s memo. This was based on misused information from VAERS, an unverified reporting system that allows anyone, including doctors, patients and caregivers, to submit entries about adverse events they believe might be linked to vaccines. The system’s own website warns that submissions can contain inaccurate, incomplete or biased information.

• Prasad’s memo used highly ideological language, repeatedly characterizing Covid vaccine requirements for schools and employers as “coercive,” calling past agency decisions “dishonest,” and arguing that vaccine regulation “may have harmed more children than we saved.” At one point, Prasad instructs staff who disagree with his conclusions to resign.

• “This is sort of science by press release,” said Dr. , a pediatrician and the director of the Vaccine Education Center at the Children’s Hospital of Philadelphia, calling the memo “irresponsible” and “dangerous.”

• Dr. Peter Marks, MD, the FDA’s former and actually legit vaccine chief who was ousted by none other than RFK Jr, Esq.: “This memo conveys a very troubling mixture of misrepresentation and lies,” Marks said. “The climate within the agency is incredibly toxic right now.”

FAST FORWARD TO NOW.

“No child deaths have been definitively linked to Covid vaccines, according to a report from the Food and Drug Administration that was quietly made public last week.”

No means zero definitively linked.

LOOKING BACK SINCE 2020?

At least 18,000 kids have died from Covid.

Does Covid matter anymore?

It’s normal to move on in life. We all have to. Many have moved on from caring about Covid, and there is understandable logic to that. A good article from Helen Branswell on STAT wrestles with whether Covid is still a thing.

Experts she surveyed agree that the Covid threat has receded but disagree on nearly everything else. Some credit accumulated immunity. Others say milder Omicron lineages explain milder illness. One virologist calls SARS-CoV-2 essentially a fifth common-cold coronavirus, but another epidemiologist says we're foolish to dismiss a virus that still causes so many problems and deaths. Former CDC epidemiologist Fiona Havers argues that the danger is underappreciated because Covid deaths often get recorded as pneumonia or respiratory failure. That’s true, I see that. The modern reality supports both readings I think:

• Covid dropped from the 3rd leading cause of adult death in 2021 to 15th by 2024

• And yet CDC still estimates 45,000 to 64,000 Americans died of it in the season ending September 2025. That’s a lot of people, people.

One in six US adults who test positive for Covid might develop long Covid

It is tricky to prove someone has long Covid and nothing else going on. It’s a diagnosis of exclusion, and there is no single blood test that might easily nail it. Brain fog? Fatigue? Shortness of breath? Muscle pains? SO much overlap. That’s why this study is intriguing, as it used AI to analyze symptoms and related diagnoses without needing the “Long Covid” ICD10 code officially stamped on patients’ charts.

Published in JAMA Network Open, researchers applied said AI algorithm to electronic health records from ~500,000 adult patients with Covid across 58 hospitals in four US regions. It identified long Covid patterns in 16.28% — roughly one in six — more than double what diagnostic codes capture, since clinicians apply the official code in under 7% of cases. Of that 16.28%, 90% had chronic conditions needing ongoing management, and prevalence climbed steadily through mid-2024.

90% means that when the algorithm flagged someone as having long Covid, what it was almost always flagging was a new chronic condition (like hypothyroidism, abnormal blood sugar, dysautonomia) rather than a temporary post-viral illness that resolves. But because the study had no comparison group of people who never caught Covid, it can only show these conditions appeared after infection more often, but with no other explanation in the record. It can’t prove Covid caused the chronic conditions, but…

Long Covid in 2026 is a bit different

A meta-analysis of 35 observational studies covering 160,000 patients across 19 countries compared symptoms before and after Omicron. Prevalence of long Covid dropped substantially, from 36% in the pre-Omicron era to 23% since. Compare that to the 16% quoted above, as these estimates are all tricky to pin down exactly.

Nonetheless, symptom profile shifted too. Shortness of breath and loss of smell dominated early on, while brain fog and tingling/numbness became more common with Omicron. Fatigue remained the top complaint throughout, persisting past six months in up to 30% of patients. Why the decline happened isn't clear, and the reviewers caution that recall and selection bias may have inflated these prevalence figures.

Recent Covid vaccination cuts household transmission by half

Remember how Xocova was shown to reduce household spread by about 70%? I also stated that staying up to date on vaccinations can help reduce spread. Here is a study that supports that claim.

A CDC cohort study published in JAMA Network Open followed 362 people with confirmed Covid and 763 of their household contacts across three states, with everyone swabbing daily for 10 days regardless of symptoms.

Contacts of someone vaccinated within the prior six months were roughly half as likely to get infected (43% effectiveness against transmission). Protection appeared to wane, as earlier vaccination than six months before exposure showed a similar trend but wasn't statistically significant.

Can Covid cause Parkinsons?

I am extra careful with my patients who have Parkinson’s Disease in terms of Covid prevention and treatment. There is the hint of a link, further explored by this study I caught.

Researchers at Toronto's CAMH scanned 24 adults with long Covid and 24 healthy controls using a PET tracer that binds VMAT2, a marker on dopamine nerve endings. Dopaminergic neurons are the ones lost/damaged in Parkinsons, specifically in a part of the brain called the striatum. Dopamine binding in the striatum was ~20% lower, and lower readings correlated with apathy, slowed movement, and worse memory.

But an accompanying commentary cautions that reduced binding doesn't prove neurons were lost. It might just reflect altered vesicular storage. With only 24 per group and no pre-infection scans, causation is unestablished. Plus, wouldn’t you know that the senior author holds a pending patent on dopamine-based long Covid treatment. But…

Is a wave of Parkinson’s coming?

The worry has a precedent. Encephalitis lethargica swept through more than a million people around the 1918 influenza pandemic, leaving many with parkinsonism, and those born between 1888 and 1924 carried two to three times the usual Parkinson’s risk. So neurologists have watched Covid closely.

So far, no definite wave. A database study of 107 million patients found more new Parkinson’s diagnoses in the year after infection, but the difference vanished after twelve months. That pattern seems to point to detection bias, not disease. Getting Covid might bring people into clinics where existing tremor gets noticed? Published case reports of post-Covid parkinsonism number in the dozens, against hundreds of millions of infections, and population incidence rates in wealthy countries haven’t changed much. And yet, in my little office, I have seen a lot more new Parkinson’s Disease than I recall. And yet my patients are aging with me, so that might be just the way it goes.

Nonetheless, Parkinson’s takes decades to develop, and the 1918 cohort effect wasn’t identified until long afterward. Six years since the Covid pandemic started is too early to make any call. That’s why I keep Covidlandia and some degree of caution coming.

The Covidlandia bottom line

• Covid is climbing again, unevenly — some Texas counties are at BA-1 Omicron peaks while other places are quiet. Check your local numbers, not the national average.

• Updated XFG-targeted shots should land in early September. Last year’s version was ~50% effective against ED visits and ~55% against hospitalization, per the study CDC leadership buried. Nuvaxovid remains a solid protein-based option with fewer side effects than mNEXSPIKE, but I’m down with mRNA vaccines, too.

• Vaccination protects the people around you, cutting household transmission by roughly half when recent.

• Xocova cuts household spread ~70%, but at $1,000 and spotty coverage, it’ll be a niche choice.

• Start antivirals early. In outpatients, early treatment meant less long Covid (NNT 24) and faster return to usual health (NNT 11).

• Reactivated dormant viruses are real but not actionable. Interesting biology, no test or treatment worth ordering today.

• Long Covid is less common than it was — roughly 23% post-Omicron versus 36% before — but AI-based record analysis suggests 1 in 6 infections still leaves something behind that human doctor coding can’t explicitly capture.

• The Parkinson’s question stays open. Suggestive PET findings, no epidemiologic wave yet, and it’s far too early to know.

• Covid still kills tens of thousands of Americans a year. Receded, yes. Gone, no.

Thanks for reading this latest installment from Covidlandia.

Keep speaking truth to power and patient alike.

Here are my thoughts as a primary care doctor, Nell. Thanks for asking (and thanks for your great comments and insights over the years)!

New mRNA flu shot

It’s called mFLUSIVA (aka mRNA-1010), and it’s made by Moderna. It’s the first FDA-approved mRNA flu vaccine in the U.S.

Read more

A recent wave of actual attacks has renewed concerns about our water safety, as has ongoing gutting of federal cybersecurity. As of this writing there has been no confirmed contamination or documented public-health injury from these recent incidents. And yet boil water advisories and manual overrides of hacked systems have already been happening in multiple states. Investigators and independent experts consider Iran-linked actors the most likely explanation. Our president has blamed Minnesota Governor Tim Walz, which would be sort of funny if it were not so tragically political and brazenly ridiculous. Like vaccine policy by federal decree.

Most experts believe Iranian theocrats will stop short of causing catastrophic disruptions here, unless they are truly backed into an existential corner. And …

Read more

So I’m going to spare you that deep dive,

and instead bring you the distilled bottom line

in this latest installment of my…

So, does cinnamon help blood sugar?

Maybe a little, but the evidence is pretty weak. A 2023 review of 28 trials in ~3K people found that cinnamon lowered fasting blood sugar and three month average blood sugars (HBA1c). But this oft-cited review was full of statistical landmines and red flags, and would have the casual reader believing that cinnamon was as effective as some prescription diabetes medications. In short, it’s a house of cards. It might have been what my patient read before seeing me, given her enthusiasm.

An earlier Cochrane review, the gold standard for this kind of analysis, looked at 10 trials and found no significant benefit for HbA1c, insulin, or glucose levels after meals. Most trials of cinnamon were found to have uncertain or high risk of bias to boot. Cochrane tries extra hard to weed out bad studies.

And this is absolutely true: unlike FDA-approved medications for diabetes, no study of cinnamon has shown prevention of heart attacks, kidney disease, or any other diabetes complication. Doubtful they even tried to look.

The bottom of the rabbit hole I fell down for a few hours

Cinnamon is not a substitute for prescribed diabetes medication. Never reduce, stop, or refuse medications in favor of a supplement here. And I would not count on meaningful reductions in blood sugar for folks with pre-diabetes, or health-conscious people trying to keep their blood glucose levels down.

The safety issue most people don’t know about

Most cinnamon that we buy in supermarkets is cassia cinnamon, which contains coumarin. Coumarin is a compound that can damage the liver in high doses. It is not to be confused with the blood thinner coumadin (although it is biochemically related, it does not thin the blood).

A level teaspoon of cassia carries roughly 4.5 to 20 mg of coumarin depending on the brand and production methods.

The same teaspoon of Ceylon cinnamon carries under 1 mg.

European regulators set a safe daily limit of about 7 mg of coumarin for an adult. So a single teaspoon of cassia can meet or exceed a full day’s allowance.

I came across a number of reports of liver toxicity from too much cinnamon, including examples in this report from Australia. Most doctors do not think of cinnamon when we are trying to figure out why someone’s liver enzymes are showing damage/inflammation… but we do have a healthy distrust of most wild card supplements for reasons like this.

Medication interactions

Our livers clear coumarin using the same enzymes used for many prescription drugs. When that machinery is already tied up with handling those meds (or ample doses of cassia cinnamon), the coumarin clearance takes a different metabolic pathway and produces by-products that can be toxic to the liver. For example, one case report involved acute hepatitis in a person taking a cinnamon supplement with their prescribed rosuvastatin (Crestor, for high cholesterol). There are genetic variants of these liver enzymes in certain people that present much higher risks than average, too.

People taking daily cassia supplements/spoonfuls with statins, acetaminophen, methotrexate, isoniazid, antifungals, or regular alcohol need to know about this potential interaction.

Additionally, if cinnamon does actually produce some glucose-lowering as some of the messy individual trials we can all find online suggest, people on certain diabetes meds (like glipizide, glyburide, insulin, etc) might need to be careful about blood sugars going too low.

Bottom line for me?

I’m going to keep enjoying cinnamon sometimes, maybe in smoothies, other rare times with melted butter and sugar on toast… and if I’m lucky again someday, on several pasteis de nata, gobbled down fresh out of a Manteigaria Bakery oven in Lisbon, Portugal:

Worth the whole trip. Seriously.

Though I’m not alarmist about this, I will probably take a look at the cinnamon in my pantry, and switch over to Ceylon cinnamon the next time I’m shopping.

If I currently have cassia-type in the pantry, I’ll keep the dosing to maybe a quarter-teaspoon at time, no more.

Speaking of which, I’m getting hungry for dinner, so I’m heading home now.

I won’t be recommending cinnamon for blood sugar regulation, especially in people with diabetes. There’s just not enough good evidence, and there are some risks.

Take good care!

You have to ask yourself, why this?

And, why this now?

Dr. Fauci did not handle his role sharing real-time pandemic communication perfectly. I’m guessing that none of us handled our roles as parents, coworkers, friends, and Americans perfectly either. It should be noted that Fauci’s actual authority making any policy was much narrower than his public visibility suggested. He was a leading member of the White House Coronavirus Task Force, not the head of CDC, FDA, OSHA, HHS, or the White House itself. Dr. Fauci’s very early communication (passed along from official CDC consensus) downplaying the need for masks was wrong. Ironic as they scream at him for promoting masking, right? I wore one anyway from the earliest days, even when that meant hanging up the couple N95 masks I possessed each night on a clothesline to dry out for repeat use. That terrifying shortage of PPE in the early days likely influenced his communication. It was obvious to me and many others that SARS CoV-2 was easily spread by airborne transmission, and the CDC/WHO could have admitted this much earlier (though it would have raised the bar for what employers would have to do to provide real protection for their workers). Dr. Fauci had limited control over this. He winged it with his estimates of what percentage of Americans would need to be vaccinated to reach herd immunity. His moving target was a real time, evolving strategy during the days when 3,000 of us were dying each day. Remember that horror? I do. It turned out that the initial 95% vaccine-gained protection against infection was not durable… but thank the gods of science and luck that protections against severe disease and death were durable. The Delta variant broke through our immunity firewalls as cruelly as it broke through our public trust. Six feet of distancing and prolonged school closures were continued for too long. That’s wasn’t his call, rather it was something he influenced, and it still saved lives even as it hurt. Dr. Fauci dismissed the possibility of a laboratory origin of the virus too early, though 6 years of credible analysis and expert science still show that SARS CoV-2 almost certainly came from nature. There is genuine debate about the history of US funding of gain of function virus research and whether that might have spilled into the world. I created this deep dive with Claude in case you want a DIY forensic analysis, or we can listen to authoritative, expert, scientific consensus that converges around a natural source of this novel new virus. And framing attacks on him personally as attacks on science in general came off poorly.

To his credit Dr. Fauci continued to serve his country during the pandemic, just as he had served as a public health and research leader during multiple prior presidential administrations. Despite chaos and dysfunction and many unknowns, he was a public communicator when there were few others as ready, willing and able. He was saddled with the impossible: explaining scientific nuance, recommendation changes as they rolled in, restraining impulsive federal leadership who told us this would all be over by Spring 2020, or that we should just disastrously let it rip. His was the impossible task of clarifying scientific information when political leaders misspoke, while trying to escape the implied politics of that necessary disagreement. Dr. Fauci soon publicized and promoted measures like masking in high-risk settings, improving ventilation, testing when sick, and physical distancing while vaccines were unavailable. He coordinated government, academia, and industry long before the pandemic in ways that facilitated rapid vaccine development and testing. He strongly advocated for those vaccines once they arrived with truly warp speed. That was incredible, a modern wonder of the world. Without all the above many more people would have died, suffered in hospitals, or sustained permanent disabilities and damage from Covid infections.

Before the pandemic introduced most people outside of medicine to Anthony Fauci, he was instrumental in developing medication regimens in ‘70s and '80s that turned once-fatal vasculitic diseases (like granulomatosis with polyangiitis) into treatable diseases with high remission rates. Dr. Fauci spent nearly forty years directing NIAID, including through the HIV/AIDS crisis during which time he was protested and picketed by activists, yet listened to them, and then rebuilt the clinical trial system around their demands. Perhaps most significantly, he served as a principal architect of PEPFAR, the Bush-era global AIDS program credited with saving just 25 million lives.

Dr. Katelyn Jetelina succinctly wrote about his role in the pandemic:

Fauci didn’t close your schools. That was your local politician, school board, and health official. Fauci didn’t mandate your vaccine. (In fact, he said it’s not the role of the federal government.) Your employer did. Fauci wasn’t the one who barred you from seeing your dying grandma. That was the nursing home. He wasn’t out to secretly kill us all. And he’s not responsible for alllll the other system failures either (like costs due to corporate influence) or political lightning-rod topics that divide this country, like abortion, brought up today in the hearing.

Like any public official, his decisions can and should absolutely be debated and scrutinized. Fauci had enormous power and influence. (I think he earned that over his 50-year career in infectious diseases). But accountability, in a world where there’s very little of it, still matters. People lost their lives. People lost their jobs. People’s values were tested and questioned.

He absolutely made mistakes—no question about it…

There should have been a 9/11-style commission after the pandemic calmed down. Review the whole thing from the White House to the house down the street. Subpoena power can be used justly, published findings synthesized expertly, a revised playbook devised proactively, without anyone’s personal pandemic diary being mined solely for political barbs and daggers. Instead we are given a public flogging in 2026, designed to take us back to the chaos, the fear, the anger, the pain, and the fundraising emails for the midterms and beyond.

Senator Moreno:

Is this a cynical harvest of a collective trauma, cooked up for dinner table conversation? We all lost something during those first years of the pandemic. Maybe it was a parent, a business, a 4th grade year at school, a marriage, a social network, a set of lungs or a beating heart. I saw all of that and more. Like many pandemic deaths, our collective grief never got a memorial. No Irish wake. No reckoning, and not even a permission to mourn, really. If I were president I would be building a big, beautiful, reverential monument to the lives lost and the sacrifices made by all of us. It would be on the scale of a White House ballroom or arch. But instead our grief and deferred dream of societal healing still curdle at times into rage, a poisoned stew stirred as if by recipe. Rage is a savory ingredient. The proceedings against Dr. Anthony Fauci offer senators the chance to point their wooden spoons at a country full of unprocessed loss, and to conjure a single scrappy Brooklynite face to blame.

Really?

Though presently singled out from the herd, in some ways Dr. Fauci is not unique. Health leaders in other countries have also been made into fall guys by similar forces. In Germany, virologist Dr. Christian Drosten was attacked in full page tabloids while receiving death threats and accusations that he was destroying the economy. In Canada, Conservative leadership candidate Derek Sloan built a fundraising drive around firing Chief Public Health Officer Theresa Tam. She was born in Hong Kong, so Sloan cynically asked in a video, does she work for Canada or for China? and then refused to apologize when his own party demanded it. In the UK, Chief Medical Adviser Chris Whitty and scientists like Sir Jeremy Farrar faced similar hostility and threats from a public frustrated with pandemic restrictions. In Brazil, President Jair Bolsonaro was the primary antagonist against his own medical community, undermining his own public health officials, firing dissenting health ministers, and promoting pandemic denialism. BTW, in late 2021 a congressional panel accused Bolsonaro of crimes against humanity, citing his deliberate actions to spread the virus and undermine public health measures. Brazil had one of the highest Covid death tolls in the world, besides the USA.

Does an attack on Dr. Anthony Fauci hurt all of us? Senator Randal Paul described his hearing last week as “the capstone to Fauci’s four decades of abuse of power at NIH.” Really? Under multiple Republican and Democratic administrations? Not just a few questionable or indeed bad pandemic moves along with many good ones? What changed? Could such statements be a way of establishing that federally funded science is corrupt from the top down? Why? Could it be another way to justify the massive research budget cuts that have gutted our country’s leadership in science, the ideology-driven vaccine policy rewrites and cancellations, the historic purges of career scientists and institutional knowledge underway at HHS? Our federal support of research helped bring us The Human Genome Project, the internet, modern vaccines and cancer treatments, the Global Positioning System, and the Apollo and Artemis missions to name just a few.

Anti-democratic leaders like to discredit/destroy the people, positions, and institutions that establish facts independently. Without inconvenient and decentralized checks on power, truth becomes what power makes it.

Humiliation is a powerful tool. More than 1,000 pages of Dr. Fauci’s private diary were pulled off government servers at the direction of Secretary Kennedy after an eight-month search and published in full. Dr. Fauci was not notified in advance. The words in the journal were mined for embarrassing moments. Instead of constructive analysis we got senators then pouncing on Dr. Fauci as a “megalomaniac” and “an infamous villain” and dropping gratuitous, performative F-bombs. We know where this leads. In 2022 a Maryland man was sentenced to three years for emailing threats to kill Fauci and his family. And yet, just weeks later, the governor of Florida told a cheering crowd that “someone should grab that little elf and chuck him across the Potomac.” Last year our president revoked Dr. Fauci’s security detail.

Senator Andy Kim of New Jersey pointed to the obvious:

A chilling effect for the next generation of people who might consider stepping up to serve our nation, to be the next generation of researchers who now are wondering whether or not this is the right thing for them to do at a time when they see some of their colleagues, or those that they looked up to, being attacked.

As Dr. Fauci pointed out in his statement before the Senate, some of this is simply personal. Senator Paul has pursued Fauci for six years. He’s made criminal referrals that even the Justice Department declined to act on.

Most importantly, for all Americans, let’s consider what was not on the agenda of the Senate that day last week as spittle flew from enraged lips, and this week as senators try to hold him in contempt. We are still mired in a strait in the Middle East, a war of choice, incredibly expensive to run, choking the world economy, making stuff more expensive at home, costing military lives and security. New tariffs consumers must pay. Millions are losing health coverage, millions more are seeing their insurance premiums skyrocket. Fellow Americans are going hungry without basic food assistance. We will see more and more people without homes on the streets of our cities. The planet is visibly burning, with thick plumes of smoke choking the very atmosphere. And it’s flooding. They are taking away the relevance of our vote, and maybe our actual vote. Our vote, people! Sordid Epstein files have been heavily redacted and hide the abuses of power and women and children in plain sight. Measles is at a 35-year high… while the Senate puts one man on the gallows.

I agree with many others who point out that this will cost future lives, future doctors, future scientists, future public servants (who serve all of us, red white and blue), future trust, future healing, future reconciliation, and present energy. We only have so much to go around.

As a physician I stand with Dr. Anthony Fauci and all the other imperfect doctors, nurses, public health workers, medical assistants, trash collectors, grocery store workers, meat packers, Asian Americans, bus drivers and other folks at times singled out from the herd because they were essential, or potentially blamable, or both. I stand up not because Fauci was right about everything. He wasn’t, and reasonable people can disagree.

How will history view the scapegoating of Dr.Anthony Fauci these six years on, in another twenty, in another hundred?

How will we come back together as Americans before the next pandemic divides and conquers us more than any army ever could?

Reasonable people can agree, this is not the way.

I want to propose (or at least remind us of) a kind of exercise that we can do all day long. We never really break a sweat doing it, and like most light exercise it has numerous health benefits. We might even improve the profiles of our gluteus maximi. What is this magical exercise, and how much will it cost to take classes?

It’s free. It’s determined, doggedly good posture. But before I present the case for posture as a kind of exercise, let me review the amazing basics with a run-on sentence. Good posture supports reduced pain in joints and ligaments, better spinal alignment which reduces wear and tear on discs, improved breathing that allows full lung expansion, enhanced digestion from less mechanical pressure on the whole works, better circulation from reduced compression of nerves and arteries, fewer headaches generated from the cervical spine, improved mood from all of the above and standing taller, and better upstream/downstream joint health particularly in shoulders hips and knees.

Good stuff, right? So let’s move on to the overlooked aspect of posture as exercise. Regular standing burns only seven to nine more calories an hour than sitting consumes. So if we just stood for most of our days that would burn off the extra calories of one lousy banana. But that average 7-9 calories more per hour of standing assumes that all standing and all standers are created equal. We are not. Studies show wide variation, with roughly two-thirds of us qualifying as energy savers who can stand with quite minimal extra calories burned as compared with sitting. But slouching is different than what a body can do when it consciously, actively, purposefully takes on gravity like a free weight. Can we improve calories burned with standing?

Small numbers of calories add up. Have you heard of “NEAT?” It means Non-Exercise Activity Thermogenesis. One journal explains it this way:

NEAT is the energy expended for everything we do that is not sleeping, eating or sports-like exercise. It ranges from the energy expended walking to work, typing, performing yard work, undertaking agricultural tasks and fidgeting. Even trivial physical activities increase metabolic rate substantially and it is the cumulative impact of a multitude of exothermic actions that culminate in an individual's daily NEAT.

I don’t know why actively standing with good posture gets snubbed.

In researching this post I came across this study which found that with overeating the strongest predictor of who gained the most weight was how much people unconsciously moved. Not consciously exercised. As I will explain below, if we can keep moving, fidgeting, and incorporate more standing with active engagement of core, gluteal, and back muscles, the total calories spent and NEAT generated might be surprising. For example, another study found that shifting two hours a day from sitting to light upright activity added 134 calories burned. That would be about the same as a brisk, scheduled, half-hour walk. Do that too if you can.

Let’s make an intuitive, common sense differentiation between the kind of standing most of us do by default and the kind we can aspire to practice. The former has the shoulders rolled forward, the belly slack, the buttocks barely firing, the head and neck tilted downwards. The skeleton and joints are doing much of the work against gravity, with only the essential stabilizer muscles recruited. Now picture the latter with a second run-on sentence. Shoulders rolled back and pulled there by scapular heroics, paraspinal muscles like tenderloin ropes on a thoracic crane, the belly tight and held firm by abdominal and core muscles firing, the flexed gluteus muscles tilting the pelvis backwards from its tendency to spill forward, the head and neck also level with the plane of the Earth as it spins below. It’s kind of hard work if we’re not used to it. Try it right now and tell me you don’t feel the hint of a work out!

Speaking of which, this Good Posture Workout™ also produces isometric thermogenesis. Isometric muscle contractions like the ones used for standing involve active energy expenditure, muscle firing, and metabolic heat generation all while the length of the muscle stays the same. Other people don’t even see our workout in progress, but they do subconsciously sense something more confident and powerful going on. One lab measurement found that a moderate sustained contraction of muscle roughly doubles the resting thermogenesis rate. Taken by itself, good posture is not going to produce meaningful weight loss, but when added to the NEAT grand total for the day, it absolutely makes a beneficial contribution. Plus, our bones, ligaments, tendons, hearts and lungs appreciate the protection and gravity assist.

Now let’s consider the gluteal muscles specifically. The gluteus medius, minimus and maximus keep our pelvises level while we are standing on one leg. Watching someone walk in slow motion reveals that we actually spend a good amount of time standing on one leg while the other swings forward. Weakness of the glutes is associated with injurious falls in older adults. Strong butts (and upper thigh muscles) are also associated with longevity, and are pleasing to many folks, not just Sir Mix-a-Lot.

So, can super-standing, with exaggerated tensing of the buttocks, actually build muscle here, too? It seems there is a study for everything. This one found that eight weeks of daily gluteal squeezes alone, using no weights or movement, matched bilateral bridge exercises for hip extension strength and significantly bumped up gluteal size. Passive standing won’t cut it, but active standing just might.

Now it should be stated that prolonged isometric muscle contractions, like with this sort of hyper-engaged standing, will cause temporary increases in blood pressure. But just like regular exercise, after we are done exerting our muscles, blood pressures usually settle in at a lower and better level than before said activity. Short, medium, and longer term BP reductions are typical with exercise that we can safely tolerate. Here are some references that back up this physiological phenomenon. Control uncontrolled high blood pressure and make sure heart disease is stable.

Engaging the whole trunk musculature while standing recruits deep stabilizers even better than fancy “hollowing” movements. I had to look up hollowing, which sounds like a great thing to do but takes some fuss:

Hollowing is a core-strengthening exercise where you lie on your back, press your lower back flat into the floor, and lift your shoulders and straight legs slightly to form a shallow "boat" or "U" shape.

Isometric training has also been shown to reinforce torso stiffness better than dynamic exercises.

I don’t think there are any official guidelines for the Good Posture Workout™, especially since I just coined that and now plan to sell it to Peter Attia or Andrew Huberman. There are plenty of workouts that aim to strengthen the muscles that improve posture, but I couldn’t find any that just dive into posture itself as a kind of slow workout. So let’s agree that intermittent contraction is preferable to prolonged. Like trying out ten to thirty seconds of isometric engagement while we are standing, and trying to get up and stand several times an hour. That’s pretty much in line with the isometric training literature.

Are you going to try more active, intentionally good posture? Anecdotally I use a standing desk for half of my patient encounters. Every once in a while a patient will join me standing. At the end of a standing visit I’m ready to sit, and at the end of a sitting visit I’m ready to stand. My axial skeleton feels better at the end of a day in which I’ve remembered to tighten up and straighten up. Maybe there’s a little muscle gain here and there. Posture won’t replace that 150 minutes of real exercise we are supposed to shoot for each week, but it is certainly a NEAT addition to our daily puttering and positioning.

When I’m discussing posture with a patient, usually in the context of back and neck pain, both of us shoot upward like bean sprouts for a good 5-10 seconds before we wilt back to our baselines. If only good posture were automatic like breathing.

Gravity can be a constant bully, can’t it?

Let’s keep standing up to it while we can.

So have doctors counseling patients about their bodies.

A fifth of the world’s seaborne oil and large amounts of vital cargo, liquified natural gas, and petrochemicals pass through a channel barely twenty miles wide. That is the danger of the Strait of Hormuz: enormous throughput squeezed through a tiny physical footprint with no cheap detour, so a disruption trivial in size produces massive worldwide consequences. Chokepoints are not dangerous because they fail often. They are dangerous because they fail suddenly or can be exploited, sometimes from a colossal failure of strategic thinking, and because the cheapest way to hurt a vast system is to strike its narrowest passage.

There are parts of the human body that are governed by the same tight geography. Anatomy and physiology can be thought of as networks organized around a handful of narrow passages that carry disproportionate consequence, most of which stay silent until they are nearly closed. That makes the strategist’s map genuinely useful for thinking about health. But a map of chokepoints tempts a false assumption; that because a passage matters, we should be aggressively watching and intervening at every one. Imaging and blood tests can look almost anywhere. So the strategic question becomes does looking, and even more importantly acting on what we find, actually leave us better off?

What follows describes 10 Straits of Hormuz in our own bodies. First I’ll review the anatomy and the vulnerability, then the honest intel on stewardship and smart diplomacy. I’ll rely on US Preventive Services Task Force recommendations and other well-informed sources, even as they are now taking heavy fire from a self-sabotaging, anti-science regime.

Most advice converges around the goal of keeping each straight open, undisturbed, and harmonious wherever we can, and not exposing vulnerabilities unnecessarily.

1. The coronary tree and the proximal LAD

A few millimeters of channel in the left anterior descending artery feed the entire front wall of the heart. Decades of high lipids, blood pressure, inflammation and natural wear and tear can narrow it silently, and a single plaque rupture closes the strait in seconds. It’s colloquially called the “widowmaker.” The LAD is the archetypal chokepoint: small caliber, vast dependent territory, with potential for catastrophic and abrupt failure.

Here stewardship works, and the consensus is unglamorous. Healthy lifestyle including diet and exercise are well established foundations. But especially for adults 40–75 with elevated estimated risk, statins, blood-pressure control, and not smoking help keep the passage wide over a lifetime. The temptation is to escalate to routine calcium-artery scanning, or even screening everyone with CT coronary angiography… but the USPSTF finds that evidence for coronary artery calcium scanning insufficient in asymptomatic people; and the cardiology societies endorse it only as a targeted tiebreaker for those at borderline or intermediate risk considering statin therapy. Here is how I counsel patients about CAC testing.

The analogy holds fairly well: patient upstream management beats dramatic intervention, with high tech tools used judiciously and with deliberation.

2. The carotids and the circle of Willis

The whole brain gets perfused through a few vessels with real but finite backup. Narrowing of a carotid artery, or a clot thrown from a fibrillating atrium, can shut the strait without warning. The vulnerability is obvious… but this is a geography where the analogy inverts itself.

Read more

You’ve probably heard by now that Defense Secretary Peter Hegseth announced every service member 30 years and older (women included!) will be screened annually for testosterone deficiency. Hormone treatment will be offered voluntarily to anyone who tests “low.” Troops under 30 can opt in, too. The stated goal, per a social media post accompanying his video announcement, was a “High-T Department of War.”

This might be his most notable foray into health matters since beards or vaccines. Peter Hegseth banned beards and called out “beardos” by name, ironically, as many consider facial hair an outward sign of masculinity. A study once showed, however, that a beard is not a reliable predictor of a man’s testosterone levels. Hegseth himself once sported a beard before a shave-off on live TV, by a barber the co-hosts introduced as “Russian.” It was a bizarre spectacle that might have had a lasting effect on him:

Remember how he also ended flu vaccine mandates for military personnel, then quietly reinstated flu vaccine mandates after a fatal outbreak at an Air Force basic training facility? Stuff like that keeps degrading public trust in vaccines, and indirectly undermines trust in family docs who fight the good vaccine fight.

Now this newest policy opens the door to a modern clinical question about “low-T” that comes up all the time in my office, brought there by popular culture as much as specific low testosterone symptoms.

Why the military might be a plausible place to look for low-T

Clinically low testosterone is not a wellness myth. It can cause muscle loss, fatigue, weight gain and sexual dysfunction. Low testosterone often goes along with diabetes, obesity, osteoporosis and depression. Military life is plausibly a risk factor. Stress, sleep debt and even head injuries can all suppress hormone levels. Some researchers have described an “operator syndrome” in which long-serving special ops troops report elevated rates of multiple medical problems, decreased testosterone among them. According to reporting I’ve read, low-T stigma keeps many from getting checked, and some may even fear professional repercussions. A program that normalizes testing in military men with symptoms, but not necessarily universal screening, addresses something real.

Diagnosis is by nature tricky

A screening mandate collides with how the diagnosis works. Hypogonadism isn’t a lab value. It’s a lab value plus a clinical picture.

Most contemporary guidelines — Endocrine Society, AUA, BSSM, primary care reviews — recommend against blanket testosterone testing in asymptomatic men. They cite circadian variation, assay variability between labs, and the sheer nonspecificity of the symptoms. Routine screening mostly yields borderline “abnormal” results whose treatment has unclear benefit.

The Endocrine Society requires a low morning testosterone (drawn 8 to 10 AM, ideally fasting) confirmed on two to three occasions, alongside specific signs that actually point to androgen deficiency. Here’s a deep dive in the block below, OK to skim if you’re just looking for the gist of all this:

A universal testosterone screening program, by design, tests asymptomatic people. It starts with the result and goes looking for the disease. No other military does T screening.

For those wanting an MD-level rundown on how selective testosterone screening should be done in an ideal world, here is an even deeper dive I prepared and reviewed using OpenEvidence. Warning, it is technical!

Testosterone Screening Guidance

111KB ∙ PDF file

Download

Download

Some benefits

When deficiency is real, the benefits are real, too, and accrue in a predictable order. Society for Endocrinology guidance puts improvements in libido and depressive symptoms at three to six weeks.

Erectile function improves modestly.

Body composition and blood sugar control improvements build over six to twelve months.

Bone density starts improving a bit towards one to two years.

Anemia correction is well established, and in frankly hypogonadal men strength gains can be substantial. This is obviously important for active duty and combat forces. Strength and muscle gains confer psychological benefits for many, too.

Mood and cognition improvements are weaker claims. Controlled trials in experimentally hypogonadal men showed no real mood benefit from graded doses, and cognition has not moved in older men.

Some risks

Erythrocytosis — too many red blood cells, and thus more clots — is among the most common adverse events, at roughly 8X the placebo risk, which is why counts need checking at three to six months and then q6-12 months at least. Risk is formulation-dependent: injectable esters produce peaks and more risk; transdermal formulations, significantly less.

Older studies suggested more heart disease. But the TRAVERSE trial ( ~5,000 men, mean 22 months) is the strongest new reassurance available: no excess of major adverse cardiac events, even in men with existing heart disease. But it found more pulmonary embolism, more atrial fibrillation, and, bizarrely, in the fracture subtrial, a 43% rise in fractures of ribs, wrists and ankles despite bone density improving. This trial also showed no increase in prostate cancer risk, but testosterone does increase PSA levels, which may lead to more biopsies and detection of subclinical low-grade cancers.

Before a first prescription a clinician still rules out prostate and breast cancer, untreated sleep apnea, uncontrolled heart failure, severe urinary symptoms and baseline erythrocytosis, and takes a clotting history. That’s a real encounter, not a lab order and I hope military protocols will include all of it. Worth remembering that all of this risk buys nothing in a man whose level was never truly low, which is why guidelines warn against the “trial” prescription. The FDA has never approved testosterone for levels that naturally fall with age.

The adverse effect deserving the most reckoning, with some bitter irony, is infertility. Testosterone shuts down sperm production fast. Intratesticular levels fall 94% within three weeks. The AUA calls it a strong, grade-A recommendation not to prescribe to men trying to conceive. After stopping treatment recovery usually arrives but slowly and unevenly — roughly two-thirds by six months and nearly all by 24 months in the most cited study, though in another big study a third of real-world androgen users remain subnormal at a year. Longer use, older age and longer-acting preparations predict slower recovery. Men wanting fertility within a year should avoid TRT, or bank sperm first.

Make sure to tell the young recruits about all this, right?

Common but generally manageable effects include acne, oily skin, breast tenderness, fluid retention, sleep apnea exacerbation, and blood pressure increases. Too high testosterone typically manifests as increased aggression, dominance-seeking behavior and risk-taking, all of which increase the risk of a Department of Defense becoming a Department of War in the Middle East.

One number is not a warfighter

Another problem here is the reductionist logic.

“High-T” treats a serum concentration as a proxy for what anyone actually wants — resilience, endurance, good judgment despite physical and mental exhaustion. The confounders that plausibly explain much of the population-level decline (obesity, sedentary life, sleep debt) are the actual targets, and things militaries also know how to help. Shortcutting around these might optimize the biomarker and patch the soldier up incompletely.

The testosterone idea is visible in civilian data, too. U.S. prescriptions grew from under a million in 2000 to nearly 12 million in 2025, fastest among younger men in whom up to a third did not meet the deficiency criteria according to the American Urology Association.

The framing from Peter Hegseth and allied voices emphasizes “operating at your absolute best,” “maximum psychological and mental readiness,” and testosterone as a top marker of overall health, which stretches beyond the indications recognized in endocrine and urology guidelines. This shifts testosterone from a specific hormone with defined clinical uses to a quasi-global vitality metric, an approach more common in influencer and “optimization” culture than in evidence-based medical practice.

And the women

Including women is the least defensible piece. Since this all came out, experts highlight that women also produce testosterone, but in much lower amounts, and that the evidence base for testing and treating “low T” in women is far thinner and more controversial than in men.

Current practice generally limits testosterone therapy for women to narrow indications such as post‑menopausal low sexual desire, and even there, guidelines are cautious.

Specialists quoted in health and science coverage have stated that blanket screening of all women, without clear indications or protocols, is particularly hard to justify.

Some relevant quotes from Dr. Hugh Cassiere in The Independent:

Females have 10 times less testosterone level than men. Women in the military perform the same as men in military, and their testosterone levels are 10 times less than men… Testosterone replacement therapy was not FDA‑approved for women, and introducing it could cause severe health complications, such as blood clots or elevated red blood cell counts, which could lead to strokes and heart attacks. How about women who are supposed to have low testosterone levels, and you're doing all these negative things by treating them?

I think this quote might be qualified such that “military performance” is not equated with male=female muscular strength. But women get the job done, especially in terms of modern warfare and the many roles to play in a well-functioning, balanced military.

The contradiction

The administration’s transgender troop ban rests partly on the claim that hormone therapy is impractical for soldiers in austere deployment conditions.

The legal director of the National Center for LGBTQ Rights argues that urging male troops onto the same medication exposes that reasoning as bias.

The Pentagon has not explained the distinction, which is its own kind of answer.

The FDA movement at the same time

Hegseth’s screening program isn’t an isolated Pentagon eccentricity — it’s the military edge of a federal push. Backed by RFK Jr., the FDA removed testosterone’s boxed cardiac warning last year on the strength of the TRAVERSE data, and last month proposed rewriting the label to cover age-related symptoms like low libido and erectile dysfunction. Currently the drug is approved only for hypogonadism from a defined medical cause.

The reasoning is defensible; the timing is the problem.

Those same NIH trials that vindicated testosterone for sexual function found little or no benefit for fatigue, memory or well-being… the very things being promised to troops. And the guardrails were built for a reason: one Michigan study found just 12% of men receiving testosterone met the Endocrine Society’s own criteria. The Endocrine Society has asked the FDA for 15-to-20-year prostate cancer data before relaxing further.

From where I practice

I won’t see that many troops, though I do have lots of veterans. I’ll keep seeing lots of civilian men, some of them young, who read about this online and get influenced.

That’s the reach of a policy like this. A health claim with a federal seal on it reduces a complicated thing to a serum number that stands in for capability. Compact ideas travel.

So the request arrives, from someone tired for many reasons, who wants the test rather than the harder conversation about sleep, weight, alcohol, stress. The shortcut tempts physicians, too. Many men will just skip the hassle and buy it online.

A more examined approach: concede that service members have plausible risk factors; test only symptomatic men, twice, early morning; hunt reversible causes — obesity, sleep apnea, medical conditions; treat obesity-related hypogonadism with weight loss as a first priority; be honest about temporary male infertility; reserve TRT for men who meet criteria and understand the tradeoffs. Not just know your T.

Maybe the program helps readiness. Maybe the loosened FDA guidance opens closed doors. But very few impartial experts that I’ve read about this week expect a net benefit. The demand all this creates in civilian exam rooms and in money spent will be much easier to measure.

Here are evidence-based, non-pharmacological ways to naturally improve one’s testosterone. In a sentence, the strongest evidence points to losing weight if overweight (ideally 5–10% or more, especially via combined diet and exercise), getting adequate sleep, and limiting heavy alcohol use.

Non Pharmacological, Evidence Based Ways To Improve Testosterone Levels

294KB ∙ PDF file

Download

Download

May God protect our troops.

May their lives and health and readiness first be improved

by a holistic approach that improves their actual lives.

Where things stand

The United States is in the middle of a rapidly expanding, multi-cluster outbreak of cyclosporiasis. This is an intestinal illness caused by the microscopic parasite Cyclospora cayetanensis. Based on recent reporting, it’s coming from several simultaneous clusters, not a single confirmed nationwide common-source outbreak.

The numbers are moving quickly, and whatever is being detected is likely just the tip of the diagnostic iceberg (more on why later).

• As of July 10, the CDC had confirmed 843 domestically acquired cases across 31 states and was evaluating more than 1,500 additional reports to determine whether they qualify.

• I like how Your Local Epidemiologist Katelyn Jetelina derived her numbers better: “This outbreak, the largest in U.S. history, has topped 3,000 cases, and it’s not slowing down. That number comes from adding up state-level case counts, which are running well ahead of the counts on CDC’s website. For context, the U.S. typically sees around 3,000-4,000 cyclosporiasis cases in an entire year…”

• I agree that many more people are not seeking care or getting diagnosed yet. The logistics for testing involve people seeing a doctor/urgent care, getting the right order for the right stool testing (cyclospora is not detected in the usual “ova and parasites” screen that most doctors order), and often multiple stool samples need to be checked.

• The Midwest is bearing the brunt: Michigan alone had surpassed 1,500 cases by July 10, against a typical annual total of roughly 50, and Ohio and New York appear bad, too.

• At least 86 people have been hospitalized so far, no deaths have been reported, and officials expect counts to keep climbing.

The CDC has launched a traceback investigation but has not yet named a source. Previous U.S. outbreaks have implicated fresh produce like berries, leafy greens, and herbs… but no specific item, farm, retailer, or restaurant chain has been linked to this event yet, and there is no food recall as of this writing.

Symptoms

After an average incubation of about a week, cyclosporiasis typically causes:

• prolonged, watery, sometimes explosive diarrhea

• abdominal cramps

• bloating

• nausea

• fatigue

• loss of appetite

• weight loss

• sometimes a low-grade fever

• The signature feature is its course: symptoms often wax and wane, can persist for weeks, and may relapse if the infection isn’t treated. That drawn-out, stop-and-start pattern is another big reason source attribution is so hard. People struggle to recall what they ate a week or two earlier. Can you? Me neither! Plus, I ate more than one thing a week ago.

Differential diagnosis

Several summer diarrheal illnesses look similar at first. The main parasitic mimics are Cryptosporidium, Giardia, and Isospora. The most common viral cause of diarrhea is usually norovirus.

Two clues point toward Cyclospora however:

• diarrhea that lasts longer than a week and waxes and wanes

• illness that doesn’t spread the way a typical stomach bug does

Because Cyclospora is shed in a non-infectious form and needs one to two weeks in the environment to mature, it is not transmitted person-to-person.

Contrast that with the dreaded norovirus, which spreads readily within households (and even pools), and only needs a tiny viral dose to cause infection.

How to get tested

Here is some family doc practical advice, should you find yourself with a suspicious case of diarrhea this summer. The single most important point: you have to ask for cyclospora testing specifically, AND YOUR DOC HAS TO ORDER IT BY NAME.

*A routine stool ova-and-parasite exam (what most of us docs order, and what comes up on our electronic medical record’s menu of test options) does not include Cyclospora. I checked my EMR just now. I could not even order “cyclospora” on the system we use. That system, called EPIC, is used by about half of the nation’s doctors, and that is a real problem, but I digress. So I will have to break out the paper prescription pad and write out: “Cyclospora stool testing.”

That will prompt the lab (usually Quest or Labcorp) to run either:

• A GI multiplex PCR panel that includes Cyclospora. Looks like Labcorp uses this one. Apparently it is the most sensitive option, at roughly 95% sensitivity and specificity.

• If the lab uses microscopy, they will run a modified acid-fast staining; the oocysts are 8–10 microns and can also be seen by fluorescence. From my quick research it looks like Quest runs this one, and Labcorp will, too.

• Because shedding is intermittent, providers may/should collect multiple stool specimens 2–3 days apart. Have you ever done one? Getting people to sign up for multiple stool samples is not easy… and I don’t blame them. But in the context of the current outbreak, this should be strongly considered, especially if the first tests do not find a different explanation for the diarrhea.

• You can imagine how all of this reduces the reported case numbers, right?!

How it’s treated

The first-line treatment is an antibiotic many of us have heard before: Bactrim. Scientific/generic name is trimethoprim-sulfamethoxazole (TMP-SMX).

How to avoid it

Until a source is identified, the sensible approach is to reduce risk without giving up produce entirely. I admit that I’m going to keep eating strawberries and the like, but just be aware that if I develop symptoms consistent with cyclospora, I need to be on top of that.

• Skip bagged and boxed salads for now. Whole heads of lettuce you wash and cut yourself are a safer bet.

• Favor produce you can peel, wash thoroughly, or cook. Bumpy, folded items like leafy greens and berries give the parasite more places to hide.

• Know washing’s limits. Rinsing removes some oocysts but not all, and the parasite resists standard chlorine disinfection, so a rinse won’t sterilize produce. Cooking reliably kills it. Anyone have a good recipe for boiled Caesar salad?

How about two little reassurances?

• No household isolation or bleach protocols are needed, since Cyclospora doesn’t spread through shared bathrooms or casual contact.

• U.S. public pools are not a meaningful risk — unlike another similar-sounding critter called Cryptosporidium, Cyclospora must sporulate in the environment before it can infect anyone. It’s not going to do that in a pool very well, and certainly not quickly.

• No need to boil tap water or stock up on plastic water bottles.

The policy backdrop

Many online and public health analysts in general have argued that the sprawling, slow-to-be-traced nature of this summer diarrhea outbreak reflects bad choices about how the U.S. funds and coordinates disease surveillance. As in using a chainsaw.

From my reading, the most relevant weaknesses seem to be the lack of centralized federal coordination, “siloed” health systems that don’t have easy coordination anymore, chronically underfunded state and local health departments doing this work while also chasing a historic measles outbreak and other constant threats. Every day of delayed source identification means more and more illnesses are being seeded in these multiple locations. Reasonable people weigh these factors differently, but the common thread is that outbreak detection depends on a capacity that has to be paid for, sustained, and respected.

Addendum 7/14/2026, via Heather Cox Richardson:

…on July 1, 2025, the Centers for Disease Control and Prevention (CDC), overseen by Health and Human Services Secretary Robert F. Kennedy Jr., would no longer track infections caused by cyclospora and five other common causes of foodborne illnesses.

Cyclospora and other diseases appreciate the evolutionary and survival advantages of an ideological system that tears down public health experts and science in general. Why wouldn’t they? Hard to blame the cysts.

Prognosis after treatment

The outlook is generally good (i.e. gets diagnosed and treated, and the outbreak is contained).

Most websites will say: “cases are mild and self-limiting in otherwise healthy people, and treatment works well.” But I want to examine that a bit more, as “self-limiting” makes this seem like no big deal. From OpenEvidence:

Cyclosporiasis is described as self-limiting in most immunocompetent patients, though it may present as severe, protracted, or chronic diarrhea in some cases. The disease can be symptomatic (mostly acute and self-limiting) or asymptomatic.

Duration of untreated illness: Without treatment, symptoms can persist for days to weeks to a month or longer, with a waxing and waning pattern. In the largest early study of immunocompetent patients, untreated diarrhea lasted a mean of 43 ± 24 days.

A placebo-controlled trial in Nepal found that after 7 days, 88% of placebo recipients still had Cyclospora detected in stool, indicating that spontaneous clearance within a week is uncommon. In the treated group in the Nepal trial, only 6% had detectable Cyclospora leftover after treatment with Bactrim.

A Canadian outbreak in immunocompetent adults showed diarrhea lasting 4–18 days and fatigue lasting 11–42 days, with a small proportion experiencing delayed recovery.

Endemic vs. non-endemic populations: In endemic areas, children develop partial immunity with age — in a Peruvian study, only 32% of infected children were symptomatic, suggesting that many infections in endemic populations are subclinical or asymptomatic. Conversely, travelers from non-endemic countries tend to be more severely affected.

In summary, while the infection does eventually self-resolve in immunocompetent individuals, the illness can be prolonged and debilitating without treatment, which is why TMP-SMX remains recommended to shorten symptom duration and oocyst shedding.

The main goals then might be patience and vigilance. Symptoms can relapse over weeks (one case report ran 107 days apparently), which is itself a hint to test for Cyclospora rather than assume a passing stomach bug.

Good luck out there, and hopefully this will all be figured out soon. Just stay aware for now, perhaps make a few different choices at the grocery store, and remember this if you get a nasty bout of diarrhea this summer.

Did you stay in the moment with the smoky sizzle of hot dogs, the umami delight of a glutamate-rich burger with melted cheese, the sweet mouth-game sorting of a watermelon from its seeds? On a blisteringly hot day, did you feel cool drips of condensation down your fingers as they held on for dear life to an even colder glass of water, lemonade, or beer?

Or was it hard to stay in the moment as you reflected on the legend of America, tragic and heroic, past present and future, the sacking of our exceptional fortress of diversity and opportunity by a fortress mentality?

250 can be a big number for us mortals, especially when it’s a measure of years. That’s 25 decades. How many of those have you lived?

The number 25 has inherent power. Just look at it. Biceps and triceps or something, the mathematical product of our five fingers on each hand.

This is a primary care newsletter, not a math one. But before I move on from our American 250th birthday, I would like to mine the number 25 as ruler of time.

Seconds, minutes, hours, days, weeks, months, years, and decades. Twenty-five of each.

What can we do with our health in those units of precious time?

Can we tie a long line that tethers our present finite selves to something much, much bigger? Something like purpose?

Something like a legacy 250 years in the making?

25 seconds from now

What is the most impactful thing we can do for our health in this shortest time frame?

Right now, before finishing this piece: breathe. Draw one slow breath in through your nose, maybe to a count of five, then let it out for longer than you took it in, maybe to a count of seven. Do it a couple times. That’s all. That lengthened exhale flips small switches in our nervous systems, easing us out of fight-or-flight and into something steadier. Sympathetic to parasympathetic. Channel that.

Have a few more seconds? Then stand up and get a glass of water. Not because we’re counting ounces, but because rising, moving, and drinking are elemental parts of tending ourselves.

25 minutes from now

Next we have just twenty-five minutes. What actually moves the needle before the short hand hits 25? I would go for a walk, maybe a jog, outside, where even a little green in the city, a little sky and some daylight do quiet work on our mood and our muscle. People say that being sedentary is the new smoking. I would say that, too, and that losing our democracy is also the new smoking… but more on that towards the end of this piece.

Maybe call someone you love with those twenty-five minutes. Connection shouldn’t be underestimated; it’s one of the strongest predictors of a long life.

Or spend the time clearing one thing off the health to-do list you’ve been avoiding: book the screening, schedule the physical, set up the test. If you’d rather be still, meditate. Twenty-five minutes won’t remake our health. But it can be the hinge the day turns on, opening a door to deliberate care of self.

25 hours from now

Twenty-five hours make up a single turn of our body clocks, just past one lap around the sun. One day, one night to spend working with our circadian rhythms rather than against them. The anchor is sleep: aim for something like seven-ish hours some guy says. The nightly restoration and polishing of our immune systems, memory, and cardiovascular systems depend upon rest. But don’t white-knuckle it or obsess over the number — equate good rest with sleep, and let the rhythm do the work. Open the shades and get daylight into your eyes soon after waking. Light sets the clock that tells our bodies when to feel alert and when to wind down. Then, as night comes, dim the screens or lose them, let the house go darker, and hold a bedtime close to last night’s if you can. But if Will Smith and DJ Jazzy Jeff are playing in a July 4th concert that gets postponed by rain and doesn't even start until after midnight with fireworks starting at 2:30 AM in Philly, screw it.

25 days from now

Twenty-five days is enough to plant one keystone habit and let it root. Don’t try to overhaul your whole life. Pick something small and daily. Walk or do something active for fifteen minutes after meals or at least after dinner. That blunts the blood-sugar spike and, over weeks, changes how our bodies handle food. If you can exercise, find a comfortable zone and try to hit at least two and a half hours per week. But I am a firm believer, from what I’ve witnessed, that the most long lived and content of my patients are the ones who just keep moving, puttering with purpose, gym membership or not. And those 10,000 steps a day are kind of overrated.

25 weeks from now

Half a year is habit territory, long enough for a new routine to stop feeling like effort and start feeling like the new normal. Almost automatic. Pick the foundations, the behaviors with the strongest evidence behind them, and let them compound. No supplements are needed. The throughline across four major studies I reviewed here is the same, and it's actionable and intuitive. A cluster of ordinary habits (not smoking, eating well such as a Mediterranean-style pattern, staying active, keeping a healthy weight, and going easy on alcohol) stacks up dramatic reductions in death and heart disease. Combined, these workhorses of health cut all-cause mortality by around 65% over a decade and coronary events by 80-plus percent, far outperforming what medications alone can do. The most encouraging part for the next two years: it's rarely too late to start. For example, middle-aged adults who newly adopted a healthy pattern cut their odds of dying by roughly 40% within four years, and even picking up just two of the five habits made a difference.

None of this benefit is guaranteed, but who doesn't shop with a mind for a good discount?

25 months from now

Give those same foundations two years to compound further, and hopefully the investment keeps growing. This is not a crypto scheme, unlike some out there. The habits we rooted over twenty-five weeks (eating well, moving regularly, keeping a reasonable weight, not smoking) cut the odds of dying and developing serious health problems. Two years is long enough to change our trajectory and short enough to start soon.

Two years gives sufficient time to close the gaps, even with a dysfunctional health care system. Get the screenings you’ve been postponing — colorectal, breast, cervical, and lung cancer screening save lives when done on schedule. Try not to skip the sometimes boring primary care surveillance: blood pressure, a lipid panel, a blood glucose screen. Stay or get current on the vaccines that have collectively saved some 154 million lives in the past 25 x 2 = 50 years. I’m biased, but I believe (and there is good evidence) that finding a primary care doctor and establishing ongoing care significantly helps. Continuity is one of the reasons I chose family medicine. Knowing someone over time and seeing the whole picture provides measurably better outcomes at lower cost.

25 years from now

There are readers of this newsletter from age 15 years through 100 (as far as I know), so for the purposes of this post let’s consider the average middle aged person, and individuals can extrapolate from there. Twenty-five years is the horizon where midlife arithmetic comes due. The choices and random chances are stacking up now around blood pressure, blood sugar, cholesterol, stress, connection, adequate sleep, decent weight, DNA mutations and methylations, and whether we smoked. None of these are completely deterministic, and chance can be arbitrarily cruel. Nonetheless these usual suspects underwrite the story of our seventies and eighties and beyond if we can make it there. Reach 50 free of the five classic risk factors (hypertension, hyperlipidemia, diabetes, obesity, and smoking), and the evidence says we buy back more than a decade of life, most of it lived without cardiovascular disease. This is the great filter of midlife: the stretch where individual agency matters most, where we can’t keep getting away with things forever, and where even late corrections can still help.

But I believe that just chasing healthspan and never getting our knees scraped by struggle, our pace slowed by helping others, our personal best missed by running with the team is an ultimately unfulfilling and indeed immoral race. These same twenty-five years will decide whether the village around us — clean air and water, disease surveillance, research funding, the primary care that catches trouble early — is strengthened or hollowed out. Our shared environmental and social conditions shape the risk of dying far more than our genes do, and most of those conditions are set by policy, not willpower. So the long game runs on two tracks: tend your own health garden, and defend the shared infrastructure no amount of personal virtue can replace. Plant both trees now. Look around. Who is wildly chopping down the trees?

25 decades from now

You won’t be here. Neither will I. But the choices we make about health, medicine, and community right now are the enduring bricks in a road that runs all the way to the year 2276. Will anyone still be walking at the end of it? I guarantee that many of the enlightened folks back in 1776, from founding fathers to mighty mothers, dared a dream about how this rough new experiment would turn out months, years, and many decades later.

Picture the world of 2276, should civilization make it there. Aging is treated as a condition to be managed, not an inevitability to be endured. Senescent cells are cleared, epigenetic clocks are turned back, worn out organs are regrown from a person’s own cells. Most of what kills us today is caught before it starts. A cancer reliably flagged by a fragment of its DNA years before a tumor forms, a metabolic drift corrected before it becomes truly harmful. Sensors, should we want them, woven into daily life to feed an intelligence that knows our biology better than any physician ever could. I hate to admit that, but maybe doctors hang around just to interpret, guide hard choices, hold a confidential space, and help us decide not just how to stay alive but why and for how long. Public health becomes reliably predictive rather than reactive by necessity. Outbreaks and pandemics are visible and crushable as they seed. Death, when it comes, is more often a choice than an ambush. Our still feverish planet is engineered and managed after a brutal illness, and maybe the natural world recovers as we grow cities and agriculture vertically.

But here is the thing that we should not simply let technology decide for us: who holds the keys.

Staying in my lane of health care, the same stream of data from inside our bodies, the same alien intelligence that knows everything about us, can be built to serve us or to serve a state. In one future, that data is ours; it flows to a physician/educator whose loyalty is to us and no one else. In the other, it flows upward to a system that can heal us or punish us with the same hand, that tunes our mood toward contentment and obedience… and calls it care. A system that lets the powerful live indefinitely while rationing life itself as a reward for said obedience. There, no confidential space exists between patient and doctor, because the doctor reports to the regime. The fascist doctor will see you now.

Both futures use the same technology. In my opinion only one is worth living in, and worth struggling for in the present.

The temptation and the methods that push us toward the second reality are not the property of any one party, per se, though it is self-evident to me which one is mashing the pedal to the metal in 2026. Rather this problem is ultimately structural, and it will outlast whoever holds power next. Beware of those plundering the data, overriding the experts, punishing the inconvenient findings. That is why the throughline matters. Authoritarian pressures have tested American democracy since the beginning, but especially now. Our imperfect, bipartisan stewardship of democratic guardrails is precisely the inheritance that must survive contact with tools powerful enough to make any government permanent. Totalitarian, really.

The people alive in 250 years might never know our names save for some instantaneous genealogy search, but the road to their world is paved in choices we make now. We witness federal databases merged into one centralized profile of every American. We watch scientific advisors replaced with loyalists and universities coerced with frozen grants. We watch official claims contradict the evidence on Tylenol, autism, and vaccines, former public health officials indicted, and prosecutors sending menacing letters to medical journals that publish inconvenient science. I could go on for another 25 pages.

So we must fight the small, winnable fights: for patients to own and protect their own records, their privacy of information, their empowered health choices. We need to collectively stand up for healthcare as a human right, even as it is cruelly stripped from millions and made unaffordable for millions more. It’s horrific enough to develop cancer, more painful still to be abandoned with it. That is where care and freedom become the same thing, towards a more perfect union between us all. Or we let it slip away, and watch with passivity as our collective health is dragged away by dragons hoarding more riches.

Conclusion. The throughline.

Let’s take a step back and look at the basically exponential increase of times described herein. In the next twenty-five seconds, we breathe air and reach for water. In twenty-five minutes, we walk, or call a friend, or cross one thing off a list. In twenty-five days, we root a single habit; in twenty-five weeks, we let the foundations like movement, food, sleep, and connection start to compound. By twenty-five months we’ve closed most gaps and have maybe even kept up with a doctor who knows us. By twenty-five years the arithmetic might pay out in years of life we can’t buy back any other way. And in two hundred and fifty, a familiar stranger inherits the world our choices are quietly drafting right now. That stranger is still family.

Here’s the trick the throughline reveals: it’s basically the same act at every scale. The breath and the vote, the after-dinner walk and the defense of a functioning village, are not different projects — they’re the same instinct to love what’s miraculously alive and worth protecting, pointed at different time horizons. None of it can be crammed into a pill and sold to us. We don’t have to check every box, win every struggle today. We just have to reach for the nearest one. As they say about planting fruit trees: the best time was twenty years ago, and the second best time is now.

So take the breath with me. Get the water. Start there.

Move on to a consideration of tradeoffs. Acknowledge our lack of complete control in matters of good health. Double down on connection, hope, and determination. Skip the supplement and open the windows.

Hold reverence for the future and the past, and most importantly, hold onto simple gratefulness for this tenuous, often exhilarating present.

Have you felt the thundering of fireworks lately?

As some of you might know, an essay I wrote about sleep was published in the New York Times on Sunday. I am so thrilled by this honor, and genuinely delighted with how the piece turned out! My writing has been published by other media, but this one felt quite special.

I worked with an incredible NYT editor back and forth, between some scattered vacation time and consistently long days as a clinician, through hours of revisions additions and subtractions, hours of fact-checking exercises, and finally dotting the i’s and crossing the t’s. I have a new, massive appreciation for how hard these professionals work, how thoroughly they require references and fact checks, and how talented they are as editors and writers themselves.

So, I want to sincerely thank The New York Times for this opportunity, and I trust that this essay is thought-provoking at least, and life-improving at best. See if you can shoehorn in a read yourself. The feedback I have received so far has been so fun. Here is a gift link for the article in case you are not an NYT subscriber. The encouragement and inspiration I receive from all of you who read this primary care newsletter keep me going. Thank you, too!

Ok, that’s it.

My next post will be sent out to you in exactly 25 minutes.

But before I do that,

I would just like to say one more thing…

Hey, I was just published in the New York Times!

~

P.S. Just for fun, if you would “❤️” and/or “Restack” my Substack note here, maybe we could hack the algorithm together and make this go a wee bit viral? You know, to keep up with the depressing and outrageous stuff for a moment?

But I’m going to take a walk in the solar minefield anyway, because the trend I reviewed back then has only gotten stronger. How much sun should we get, and why? Some people may not like the answer, because it is nuanced and lacks a tidy one-size-fits-all thesis. Rather, it’s still a personal risk/reward calculation, and the absolute proof from a big randomized trial still isn’t here.

But increasingly I’m still convinced the answer cannot be zero UV exposure. Who wants to live like that anyway? Even Australia, with the highest skin cancer rates in the world, has been leading the way back into the light for brief, sensible exposures. In 2024 they put that thinking into an official position statement I’ll get to below.

For decades we’ve been told to avoid the sun and constantly slather on sunscreen. New research suggests that advice, taken to the dermatologic extreme, may do some harm along with its benefit. Excessive sun raises the risk of skin cancer, wrinkles, cataracts, and macular degeneration — but some sunlight appears to carry health benefits we’ve been treating as if they didn’t exist. We obsess over the more obvious skin findings we can easily see in the examining room. The more hidden mechanisms of benefit are novel, fascinating, under the skin, and still being worked out. Much of my thinking in my post from two years ago was first shaped by science journalist Rowan Jacobsen, whose reporting in The Atlantic and Outside pulled me down this rabbit hole.

The Vitamin D reductionist disappointment

We’ve long known sunlight (UV-B) helps our bodies make vitamin D, which matters for bone health among other functions. To keep levels up while avoiding the sun, most dermatologists say just take a supplement. Very few recommend getting sunlight. Head to the American Academy of Dermatology’s FAQ on sunscreen and you still get the absolute version:

There is no safe way to tan. Every time you tan, you damage your skin. As this damage builds, you speed up the aging of your skin and increase your risk for all types of skin cancer.

From a narrow dermatology lens, that makes sense. Skin cancer is what dermatologists are first charged to prevent. But primary care asks about the whole person. And here’s the rub: swallowing vitamin D as the antidote for total sun avoidance simply hasn’t delivered. The VITAL trial gave nearly 26,000 adults 2,000 IU of Vitamin D a day for more than five years and found no meaningful drop in cancer, cardiovascular events, or death. Other pooled trials have found the same. In 2024 the Endocrine Society actually reversed course, and now recommends against routine vitamin D beyond the normal dietary amount for healthy adults aged 19–74. (I’ve gone deep on vitamin D supplementation before — here and here — and keep a crib sheet.)

The likeliest explanation is humbling: vitamin D may be less a cause of good health than a marker of sun exposure. The sunlight itself seems to act through several pathways at once, and a pill can’t replicate that.

The health benefits of sunlight

There are vitamin D receptors in almost every cell in our bodies such as immune cells, muscle cells, brain cells. So it’s not strange that research keeps turning up ways sunlight improves health:

• Lower blood pressure. UV light prompts the skin to release nitric oxide, which relaxes blood vessels. In one study, whole-body UVA dropped volunteers’ blood pressure within thirty minutes, an effect a vitamin D pill can’t reproduce, because it doesn’t run through vitamin D at all. (Honest caveat: a small trial of repeated UVA sessions in mildly hypertensive patients found the dip was only temporary. Promising, not settled.)

• A calmer immune system, with anti-inflammatory signals that begin in the skin and spread.

• Help for some autoimmune conditions like multiple sclerosis, psoriasis, and rheumatoid arthritis.

• Better metabolic health and possibly lower diabetes risk.

• Mood and sleep, through morning light, serotonin, and endorphins.

• Possibly longer life. In a Swedish cohort of nearly 30,000 women followed for two decades, those who avoided the sun died at roughly twice the rate of those who sought it out. The authors went further still: nonsmokers who avoided the sun had a life expectancy similar to smokers who got the most sun. Yikes. That’s certainly overlooked, right?

But I have to insert the standard qualification about that last one, because tighter logic demands it. Most of these are observational studies. People who spend more time outdoors may simply be healthier, more active, and better off, you know, the “healthy user” effect. Unfortunately there’s no randomized trial proving that deliberate sun exposure makes us live longer, and other reviews find mixed results all over the place. Doing an RCT about this would be tough if not impossible to contain. Nonetheless, the gap in health outcomes in these observational studies (adjusting for confounding variables as best they can) is now common enough that some researchers call insufficient sun exposure a genuine public health problem.

So how might a little sunlight help? A few of the pathways:

• Vitamin D synthesis: UVB turns a cholesterol-like molecule in the skin into vitamin D, finished off by the liver and kidneys.

• Circadian and mood chemistry: morning light resets the body clock and nudges up serotonin and beta-endorphin, the same endorphins that make sun feel good, and plausibly a little addictive. Know that feeling? Sheryl Crow does: “I’m gonna soak up the sun / While it’s still free / I’m gonna soak up the sun / Before it goes out on me"

• Nitric oxide: UVA frees nitric oxide stored in the skin, dilating vessels and lowering pressure — no vitamin D required.

• DNA repair: this one still surprises me. Excess UV damages DNA, but moderate exposure can actually rev up the skin’s own repair machinery.

Balanced, non-burning exposure might just be the whole game. Too much still means more skin cancer, premature aging, and cataracts. There’s no single prescription for all the world’s people… but Australia is trying, and I’ll riff on their newest guidance again below.

Rethinking skin cancer risk

I don’t want to trivialize skin cancer in any way. I see it frequently in primary care, and people are left with real scars. Sometimes it can be fatal, mostly with melanoma. But “skin cancer” is an umbrella, and the types underneath it are genuinely different:

• Basal cell carcinoma: very common, rarely life-threatening, usually a minor outpatient excision that stays local.

• Squamous cell carcinoma: more serious, but usually treatable when caught early.

• Melanoma: the dangerous one — and the least common, only a small fraction of skin cancers. I have a healthy fear and respect for it, though treatment and potential for cure has come a long way since I started practice!

Going beyond statistics, the pattern that matters for our purposes emerges: the prime villain is the burn, not the daylight. Intermittent, blistering, vacation-style exposure and a history of sunburn especially in childhood are what seem to really drive melanoma. Steady, brief, non-burning exposure is a different process.

And the risk isn’t evenly distributed. Lighter skin is the clear melanoma risk factor. In fact, one systematic review found that more UV exposure wasn’t associated with melanoma in people with darker skin — which is another reason the tools we use to sort risk deserve a second look.

A more balanced approach

Doctors and researchers often sort skin tone using the Fitzpatrick scale. But be warned: many experts now argue the Fitzpatrick system is antiquated and even dangerous for people of color, offering a false sense of security when it comes to overall skin cancer risk.

Here is a pretty good representation I made with Gemini:

In 2024 Australia released a revised position statement that stratifies advice three ways. Oversimplifying for the purposes of this post today:

• Highest risk (fair skin, personal or family history, immunosuppression): the risks of UV outweigh the benefits; protect your skin and get vitamin D from a supplement.

• Intermediate risk (mid-range skin, no major risk factors): keep protecting, but ordinary incidental time outdoors (often ten minutes or so in a t-shirt and shorts in summer) is enough for vitamin D.

• Deeply pigmented skin (lowest cancer risk, highest deficiency risk): routine sunscreen isn’t recommended; brief, regular sun is appropriate.

They didn’t throw out caution. Their “slip, slop, slap, seek, slide” mantra stands, and they insist the public message stay focused on skin cancer prevention. Their own disclaimer says it best: “the risks and benefits of sun aren’t the same for everyone, and this new nuance must not undermine prevention.”

Which brings me to the cleanest way I can now summarize the whole tightrope. The math isn’t the same for any two people.

The strongest case for some deliberate, non-burning sun is a darker-skinned person at a high latitude (low cancer risk, common vitamin D deficiency, minimal deep-skin DNA damage from brief exposure, and the most to gain on the heart-and-mortality side).

The strongest case for strict protection is a fair-skinned person, anyone immunosuppressed, anyone on a photosensitizing medication, or anyone with a genetic or other photosensitivity where even modest UV carries real risk.

There exists a continuum between the two extremes. A single blanket rule can’t hold both of those truths at once, which is exactly why “just avoid the sun” is starting to look inadequate.

Bringing the solar-powered ship in for a landing

As someone who lands somewhere around Fitzpatrick II+ (I think?!), I don’t avoid the sun completely. I aim for short bouts of direct sun, avoid sunburns at all costs, and cover up with sunscreen, a hat, and clothing for longer stretches outside. I’m extra careful at altitude, around reflective snow and water, and this time of year close to the summer solstice. I always wear sunglasses outside now, and I very much prefer shade. Should I keep making it to older age, I will probably have a few pre- or actual skin cancers removed.

My examining rooms have zero windows and my office is tragically short on sunlight. Were I never to escape such a subterranean-feeling world, I would 100% increase my risk of burnout. Weigh this: assured burnout in a dark cave, versus sunburn risk. I feel happiest when I am living sun-adjacent, with brief direct exposures.

So I don’t think we should ever think of the sun as our enemy. Humans evolved in sunlight, and our bodies need some of it to work well. Excessive exposure and burns should absolutely be avoided, and the fairest among us really do need to be very careful. But for many people, tailored, sensible sun looks like part of a healthy life, not a vice. I won’t be surprised if American recommendations keep evolving as we learn more about the sun’s complex effects on human health, and I’ll update this again when they do.

Two years have passed since my original post, and that journalist Rowan Jacobsen just published In Defense of Sunlight: The Surprising Science of Sun Exposure last month.

He has a pretty killer Michael Pollan-esque quote that I will end on:

Get sun. Not too much. Go outside.

PS - Happy Fourth of July weekend!

Nationally, prevalence rates are estimated at 1 in every 310 people infected, with a high of 1 in 39 in Mississippi, and a low of 1 in 1,848 in West Virginia:

It has also been estimated mathematically that the average person has had 5 Covid infections by now (not all symptomatic, some terrible and some mild), with an average of 14 months in between.

There have been 12 waves since this started. If you look all the way to the right on the following graph, that’s us down there now hanging out in pretty good valley:

Canada seems to be in relatively good shape, as does much of Europe and Australia.

Do you know about TWiV - This Week in Virology Clinical Updates? It’s a fantastic show available as a podcast or video. Drs. Vincent Racaniello and Daniel Griffin lay out the state of viral illnesses like Covid, influenza, hantavirus, Ebola, measles, and other viral pathogens, most of which are ascendant with our incompetent leadership’s grim and undeniable anti-science ideology. Anyway, Vincent and Daniel take listener questions at the end of each show. See if you can guess which “Ryan” sent in this letter, with an eventual question about treating Covid with antivirals in whomever wants them when sick (and not just for preventing hospitalization and death):

I greatly appreciate the validation and implicit expertise of Dr. Griffin’s answer (Infectious Disease specialist), and that his daughter will be starting her teaching career at the same school in Virginia where I was once a 4th grader!

Here is that post about Paxlovid that I wrote recently, pushing back on the notion that this Covid antiviral has become obsolete in 2026 and beyond, especially if you are playing the long game, and average people are getting infected up to every 14 months or so.

Thanks for reading my email (and Substack post) Drs. Vincent and Daniel!

Cheers to less Covid in the world right now, though it’s always out there to some degree. Some of my older patients who typically get 6 month boosters in the Spring are delaying their shots until next month… when infections will start heading up again most likely. Seems like a reasonable wager.

Have a great weekend if you can :)

Periodontal health keeps coming up as a quiet predictor of broader health. Gum inflammation tracks with cardiovascular risk, diabetes control, and even cognitive outcomes. The column I wrote a year ago entitled “Can flossing help prevent cancer, dementia, and stroke?” was surprisingly well read (and brought 19 new subscribers - hi again :) I also wrote about the overlooked problem of micro/nanoplastics generated from brushing and flossing. As a primary care doc I’m a jack of all trades… and often that spills over into dental problems. So when a patient tells me about a dental abscess, or asks whether high levels of inflammation might be coming from their mouth, or wonders whether their $5 manual toothbrush is good enough compared to the $200 electric one their dentist keeps recommending, I… first steer them back to their dentist. But then I circle back, examine stuff with them, and try to help. It’s worth answering people carefully with research, rather than parroting clichéd advice.

The short version: electric brushes have a real, evidence-backed edge — but it’s smaller than the marketing suggests, and technique matters more than which device is in our hands. Maybe we should be doing both, actually? When was the last time we really brushed up on how to best do this daily maintenance that helps molars and hearts?

With all the wellness trends and influencers out there, perhaps it’s time we reclaim the term “brushmaxxing” for dentistry. I looked it up, and right now it refers to “dedicating intensive, hours-long daily sessions to brushing hair with varying textures of brushes to train, lay down, and sculpt the hair into deep waves or patterns.”

But instead of this guy, whom we can assume does both types of brushmaxxing…

…let’s bring the references, an expanded synthesis of ideas, and then you can decide for yourself and your hydroxyapatite.

What the evidence shows

Before I dive in with you, I want to acknowledge that I’m coming at this from a primary care angle, informed however by a deep review of high quality sources. The most authoritative single source here seems to be the 2014 Cochrane systematic review, which pooled 56 randomized trials and over 5,000 participants. It found that powered brushes reduced plaque by about 11% in the first three months and 21% beyond three months, with gingivitis reductions of 6% and 11% respectively compared to old fashioned toothbrushes. That’s a real effect, but it’s kind of more modest than I would have guessed. Not the night-and-day difference implied by toothbrush commercials and pamphlets in dental offices.

Among electric brush types, oscillating-rotating brushes (the Oral-B style, with a small round head that spins back and forth) consistently outperform sonic, side-to-side brushes in head-to-head comparisons. This was news to me, and I might have to invest in a new electric brush soon because of this (and because my electric toothbrush is looking kind of gross these days).

The data that actually moved my thinking, though, is longer-term. We like outcomes data. The German SHIP cohort followed nearly 2,800 adults for 11 years and found that powered-brush users had measurably less progression of probing depth and attachment loss (measurements of dental health), about 18% less caries progression, and close to 20% more teeth retained at the end of follow-up. To me that’s a meaningfully better, outcomes-based conversation than just plaque scores at six weeks. This is looking at actual gums and teeth, kept healthier in actual mouths, over a decade.

Notably, the benefit was strongest in patients with mild or no periodontitis at baseline, which is a useful detail for counseling: electric brushes seem to help most when you use them before things get bad, not as rescue therapy once periodontal disease is established.

Where manual brushes hold their own

It would be oversimplified to present this as settled, then end the post here. There are good quality studies that push back on the idea of electric toothbrush hegemony. Personally, I used a manual toothbrush for the first three decades of my life, and never developed a cavity. But I’m older now, and I do spend more time brushing, flossing, rinsing, rushing in the morning, pondering oral health before bed, you know… kind of half-hearted brushmaxxing.

A different meta-analysis of adults 55 and older found no statistically significant difference between powered and manual brushes on plaque, gingival, or bleeding indices. The UK’s national dental prevention guidance states plainly that teeth can be cleaned effectively with either type, and that patient preference is the dominant variable. The American Dental Association’s position is similar: technique quality matters as much as, or more than, which brush is in your hand. A layperson with excellent manual technique can beat a wannabe brushmaxxer using an electric brush poorly.

This matters clinically. If a person already brushes well manually and has no dexterity limitations, there’s no urgent reason to push them toward a new device. That’s my read of the professional society guidance. Perhaps where electric brushes earn their keep is with patients who have arthritis, limited fine motor control, cognitive impairment, or who like most people have never been taught proper technique and are unlikely to learn it from a pamphlet. More on that below.

Tissue safety

One under-appreciated point is that electric brushes, particularly oscillating-rotating models with pressure sensors, appear to cause somewhat less gingival abrasion than manual brushes, mainly because they prevent the heavy-handed scrubbing that damages gum tissue over years. Despite my attempts at chilling, I am historically an aggressive brusher according to my dentist.

Actual recession rates were similar between groups in the available data, but the abrasion finding is a reasonable tiebreaker for patients who tend to brush aggressively.

Technique: manual brushing

The best-supported manual technique that I could find, and the one most professional bodies recommend, is the Modified Bass technique:

1. Hold the brush at a 45-degree angle toward the gumline, so the bristles sit partly on the tooth and partly tucked into the sulcus (the small groove between tooth and gum).

2. Use short, gentle vibrating or back-and-forth strokes — not big scrubbing motions — covering only one or two teeth at a time.

3. After a few seconds of vibration at the gumline, sweep the bristles away from the gums toward the biting surface. This sweep is what distinguishes “modified” Bass from plain Bass, and it’s the motion that actually clears loosened plaque off the tooth.

4. Work systematically: outer surfaces, then inner surfaces, then chewing surfaces, for both arches.

5. Spend roughly 2 minutes total — about 20–30 seconds per quadrant.

6. Use a soft-bristled brush. Medium and hard bristles don’t clean better; they just abrade gum and enamel faster.

7. Don’t forget to end with brushing the tongue, too.

Most people brush too hard and too fast. If our toothbrush bristles are visibly splayed within a month, we’re using too much pressure.

Technique: electric brushing

With electric brushes, the technique shift is almost counter-instinctual. We do less, and let the device do more.

1. Hold the brush head at the same 45-degree angle to the gumline.

2. Do not scrub. Place the head gently against each tooth and let the oscillation or vibration do the cleaning work. Manual scrubbing motions with an electric brush just add unnecessary pressure without adding cleaning power. This takes all the restraint I can muster!

3. Move tooth by tooth, holding the head in place for a couple of seconds before gliding to the next tooth, following the curve of the gumline.

4. Apply only light pressure — many modern brushes have a sensor that lights up or pulses if you’re pressing too hard. Heavier pressure does not clean better and increases abrasion risk.

5. Let the built-in timer guide you to 2 minutes, typically with a pulse or chime every 30 seconds to signal quadrant changes.

6. Don’t forget the tongue, though I think it’s best to do the work here yourself with actual brushing motions similar to an old-fashioned brush.

Can we combine both?

I like to get a little crazy here at Examined. Mix stuff up, break it, recombine it a little? What about doing both techniques, both modalities, less filling and tastes great (though in the case of light beer I would argue neither, and don’t swallow toothpaste, so not a great analogy, sorry).

The honest answer is that the trial evidence for employing both electric and manual is thin. There’s no study that I could find testing “electric in the morning, manual at night” as a formal protocol, much less doing both at the same brushing. What exists is mostly expert opinion, plus one small RCT on a true hybrid brush (sonic vibration plus manual Modified Bass motion simultaneously) that showed a modest additional plaque and bleeding reduction over manual alone, especially on the tongue-side and back-molar surfaces that are hardest to reach.

What do I do? Might as well confess. I use a manual old fashioned toothbrush in the morning before seeing patients, but after eating a breakfast of Greek yogurt in the car during my commute, and spilling some globs on the car seats yet again.

At night before bed I do a brief manual Modified Bass with the old fashioned brush, then floss, then use an electric toothbrush to polish stuff up and make up for any missed opportunities with manual only. That’s crazy, right? Takes me about 3-4 minutes total, but I try to stay gentle to avoid excessive scrubbing and gum damage. I use silk dental floss to cut down on wasteful plastic in the world, and also maybe cut down on some personal microplastic ingestion from regular nylon floss.

My teeth do feel much cleaner and smoother than either method alone, if you want a testimonial. Some have compared me to Nicholas Cage when I’m done:

Ok, so no one has done that until just now.

A final practical take: if a person is already motivated to brush twice daily, alternating device types is low-risk and plausible in its rationale — electric for the fluid dynamics and rotational plaque removal and for those with dexterity issues; manual for the tactile feedback, portability, and the swiping away from the gums maneuver to dislodge stuff. But I’m stopping short of claiming this is true brushmaxxing, whatever that means, and it shouldn’t be claimed as proven superior practice. It’s a reasonable preference, not a guideline.

Bottom line before the chair

• Electric brushes — specifically oscillating-rotating models — have some better long-term evidence, particularly for tooth retention and periodontal stability over years, not weeks.

• The effect size is real but modest in patients who already brush well, and some other meta-analyses find little difference.

• Electric brushes are most clearly indicated for patients with dexterity limitations like arthritis, or cognitive impairment, or less-than-ideal brushing abilities/motivation.

• Technique matters more than device. A patient using Modified Bass correctly with a manual brush will usually outperform a patient scrubbing carelessly with an electric one.

• Soft bristles, light pressure, 45-degree angle, and ~2 full minutes twice daily remain the non-negotiables regardless of which brush is in hand.

And finally, there are a few dentists who read my column, and I welcome their feedback! I’ll publish an addendum if they have substantial additions, subtractions, or opinions on what I’ve presented here... or just drop thoughts into the comments. I’ve fortified this post with academic references as usual, but I also welcome clinical experience and judgement as a fellow practitioner. I’ll be responding to comments from my last post soon, too! Back from vacation and right into a massive pile of work, but wanted to get this post out to you today.

Good luck!

When the people urging you to eat three times the recommended amount of something also profit from it, it’s worth looking carefully at the evidence before following along. Chicken and beef, bars and powders, tofu and crickets. So I researched what I could on this airplane, and here is my take. References include one of my own posts about the sketchily inverted food pyramid, a post by Dr. Eric Topol, and a plethora more upon request from OpenEvidence (otherwise formatting hyperlinks on an iPad is too painful!).

What “high protein” even means

The longstanding recommendation of 0.8 grams per kilogram of body weight per day was not meant to be optimal. It’s the floor, the amount that prevents deficiency in a healthy adult, derived decades ago from nitrogen-balance studies. Few Americans fall below it. By USDA figures, more than half of men and a third of women already exceed it, and roughly a quarter of us eat double.

The influencer target is something else. Last I checked many including Attia recommend 2.2 g/kg/day, close to three times the usual number. What are the possible benefits, and more importantly, are there risks to consuming this much protein? Beef at the top left of the food pyramid?! What are the best sources of protein? Is there a convergent conspiracy between sincere ideologies and notable conflicts of interest?

Maybe there is room for compromise and healthy debate, even as everything in America careens towards conflict and extremism? The controversial 2025 Dietary Guidelines raised the recommended target to 1.2–1.6 g/kg/day. That is a meaningful increase, and it rests on some decent justifications. So maybe the disagreement that actually matters, then, is not between 0.8 and 2.2. It is between a reasonably well-supported move toward 1.2–1.6 and a fashionable leap to twice that.

Let’s dive in…

Where more protein genuinely helps

There are situations where eating more protein is clearly wise, and we shouldn’t lose them in the skepticism.

The first is weight loss. In a calorie deficit, higher protein helps preserve muscle while we lose fat, and it helps us feel full. The effect on the scale itself is modest (meta-analyses put it somewhere between 1-5 pounds of advantage) but the benefit to body composition is the real point. We want to lose weight, but not become weaker. This matters more than ever now that so many patients are taking GLP-1 medications, where muscle loss is a real concern. For them, adequate protein paired with resistance training can be crucial rather than optional.

The second is aging. After about sixty-five, muscle becomes somewhat less responsive to protein (a phenomenon called anabolic resistance). The slow erosion of muscle can lead to sarcopenia (poor body muscle), one of the under-recognized threats of later life. Here the evidence supports a modestly higher intake, around 1.0 to 1.5 g/kg/day. But protein on its own does very little for aging muscle. The benefit appears only when it is paired with resistance training. We can’t just gobble down bars, powders, chicken breasts. The protein is just the raw material but the movement is the signal to build with it. Without some exercise, much of the extra is simply spun into generic calories or even excreted.

Here’s a summary of the ranges recommended by different sources and in different situations:

A few points of nuance and clarification are in order. The traditional RDA of 0.8 g/kg/day at the top represents the minimum to prevent deficiency, not optimal intake, and has been criticized as insufficient for muscle preservation, especially in older adults. The updated 2025–2030 Dietary Guidelines now recommend 1.2–1.6 g/kg/day based on evidence for muscle, satiety, and metabolic benefits. But these were also heavily influenced by MAHA and RFK adjacent ideologies, so read on for more considerations.

For individuals with obesity, protein targets should be based on adjusted or ideal body weight rather than total body weight, since adipose tissue does not require the same protein support as lean mass.

Higher intakes up to 2.0 g/kg/day may benefit athletes, older adults with sarcopenia risk, and post-surgical patients, though evidence for benefit beyond 1.6 g/kg/day in the general population remains limited.

I don’t know about you, but I suck at conceptualizing protein based on the metric system. So here are some translations into typical American pounds of body weight, and grams of protein per day. I’m including 300 pounds to demonstrate the folly in just following grams of protein per unit of body weight… otherwise people at these higher weights would be chasing over 200g a day!

And now, here is a sampling of grams of protein from some common foods.

In this table you’ll see a “protein quality score.” This estimates how well a food provides all nine essential amino acids in digestible form, scored using a system where 1.0 is the highest rating. Animal proteins (meat, dairy, eggs) consistently score ~1.0, while most plant proteins score lower (0.4–0.7) due to limiting amino acids, particularly lysine in grains and methionine in legumes — meaning larger portions or complementary combinations are needed to achieve equivalent metabolic benefit. Vegans especially have to know this nutritional science to get all their essential amino acids.

Where the evidence runs out, and where we might have concerns

Is there too much of a good thing? Usually the answer to this generic question is yes.

Several lines of research now implicate leucine (the amino acid most abundant in animal protein, and the one some athletes supplement deliberately) in activating a cellular pathway called mTOR. When chronically overstimulated, mTOR appears to accelerate atherosclerosis in animal models, with similar signals in humans. Large observational studies link habitually high intake, particularly of animal protein, with more cardiovascular disease and higher mortality, and there is a cancer signal in middle age tied to elevated IGF-1 that appears to reverse after sixty-five.

To get a general sense of where the studies suggest potential problems with eating too much animal protein, but not necessarily plant protein, check out this table below:

We should consider these findings loosely, because most of the work is observational or done in mice. But it usually comes back to all things in moderation, not eat as much as you like because too much protein can’t hurt you. At the extremes, like pretty much everything, it plausibly can.

Instead we see that the clearer and more useful lesson is about source. Across most outcomes like mortality, heart disease, kidney health, the kind of protein matters more than the amount. Plant protein is consistently associated with lower all-cause and cardiovascular mortality, while the concerning signals attributed to “animal protein” come mainly from red and processed meat, not fish, poultry, or dairy. Replacing even a small amount of processed-meat protein with plant protein tracks with meaningfully lower mortality.

I had to look up TMAO (trimethylamine N-oxide). It’s a metabolite produced when gut bacteria convert nutrients found mainly in red meat into trimethylamine, which the liver then oxidizes to TMAO, a compound linked to increased cardiovascular risk through promotion of atherosclerosis, platelet reactivity, and inflammation.

We also need to consider the massive environmental and energy costs of producing red meat as our planet is really screwed, and therefore so are every one of us. Cows are sweeties, too.

Politics and ideology

Briefly.

The 2025–2030 Dietary Guidelines for Americans, heavily shaped by RFK Jr. and the MAHA initiative, markedly elevate protein targets and explicitly promote animal‑source protein (red meat, full‑fat dairy, eggs) as “real food.” They downplay concerns about saturated fat compared with prior mainstream guidance, while sharply elevating concern about seed oils and ultra‑processed foods. Concerns like the ones I mentioned above about red meat are usually dismissed. More tallow. Gross. At the same time, news sources have documented substantial financial ties between key new nutrition advisors and meat/dairy industry groups, raising conflict‑of‑interest concerns, even though formal findings of corruption have not been made. A careful characterization is that their final dietary guidelines come from a mostly sincere, MAHA‑aligned preference for animal protein and animal fats, though ignoring much inconvenient evidence about risks, and then accepting convenient reinforcement by industry‑aligned conflicts of interest.

What I will tell patients

If you are reading this then rest assured; you are probably getting enough protein already. No worries. The daily gram-counting and gaming burns mental calories on a problem you most likely don’t have. Bars and powders you probably don’t need.

The real exceptions deserve attention: adults past their mid-sixties, who lose muscle more readily, and anyone losing weight (especially on a GLP-1 medication) who needs to protect lean mass. In both, protein works only alongside resistance training. Without that, the extra mostly passes through.

Consider the newly increased 1.2–1.6 g/kg/day guidance loosely, too. It was hatched through a politicized process with industry ties, despite ironic protestations to the contrary, not the usual evidence-based one. And the nuance of animal versus plant protein is just not there at best, upside down and ideological at worst.

Source matters more than amount. Shifting from red and processed meat toward beans, nuts, fish, poultry, and Greek yogurt tracks with lower mortality and a lighter burden on the planet.

Protein is a building material, not a cure.

I like to enjoy mine when I eat it, rather than thinking of literally everything as a longevity and wellness tool of optimization to be commodified.

Take good care!

P.S. I’ll respond to any comments in a couple days 🌞

I’ve grown older with people now. I have a stake. It matters to me that our country is turning 250 years old. I’ve been alive for 20% of that time, and a lot of it has been invested trying to help people. The health of our country is the grand sum of hundreds of millions of unique lives and circumstances. I help take care of only a few thousand of those… but I can think bigger, step back farther, and write about what I think the United States herself would say about the lowest lows and the highest highs in American health history, if we were to ask.

Five things we got catastrophically wrong

1. The Tuskegee Syphilis Study (1932–1972). The U.S. Public Health Service (adjacent to my profession) enrolled about 600 poor Black men in Alabama, roughly 400 with syphilis, told them they were being treated for “bad blood,” and withheld penicillin even after it became the standard cure, so they could watch the disease run to autopsy. Forty years. It ended only when a whistleblower went to the press in 1972. The debacle helped give us informed consent. It also caused a mistrust we are still trying to earn our way back from.

2. Eugenics and forced sterilization (Buck v. Bell, 1927). Another terrible Supreme Court ruled 8–1 that the state could sterilize a young woman against her will, Justice Holmes writing the line that should hang in every ethics class: “Three generations of imbeciles are enough.” Roughly 60,000 Americans were sterilized across some 32 states. Nazi lawyers cited the case at Nuremberg. We didn’t import this idea; we exported it.

3. Leaded gasoline (1923 onward). We started adding a known neurotoxin to fuel to stop engines knocking. Refinery workers hallucinated and died, and a plant earned the nickname “the loony gas building.” Industry demanded a half-century burden of proof, so we fouled the air every child breathed and shaved IQ points off a generation. Lead in gasoline has been tied to over 150 million excess cases of mental health disorders. We didn’t finish banning leaded road fuel until 1996.

Historically, leaded gasoline was the dominant source of widespread lead exposure in the U.S., even though most identified childhood lead poisoning cases these days are tied to lead-based paint, contaminated dust, soil, and water in older housing and urban environments. It has been estimated that lead is responsible for the loss of 824,097,690 American IQ points as of 2015. Among last year’s federal cuts was a CDC division that helps communities deal with lead in their water. Flouride out, lead back in?

4. The opioid epidemic (1990’s to present). Purdue Pharma launched OxyContin in the mid‑1990s and trained its sales force to tell clinicians that the addiction risk was “less than one percent,” a claim that misrepresented the true risk in chronic pain populations and was transmitted to patients via trusted prescriber relationships. The Sackler family earned billions from OxyContin sales while the U.S. opioid epidemic unfolded. CDC estimates that from 1999 to 2023, approximately 806,000 people died from opioid overdoses, including those involving prescription opioids, heroin, and illicit fentanyl. Of course this is a multi-faceted problem, but producers (and prescribers) share part of the blame.

5. The deliberate dismantling of American Public Health by a radical regime (2025–PRESENT). This is happening now, on purpose, and the body count and human suffering is not hypothetical. Here is just a partial accounting, with every figure sourced:

• Coverage. The reconciliation law signed July 4, 2025 enacted the largest Medicaid cut in history. The CBO projects about 10 million more uninsured over the next 8 years from this alone — and roughly 16 million more once the lapsed ACA subsidies are counted. Researchers at Penn and Yale estimate the coverage and nursing-home provisions will kill about 51,000 Americans a year. A Harvard/CUNY analysis in Annals of Internal Medicine put the Medicaid-cut death toll alone at 8,000 to 25,000 deaths a year.

• The childhood vaccine schedule. In January 2026 “the CDC” stripped universal recommendations from six childhood vaccines, including the hepatitis B birth dose, in place since 1991 and responsible for a 99% drop in pediatric infection, and the arbitrarily halved HPV dosing. One published model finds that delaying the hep B birth dose for a single year’s birth cohort adds 482 deaths and 304 liver cancers. A federal court has since paused the changes, but the president is trying his hardest to force this through all by himself.

• The vaccine advisers. Secretary Kennedy fired all 17 members of the CDC’s immunization committee and replaced them with skeptics after personally promising Republican Senator and onetime proud medical doctor Bill Cassidy that he wouldn’t.

• Health and Human Services shed roughly 20,000 jobs and collapsed from 28 divisions to 15, gutting the labs, the disease detectives, and the staff without whom the scientists can’t function. The list of offices eliminated entirely or reduced to the point of non-functionality is what you might expect if an archenemy were trying to do a disservice to our health and humans.

• NIH funding and science research, gutted by billions, with political strings attached to funding and a massive brain drain away from America. This will hurt our economy, competitiveness, and future treatments and cures that will not be researched and discovered. Click to read more of the note I wrote about this travesty last week, and leave a public comment before it’s too late. More background from YLE published this morning, too.

• Preventive care. “You’re fired” to the leaders of the U.S. Preventive Services Task Force, the body that guarantees no-cost cancer screenings, HIV prevention, and depression screening for roughly 100 million insured Americans. Put a copay back on a mammogram and fewer women get one. Cancers simply show up later, larger, and less survivable. For those of us in primary care, the impact is very concrete: more patients delaying all sorts of preventive care, or simply not qualifying for it, more confusion about what’s covered, and a steady erosion of the progress we’ve made in preventing cancer, heart disease, and other chronic illnesses.

• Planned Parenthood. They severely cut Medicaid reimbursement to a health network where abortion is actually less than 10% of services. About 1.1 million patients risk losing care and some 200 clinics face closure, 60% of them in rural or medically underserved areas, red and blue. The early data: breast-exam visits down 25%, IUD insertions down nearly 40% already.

• Bodily autonomy. The abortion bans this radical Supreme Court made possible keep killing. Maternal mortality rose 56% in Texas in the ban’s first full year, while it fell in states that protected access. Researchers attribute roughly 478 excess infant deaths across states with bans through last summer, more by now. That’s simply horrendous.

• The diseases we’d beaten. Measles came roaring back with 2,144 cases in 2025, the most since 1992, three dead, and elimination status de facto lost. The counts just keep climbing in 2026. Whooping cough hit about 35,000 cases in 2024 and 28,000 in 2025, with at least 13 deaths, most of them infants.

• The world. The new massive Ebola outbreak, from a strain that has no approved vaccine or treatment, is burning through several African nations, with hundreds already dead. It has been declared a global emergency much later than it could have been nipped in the bud. It arrives precisely as the administration fed USAID, in Elon Musk’s phrase, “through the woodchipper.” A Lancet model ties the global aid cuts to more than 14 million avoidable deaths by 2030, a third of them children.

• There’s much, much more, but I am really trying to keep this in my lane. Of course there are also for-profit, taxpayer-funded, literal concentration camps in America in which we have hunger strikes and Unites States Senators being pepper-sprayed. Didn’t think you’d read sentences like that for our 250th did you? We could all write books of them.

Is the present and looming health catastrophe the worst the country has ever had? In some ways it is. Tuskegee and eugenics were more grotesque in kind; nothing here matches that cruelty of intent. But in the sheer scale of preventable death and suffering this seems unmatched. Every prior catastrophe on this list was eventually corrected by institutions like the CDC, the FDA, the NIH, the ethics boards, the disease detectives. But this is the first time they have set about thoroughly dismantling the corrective machinery itself. That is what makes it qualitatively different, and quantitatively devastating. You can survive a disease. It is much harder to survive the destruction of your own immune system. That is what the surveillance networks, the advisory committees, the research pipelines, the institutional knowledge, and the aid programs were: the body’s defenses, built over a century, dismantled in eighteen months of tantrums and trauma. A year ago I wrote about why these project 2025 disciples set about dismantling everything… and over 36K people have read that now.

Five things we got gloriously right

We need hope. We need moral elevation.

We need to recall progress and historic wins even as we are surrounded by present losses.

1. The Framingham Heart Study (1948). Researchers in a Massachusetts mill town followed about 5K people who weren’t sick yet and invented the most useful idea in primary care: the risk factor. You know, like blood pressure, cholesterol, smoking, diabetes, the risk-assessing vocabulary I use 100 times a day? The entire paradigm by which primary care succeeds, the ounce of prevention truly weighing in at a pound of cure, the fact that we can modulate our health in evidence based ways… it all starts with discerning true risk factors. Before this, doctors pretty much just treated diseases. After this lightbulb, we gave much more credence to prevention.

2. The 1964 Surgeon General’s report on smoking. Adult smoking fell from 42% to under 12%. A 2014 analysis in JAMA credits the tobacco-control era it launched with saving roughly eight million American lives — more than any drug, surgery, or device in my lifetime.

8 million lives.

Enough said.

3. The community health center (1965). In the heart of the civil rights movement, Drs. Jack Geiger and Count Gibson opened the first neighborhood clinics on a radical premise: a poor person deserves the right to health care like anyone else. Sixty years later, some 1,400 health centers care for roughly 30 million Americans. Where they open, birth weights rise, hospitalizations decrease, and mortality drops. Communities with them did better during the pandemic as they expanded hours of care, educated their communities, created outreach programs that facilitated testing, and distributed vaccines.

4. The polio vaccine (1955), the pediatric vaccine schedule in general, and mRNA Covid shots in particular. First, the polio vaccine. It emptied the summer wards of paralyzed children, down from the previous 13,000-20,000 a year before the shot arrived. Asked who owned the patent, Dr. Jonas Salk answered that the people did: "Could you patent the sun?"

Second, the pediatric vaccine schedule. “Among (US) children born during 1994–2023, routine childhood vaccinations will have prevented approximately 508 million cases of illness, 32 million hospitalizations, and 1.13 million deaths, resulting in direct savings of $540 billion and societal savings of $2.7 trillion.” It’s excruciating to picture one child dying, but then multiply that times 1.13 million and you can see why we work so passionately to oppose anti-vax ideologies.

Third, mRNA Covid shots. “More than 2.5 million (Covid) deaths were averted… Eighty-two percent were among people vaccinated before any infection, 57% were during the Omicron period, and 90% pertained to people 60 years or older. Sensitivity analyses suggested 1.4 to 4.0 million lives were saved.” The mRNA shots were built on Nobel-winning work done largely here in Philadelphia at UPENN by Drs. Karikó and Weissman.

5. PEPFAR (2003). A bipartisan commitment to treat HIV across Africa that went on to save more than 26 million lives— the largest stand any nation ever took against a single disease. George W. Bush committed the United States to treating HIV across Africa, and it passed with rare bipartisan force. “CDC’s role in PEPFAR had benefits beyond HIV/AIDS. Its expertise and the systems it helped build in each country aided the response to other disease threats such as Marburg or mpox (and Ebola), ultimately providing health security to the United States.” Well done… but now executed in the literal sense by the current administration. Sorry, I couldn’t help myself on that one. To make it up, I’ll list simply list some more honorable mentions, and let the triumphs stand even as we know they are presently being undermined:

• Water fluoridation, first piloted in Grand Rapids in 1945 and expanded to protect teeth across every income bracket

• Medicare and Medicaid, which in 1965 opened the door to care for tens of millions of older, disabled, and low-income Americans overnight

• The American-led eradication of smallpox, declared complete in 1980

• Newborn screening, the heel-prick test pioneered by Robert Guthrie that now catches dozens of treatable conditions at birth

• The Pap smear and the dramatic decline in cervical-cancer deaths that followed, not to mention the HPV vaccine’s incredible success at preventing cancer in the first place going on right now

• Federal seatbelt and auto-safety standards that turned the car from a death trap into something survivable

• The March of Dimes model of mass public fundraising that bankrolled the polio fight

• The Clean Air and Clean Water Acts, which quietly saved more lungs and lives than most heroics that ever happened in a hospital.

The assessment and plan

What can we do now? What kind of birthday present might our country want for her 250th?

Let’s not treat that as a rhetorical question. Hopelessness and despair are crappy gifts and exhausting feelings. Exhausted people obey. So let’s acknowledge the exhaustion, but then keep getting up. We’re not the first to watch a free society get dismantled, and the scholars who studied the last century left us a playbook. Erica Chenoweth found that no movement mobilizing just 3.5% of a population (about eleven million Americans) has ever failed. And Dr. Timothy Snyder’s On Tyranny reads at times as if it were written for those of us in medicine.

Snyder’s first lesson: do not obey in advance. Most authoritarian power is freely given by people guessing what the regime wants before it asks — the family doc who quietly stops educating and recommending routine vaccines because a committee of cranks downgraded it. Don’t. The recommendation changed; the immunology did not. When a frightened parent asks about a shot, we can’t just send them a study. We have to ask what scares them, and listen, because people change their minds for people they trust, not for arguments they lose. None of us should accept millions of our friends and neighbors and selves being ruined by the loss of healthcare insurance so that greed can prosper from sickness and misery.

His fifth applies here, too: remember professional ethics. The professions are a firewall, and it’s mostly holding. When RFK Jr’s committee began rewriting the childhood schedule, the vast majority of doctors didn’t fall in line. Instead the AAP, AAFP, ACOG, and AMA, over a million clinicians, kept the real recommendations. Even health insurers we love to hate, covering 200 million Americans, pledged to keep paying for vaccines at no cost through 2026. And the states stopped waiting: the West Coast Health Alliance, a Northeast collaborative, and a bipartisan bloc of fifteen governors now issue their own science-based guidance.

A few more. Believe in truth, and investigate. Tuskegee ended not because the system corrected itself but because one person took the story to a reporter. Keep standing up and out, because the moment one person breaks ranks the rest discover they can too. Practice corporeal politics, because 3.5% isn’t a tweet, it’s people in the street, again and again.

What turns this into a chain reaction is the oldest medicine we have, the one thing this regime cannot defund: moral elevation — the lift in the chest we feel watching someone do the right thing at cost to themselves. The suite of feelings people may experience when witnessing an instance of moral beauty. Jefferson named it 250 years ago, Jonathan Haidt revived it recently, and it’s as real as a reflex. Decency, witnessed, is contagious. One act becomes two, then four. A nation, like my 103-year-old patient, is the grand sum of such acts.

So let our 250th birthday be less a pugilistic, profiteering, grotesque carnival on the White House lawn than a renewal of vows to the science that lets us see risk before it harms us, and to the idea that every life is worth defending. Improving. Healing. From the newborn’s first heel-prick to the centenarian who has lived 41% of the whole American experiment.

Snyder’s hardest lesson is his last: be as courageous as you can. This won’t be undone by one hero. It will be undone the way every American correction has, by ordinary people of common decency refusing, together, to obey in advance. Refusing to normalize the historic plundering of our nation and our world’s health.

Be one of them.

Then be the reason your lovely neighbor becomes one, too.

Subscribe now

Ensitrelvir/Xocova is now approved in the US for post-exposure prophylaxis in anyone 12 and older who’s been exposed to someone with Covid. That’s a first. We’ve had pills to treat the infection for years (Paxlovid and molnupiravir). We’ve had IV remdesivir. Our Doctor/President/Jesus-figure recommended a disinfectant like bleach, and hydroxychloroquine, and many others have touted horse de-wormer. But ensitrelvir is the first oral one cleared in the U.S. that can actually keep us from getting sick after the coronavirus has already made it into our houses.

Ensitrelvir is a SARS-CoV-2 main protease inhibitor. It gums up an enzyme the virus needs to copy itself, the same target Paxlovid hits. The difference is a longer half-life, so it’s a lot less pills taken over 5 days, and it skips needing to add ritonavir, the booster behind Paxlovid’s metallic-mouth side effect and much of its forbidding interaction list. But more on that shortly.

The prophylaxis data, which genuinely surprised me

The approval rests on SCORPIO-PEP, a global trial that enrolled household contacts of people with symptomatic Covid and started them on the drug within 72 hours of the sick person’s first symptoms. That’s key. Among contacts who took at least one dose, 2.9% came down with Covid by day 10, versus 9.0% on placebo. That’s a 67% drop in the odds of catching it from the person coughing across the kitchen table.

I will add that the 9% household spread (secondary attack rate) is much lower than what we see in real life. Previous studies estimate that about 30-40% of household contacts usually pick up Covid. Why the difference? This trial required both PCR confirmation and at least one symptom lasting 48 hours or more, filtering out the subclinical and short-duration infections that Omicron routinely produces in an already-immune population. When the trial measured any PCR-confirmed infection regardless of symptoms, the placebo rate rose to 21.5%, much closer to what we'd expect, suggesting transmission was happening at a familiar pace. Also, households enrolled in a clinical trial are counseled on exposure precautions like masking, separate rooms, better ventilation, etc. Therefore the 9% control arm number undersells how useful this drug could be in a higher-risk setting, like a nursing home outbreak or in a household with higher risk family members for whom a Covid infection presents a significantly bad risk.

More than 98% already had antibodies, from vaccination, prior infection, or both. This was not a naïve population. It was us, the immunologically experienced majority, and the pill still worked, on top of the immunity we already carry. For people with risk factors for severe disease, the gap was wider still with about a 70% reduction in spread.

Another small catch: protection tracked with the five-day course. Once the drug cleared, the treated group lost its edge against any new exposure, with fresh infections accruing at roughly the placebo rate. So it’s important to use other measures while people are sick in the house, like ventilation, beyond just the 5 days of Xocova during the most infectious period.

In the exam room, the limiting reagent won’t be the science. It will be the clock. Getting a real diagnosis in the household, a prescription written, and the first dose swallowed inside 72 hours is a tall order for a working family with one car and three jobs. Some people might prep in advance, the way I talked about with influenza and baloxavir (Xofluza, another weird Xo-named drug).

It’s not an on-label treatment in the US

Here’s where I’d gently correct the natural assumption that a new antiviral means a new way to treat Covid. In the U.S., ensitrelvir is approved only for prevention. The treatment trials in vaccinated, Omicron-era patients (SCORPIO-HR in outpatients, STRIVE in the hospitalized) reliably knocked the virus down on lab measures but failed to move the symptoms that actually matter to a sick person. In hospitalized patients there were even some worrying safety signals and no reduction in mortality. So it’s a preventive, not something I’d reach for once symptoms start. Japan approves it for both. We don’t.

Long Covid? A hopeful maybe

It’s already being floated as a long Covid preventive, and there is a signal, but I want to stay realistic about it. The randomized data showed reductions in post-Covid symptoms that never reached significance, with confidence intervals that all crossed zero. A large Japanese observational study was more encouraging, roughly a 14% lower risk, with a number-needed-to-treat around 26. Promising, and plausible if less virus early means less long-term damage, but not proven. Here are some stats on viral load reduction, if you too like that sort of thing:

The PLATCOV trial (Lancet Infectious Diseases, 2026) provides the first direct randomized comparison of ensitrelvir vs. nirmatrelvir-ritonavir (Paxlovid) in 604 low-risk outpatients (93% vaccinated) with early Covid-19 disease. This trial used ensitrelvir for treatment of Covid.

• Viral clearance half-life: ensitrelvir 5.9 hours vs. nirmatrelvir 5.2 hours vs. no drug 11.6 hours. This is the key metric for those concerned about viral loads and kicking this virus out the body faster.

• Ensitrelvir accelerated clearance 82% faster than no drug; nirmatrelvir was 116% faster

• Ensitrelvir was 16% slower than nirmatrelvir, failing to meet the non-inferiority margin of 10%.

• Viral rebound: 5% (ensitrelvir) vs. 7% (nirmatrelvir) vs. 7% (no drug) — no significant difference

• Bad taste: 1% with ensitrelvir vs. 26% with nirmatrelvir-ritonavir. This is a big deal actually, as Paxlovid can really taste terrible and people often stop taking it mid-course!

• Symptom resolution: Restricted mean symptom duration was identical at 5.4 days for both antivirals vs. 5.9 days for no drug

Do lower viral loads matter for each infection, for each year, for the cumulative exposures we will be getting for the rest of our lives in terms of Covid infections and trillions of coronaviruses running through our bodies? I think they will. I like lower viral loads. In my younger days I always hated parties if my apartment got trashed by the guests.

And finally, in a meta-analysis of all drugs tested in the PLATCOV platform (1,157 patients), nirmatrelvir and ensitrelvir had the largest antiviral effects among all small molecules, exceeding remdesivir and molnupiravir. All of this matters for future variants that might still come bulldozing through. We’ve been lucky so far that SARS CoV-2 has been stuck on the Omicron branch of the family tree for a few years.

The “no ritonavir ingredient like Paxlovid, so no interactions” story is way oversold. Ensitrelvir is itself a strong CYP3A inhibitor, so we still need to check for drug-drug interactions. Darn it. And it can cause fetal harm, so it’s a no-go in pregnancy, with breastfeeding paused through treatment and for two weeks after.

Bottom line

For those of us still quietly trying not to catch a gratuitous case of Covid (yes, I’m the guy still masking on the cough-filled plane and trying to enjoy my hard-earned vacations without whatever viral illness), a well-tolerated pill that cuts the odds by two-thirds after a known exposure is a solid option to add to the kit.

Would I stock up and take it if a family member were sick? Maybe. For higher risk family members? Seems prudent.

For interested patients I’ll be watching the 72-hour clock and their rapid antigen tests, checking the medication interaction list, prescribing when people want it, and reminding Americans that it prevents rather than treats Covid well.

This is the world we practice in now. A recent industry survey found that doctor recommendations and social media are the top sources patients use for supplement information. Another survey from Pew Research Center found that 75% of Americans most highly value medical training, transparency about conflicts of interest, and ease of understanding… with health care providers rated highest (even above AI for now). So here is the best I can do for magnesium. The version I would give in the office if only I had more time. I make no money from commissions or selling stuff.

The strongest case for supplementing is with genuine magnesium deficiency. Certain people are far more prone to it than the general population, where low magnesium levels still run about 3–10%. Antacids like omeprazole cause deficiency in roughly 20% of long-term users, and diuretics used for treating conditions like high blood pressure waste magnesium through the kidney. Poorly controlled type 2 diabetes (10–30% prevalence), alcohol use disorder, and chronic diarrhea or malabsorption are classic culprits, as are certain chemotherapies and older folks on five or more medications. If you fit one of these, the conversation shifts from wellness trend to genuine medicine. Nonetheless, we will briefly review the evidence for magnesium and sleep, migraines, blood pressure, insulin sensitivity, cognitive function, anxiety, and muscle cramps to name a few.

Read more