It feels satisfying to be on this side of the mountain, even though the hiking is still rough.

National/federal public health powers are a Hamiltonian success story. It’s sad to see them dismantled and hamstrung in many red states.

Even in a post-vaccine America, death rates in red states were 38% higher than in blue states.


And this from Scientific American:

“ Cultural differences between red and blue counties also likely contributed to COVID deaths. “You’re affected by your neighbors,” says Neil Sehgal, a public health professor at the University of Maryland and co-author of a recent study of the association between COVID mortality and county-level voting. Sehgal and his colleagues found that through October 2021, majority-Republican counties experienced 72.9 additional deaths per 100,000 people relative to majority-Democratic counties. To the researchers’ surprise, however, vaccine uptake explained only 10 percent of the difference. The finding suggests that differences in COVID outcomes are driven by a combination of factors, including the likelihood of, say, engaging in unmasked social events or in-person dining, Sehgal says. By February 2022 the COVID death rate in all counties Donald Trump won in the 2020 presidential election was substantially higher than in counties that Joe Biden won—326 deaths per 100,000 people versus 258. “COVID was probably the most dramatic example I’ve seen in my career of the influence of policy choices on health outcomes,” Woolf says.”


Science-minded, centralized leadership and public-minded, community spirit actually matter. A lot. Not just for Covid.

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This is easily falsified. The entire pandemic premise that "Red = bad, blue = good" was a lazy, poorly researched story that journalists kept repeating but never double checked (David Leonhardt would famously regurgitate this in a quarterly column in NYT 2021-2022).

As a physician - and especially in Family Medicine - you should know the reason why red counties have higher death rates than blue counties - and you should know it has nothing to do with "being more likely to engage in-person dining or not wearing a mask" (oh! the horror!).

The disparity in death rates between Red and Blue is merely the difference between Old and Young, Fat and Healthy, Rural and Urban, Smokers and non Smokers.

It's no big mystery that elderly obese were at risk for Covid. Which political party skews older and fatter? Republicans. Which party generally lives in urban areas with less access to excellent healthcare? Republicans.

This is well known and studied. You should know this and be correcting authors when see this nonsense, not me correcting you.

A quick literature review reminds us that this is a known issue public health has sought to address for decades



Where was the media outrage in 2019 when West Virginia had 1270 deaths per 100,000 compared to Illinois' 832 deaths per 100,000? That's 50% more deaths! How could this be?!?

Which state did worse in 2020 then, with West Viriginia rising to 1435 deaths per 100,000 compared to Illinois' 1029 per 100,000?

If the ridiculous claims Seghal makes in the SA article were true, then why did the countries that didn't participate in covid theater (masks, lockdowns, halting in person dining) have the best outcomes?

If the reason red counties had .32% of their population die compared to .26% in blue counties was because they dared to engage in social events or dine in person, then why didn't the blue counties see a spike in deaths when they too put away their masks and rejoined society throughout 2021 and 2022? (Sidenote - gotta love using the scary relative difference of 38% instead of the not-so-threatening absolute difference of .06% - another tactic of the lazy journalism, committing the basics of How to Lie with Statistics)

Taking advantage of the predisposition that fat, rural, older populations with higher alcohol and drug use have to dying and claiming it's because they voted for Trump, or that they went to a birthday party without a cloth mask is embarassing.

Sorry, cranky morning, just stunned to see this debunked nonsense repeated in year 3.

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Hi Michael- I’ll read your references here later, but here in Philly, the poorest big city in the country, and the most overweight, and with high urban population density, we still did much better than say Ocean County, NJ, demographically a healthier, wealthier, thinner, more spread out region. So there are lots of factors going into discrepancies in outcomes, but different political leadership and messaging to loyal constituents cannot be discounted as among the major factors explaining successes and failures

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You are just anecdote fishing though. I could counter that Hunterdon County NJ, a Republican stronghold for the state, and just as close to Phillie as Ocean County, performed much better than Phillie with only 238 deaths per 100K than Phillie 351/100K [1]. Who's anecdote is better?

But suppose I trust you - that your insinuation of Phillie's success is due to masking and not going out to eat (never mind all of that stopped and they paid no price) - how would you explain the all-cause mortality data discrepancy between Philadelphia and Ocean County?

Official covid deaths are 5606 for Phillie and 3290 for Ocean County (351 vs 516 per 100K), yet Philadelphia has a much higher all cause mortality increase than Ocean City.

Could it be perhaps because of the discrepancies in how we count deaths for Covid? Isn't the excess deaths the true best measure?

Because if so, then Philadelphia performed far worse than Ocean City - all causes deaths jumped from 14,200 to 18,123 for 2020 - a 28% increase. Meanwhile Ocean City only jumped 7,400 to 8,600, a 16% increase.

Pulled from Wonder:



[1] https://www.nytimes.com/interactive/2023/us/philadelphia-pennsylvania-covid-cases.html

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You cite obesity as one example for why the differences in COVID-19 mortality are not due to political affiliations. Obesity certainly is a major risk factor, but it is most prevalent in Blacks and in Hispanics (49.9% and 45.6%, respectively) compared to Whites (41.4%).


Blacks and Hispanics are strongly Democratic groups.



Additionally, obesity is less common in those 60 and older (41.5%) than in those of middle age (44.3%) (see the CDC link above).

Finally, Republicans are older than Democrats, but the difference is smaller than you might think. According to Pew Research, 25% of Republicans are 65 and older vs. 23% of Democrats.


Your contention that the mortality differences can be explained, in part, on Republicans being more likely to be obese and older does not hold up under closer scrutiny.

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DH: "Obesity certainly is a major risk factor, but it is most prevalent in Blacks and in Hispanics (49.9% and 45.6%, respectively) compared to Whites (41.4%)."

Which explains why minorities were hard hit with deaths too, though according to Mayo clinic it wasn't obesity, but rather racism [1]

DH: "Additionally, obesity is less common in those 60 and older (41.5%) than in those of middle age (44.3%) (see the CDC link above)."

That is an irrelevant statistic considering the fact that obesity+ age was the key driver in mortality from Covid. Your argument is equivalent of saying "99% of drivers aren't drunk" when responding to a statistic that 60% of all traffic accidents involved alcohol.

The base rate may be that older populations are less obese than middle aged, but that doesn't change the fact that obese older people accounted for majority of covid deaths.

DH: "Finally, Republicans are older than Democrats, but the difference is smaller than you might think. According to Pew Research, 25% of Republicans are 65 and older vs. 23% of Democrats"

Here, you present the absolute percentages so we can see the difference of 2%, why not the relative difference of 9%? - joking, but another reminder how we like to choose absolute vs relative when it fits our position.

You (unintentionally, I am sure) make the mistake of averaging the average to minimize age discrepancy - the source Ryan cites talks about Red vs Blue *counties* - we know that Red counties are overwhelmingly rural. We know the rural counties are older by a larger margin than the top-level R vs D designation.

You can say "Well look, Republicans on average are only 9% older than Democrats" (my turn to switch to relative) - but that ignores that at the county level, the age discrepancy increases.

DH: "Your contention that the mortality differences can be explained, in part, on Republicans being more likely to be obese and older does not hold up under closer scrutiny."

I feel like I am in bizarro world, where facts and data no longer matter.

The fact is there is almost NO mortality difference between Red and Blue, masked and unmasked, Florida or California, kids in school or out of school, highly vaccinated states or lowly vaccinated states [2].

Everyone had nearly identical outcomes. There are small differences we can find, but they are easily explained by baseline health of the population - easily provable by doing a "but what about before" analysis.

That X has 50% more deaths than Y in 2020 isn't notable if that difference was there in 2019, 2015, 1995...

The problem is that people who claimed that masks, or closing school, or voting for Trump mattered are now left looking foolish because we can see with our own eyes, with the data before us, that none of this mattered.

Those were fine hypotheses 3 years ago. But in science when you make a hypothesis and it fails you accept it. You find out why it failed. You don't data drudge your way to justify your nonsense.

And that is what is happening.

You are clinging to falsified theories which were unable to predict anything, which can't be replicated. It's pseudoscience.

It's time to move on. It's ok that masks didn't work, or that closing down a restaurant did nothing. Just like it's ok that bloodletting, ingesting mercury, RotaShield, or measuring skulls. For every success in medicine there are a thousand failures. It's not a bid deal to be wrong.

Unless, in the face of evidence, you cling to these superstitions. Then you are no better than an astrologer or shaman.


[1] https://www.mayoclinic.org/diseases-conditions/coronavirus/expert-answers/coronavirus-infection-by-race/faq-20488802

[2] For example, Unvaccinated Missouri wound up having an identical outcome to max vaccinated Ilinois, despite claims from the Media they were "becoming a cautionary tale for the rest of the country"


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I won't bother to refute the entirety of your reply, but I will comment on your contention that masks were or are ineffective. The vast majority of well-done studies clearly shows that masking reduces the risk of contracting an SARS-CoV-2 infection.

You can see a summary of some of those studies at https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html.

Also, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9191667/

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Using the initial 70 studies Katelyn posted to Facebook Nov 2020 [1], I created a spreadsheet to track every mask study I could find over the last 3 years. I keep a shareable version here [2].

In other words, I read those studies you posted, and all the others.

I was completely open to them working.

But it was an extraordinary claim - that we had a simple tool we knew about for the last hundred years - a tool that could have saved a hundred million lives from Tuberculosis. 20 million lives from the flu alone in the 21st century.

That seemed hard to fathom that we knew about masks, decided they didn't work, but all along they were a game changer - especially given the physics of airflow.

But like I said, I was open to them working - it would just be a colossal fuck up if true

So I looked for extraordinary evidence.

What I found, instead, was a high of number of papers were already easy to double check and find the claims couldn't be reproduced. A lot of the early observational studies made the mistaken correlation to countries wearing masks spring 2020 and cases dropping, so they incorrectly ascribed that drop to the mask (PNAS "Identifying airborne transmission..." Zhang et al is a great example of an influential paper that couldn't be replicated). They didn't realize they were looking a seasonal decline at the time.

From that mistake lead to a flurry of experiments, opinion pieces, and models - all citing the original, now falsified, observational studies.

You can pick any one of them and find glaring errors, but many in PH got gish gallopped - they didn't take the time to read and replicate these studies, they merely assumed with so many studies, the claim has to be right.

It's truly scary that this could happen in the way we've organized science. 3 years ago I wouldn't have thought it possible our hysteria could "will into existence" a claim which is easily debunked. A claim which can't predict anything.

Don't get gish galloped D Hart. If you are a physician I know you had to be way too busy to read all of those the last 3 years. You assumed, which is reasonable, that with so many paper saying something it has to be true.

I'm telling you, read some of them. Closely. As a skeptic. Start with #4 in my spreadsheet. You will understand why in the real world it didn't matter who wore what masks. It's something you can only find how incredible they work in papers.


[1] https://www.facebook.com/permalink.php?story_fbid=202002698114314&id=101805971467321

[2] https://docs.google.com/spreadsheets/d/1ahaJui6Af0kGYMwHgAtnKCE6-bHbCLxnrQxuMC0kygA/edit?usp=sharing

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Just so we're clear, these studies show that mask mandates don't work. I agree that they may not work on a societal level - or at least, they need a better enforcement model that doesn't require frontline workers to enforce them. They have little bearing on whether N95 masks, worn correctly, reduce the risk of getting covid.

I don't think it's intellectually healthy to think of studies as supporting one of two fixed hypotheses. Better to think of them all as pieces of a large, messy puzzle that help guide actions the next time we are faced with similar situations.

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I feel like it might be worth considering a non-coercive framework for federalism, say through an accreditation system.

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Hot take: I don't think it's Republican vs Democratic per se. The underlying philosophy, I believe, is: fatalism. The tendency to think that certain things are inevitable, and that taking steps to avoid or delay those things is....cheating. And that that cheating will have "divine" consequences. It's more common in rural than urban areas, more common among religious than non-religious people, more common among the poor than the rich, and more common among blacks than whites. I think this drives a lot of resistance to vaccination, purchasing health (or any) insurance, etc.

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May 10, 2023Liked by Katelyn Jetelina

Insightful and appreciated, even for this old, non-medical, lay person who appreciates reading qualified information. It’s why I’m a paid subscriber who values trusted sources. Keep up the great work!

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I am the same kind of citizen, so yes I concur thank you Dr. Katelyn Jetelina!

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If it’s in your wheelhouse would you consider an in-depth article sometime on research for antiviral treatments? I am in my mid 60s, and have what is nicknamed a “patchwork heart“, which makes me very high risk. Should I contract Covid or even apparently the current flu strain. Packs love it is off the list of options for me, and remdisivir seems like a crapshoot. therefore I remain isolated, going into my almost 4th year. If I didn’t want to be a burden to my daughter, I would just take my chances and frankly, I would almost take going out with Covid to the specter of more isolation. Luckily, though it is summer and more sunlight and outdoor gatherings will be refreshing. the frustrating part is knowing that there are no antivirals that could help people like me. And I’m very curious if there is any increased effort to get more nimble with treatments than there is with vaccines. I am, of course fully Vaxxed and probably over boosted… Thank you for all your hard work, we will continue to slog and celebrate those who don’t have to be cooped up anymore.

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You must have dictated this:

Paxlovid = "Packs love it"

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Thanks for that! Duh!!!

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Oh golly

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There might be some promising treatments in the future that haven’t been FDA approved yet, such as Sabizabulin or peginterferon lambda. We need more treatments, that’s for sure.

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Curious as to your reasoning around Remdesivir as crap shoot?

My memory is that it's as effective as Pax, but one is best off working out the contingencies of arranging infusion before it's a concern.

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Hi Marcia- that comes from my Cardiologist and pcp who both said their patients seem to respond well or not at all with no definitive reason. This in answer to my proposal to use it as my plan b I order to reenter some small group activities.

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What about molnupiravir?

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Would you consider a future post offering guidance on how best to adapt our indivdual responses with the wastewater and hospitalization data (plus the best ways to find that info)? You have been so helpful walking us through your process for interpreting case counts and percent positives. I would love to have a similar plan for these new metrics. Thank you, as always.

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Want to second Amanda. Dr. Jetelina, you have been particularly helpful to me, friends and family, with your recommendations for individuals--you are the only one, also, who breaks the information down into higher and lower risk categories/recommendations. It would be great to get an update for the post 5/11 environment and with some emphasis on how to think about the available metrics.

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I am now going to second you, Amanda, a second time, after trying to decipher wastewater data in my area this AM. I would be interested in what others are experiencing, but I am finding it difficult to decipher how best to use it as an aid in assessing individual risk.

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Public health is a major failure of the Biden administration. All that covid aid money and now back to the past with poor data reporting infrastructure.

Over 65 and still masking in indoor public spaces.

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The pandemic response will be THEE topic of the Presidential election process, with both sides claiming victory and viciously pointing the finger at the other side. Most democrats I know, in hindsight, think we went overboard with lockdowns and restrictions, especially in states like California where I live. I, for one, am not looking forward to reliving everything that happened during the pandemic.

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I think we should have made the 2021 tranche of pandemic aid conditional on getting vaccinated by a specific date. If you don't, it becomes a loan with usurious interest.

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As a 60-something healthy person with a 68-year old low risk spouse, we have been trying to stay as safe as possible by masking indoors, even in uncrowded spaces. We got our bivalent boosters back in September and just don't want to get Covid. I would love to hear more about where you think we should be focusing our attention now that the country and world are ending the PHE. Would love your recommendations or suggestions for reading material now that so many people have had the disease and/or the vaccine, but it is still here and killing people.

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Thank you again. This is important information that so few folks are aware of. The false impression that the CDC is all encompassing and has far reaching powers is common. Same with EPA.

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Hey, have you read Zelikow’s Covid report? Good work, even though it will be ignored.

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I read the whole thing!! I was incredibly impressed.

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What was this report about?

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Thank you very much for the Big Picture analysis Public Health.& data flows One comment on the CA system specifically County public Health Departments in the Bay Area who managed the AIDs crisis. County reps know each other by first name & still meet informally once a month. Dr Silverman still goes to international conferences in his mid 80's. We benefited greatly from their coordination in the Pandemic

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Wastewater is a preferred metric over hospitalizations because (I’m assuming) wastewater increases 2-3 weeks before hospitalizations, making it a better leading indicator?

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That's my understanding. I'm not sure how useful WBE is on the other side of a wave, since it's a PCR test with an even higher CT than clinical PCR tests, so liable to pick up lots of RNA fragments long after people have recovered.

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I'm not so sure about wastewater not going away. I live in dc, and fortunately I can see that on biobot since it's still not showing up on DC's dashboards. But one of my neighboring counties, Arlington county, hasn't updated wastewater since March 29th.

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Being flexible and patient. Easier said than done!

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Not a pharmacist but oh my yes indeed!

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There is one very important reason why it makes sense to ease off on publicly available reporting when actual prevalence is low: the potential for de-anonymization. This is a serious issue with all aggregate data, but it can be particularly problematic when it's health information, that could very well point to chronic underlying conditions.

As far as test positivity rates go - isn't it safe to assume that the same labs that report TPR of other viruses to NREVSS will simply add covid to their list? I feel like it might actually be useful to see covid reported along side its cousins.

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My primary care provider, Martin’s Point, which has the contract for providing health care for retired veterans if they so choose in much of Maine, Vermont and upstate New York follows federal mandates on masking, so today’s will the last day for masks at all their primary care health care centers.

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It's appalling that the only place in NYS reporting waste water in the link you shared is Nassau County. It's quite literally insane.

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The system could be self funding if they simply tacked on a percentage to the accreditation fees that labs pay to NIST.

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I'd love to see some of the unspent government COVID funds go towards modernizing our national and state data infrastructure. This would help on a much broader level and allow us to respond even quicker the next time a pathogen arises.

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I'd like to see a system funded by adding a bit on top of NIST lab accreditation fees.

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