Category: Health

How’s the miracle drug Paxlovid doing against COVID-19?

by philg

“Paxlovid is a miracle drug,” says a primary care doc whom I know, “because it is a miracle when I can prescribe it. Anyone who is sufficiently vulnerable to serious consequences from COVID-19 is already on drugs that have interactions with Paxlovid.” The other docs with whom I’ve talked about this drug, especially cardiologists, are generally negative regarding the drug. In their view, it will interact badly with other drugs, have bad side effects, and/or result in SARS-CoV-2 attacking the patient as soon as he/she/ze/they stops taking Paxlovid.

Chinks in the miracle drug’s armor are beginning to be described in our otherwise cheerleading media. Example from the NYT, March 25:

Certain medications or supplements, including painkillers, statins and even St. John’s Wort, may have adverse interactions with Paxlovid. So you may be advised to hold off on taking them for a week while being treated, Dr. Gandhi said. But for some medications, like drugs that regulate heart rhythm, abstaining for a week may not be possible. In those cases, your doctor may recommend molnupiravir for Covid-19 instead.

From Yale, where they understand medicine if not accounting, “13 Things To Know About Paxlovid, the Latest COVID-19 Pill”:

The FDA authorized Paxlovid for people ages 12 and older who weigh at least 88 pounds. But in order to qualify for a prescription, you must also have had a positive COVID-19 test result and be at high risk for developing severe COVID-19.

That means you must either have certain underlying conditions (including cancer, diabetes, obesity, or others) or be 65 or older (more than 81% of COVID-19 deaths occur in in this group). The more underlying medical conditions a person has, the higher their risk for developing a severe case of COVID-19, according to the CDC.

Since Paxlovid is cleared by the kidneys, dose adjustments may be required for patients with mild-to-moderate kidney disease, explains Dr. Topal. “For patients with severe kidney disease—or who are on dialysis—or those with severe liver disease, Paxlovid is not recommended; the levels of the drug can become too high and could cause increased side effects,” he says.

There is a long list of medications Paxlovid may interact with, and in some cases, doctors may not prescribe Paxlovid because these interactions may cause serious complications.

The list of drugs that Paxlovid interacts with includes some organ anti-rejection drugs that transplant patients take, as well as more common drugs like some used to treat heart arrhythmias. Paxlovid also decreases the metabolism of anticoagulants, or blood thinners, that many older adults depend on, driving up levels of those medications in the body to a point where they are unsafe, Dr. Topal explains.

It also interacts with cholesterol-lowering medications like Lipitor, but that’s less challenging for patients to overcome. “If you stop taking your Lipitor for five days, nothing bad is going to happen,” he adds.

If you are pregnant or breastfeeding, the FDA recommends discussing your options and specific situation with your health care provider, since there is no experience using the drug in these populations. If you could become pregnant, it’s recommended that you use effective barrier contraception or do not have sexual activity while taking Paxlovid.

So the ideal Paxlovid patient is morbidly obese with the blood pressure and heart health of a 22-year-old tennis star.

Pfizer wants you to take your Paxlovid every day… “FDA rebukes Pfizer CEO’s suggestion to take more Paxlovid if COVID-19 symptoms return”:

The FDA rebuked Pfizer CEO Albert Bourla’s proposed solution to reports that some patients experienced a relapse of COVID-19 symptoms after treatment with the company’s antiviral Paxlovid.

After reports said some patients who took Paxlovid rebounded and started feeling symptoms again, the CEO told Bloomberg that patients can take another course, “like you do with antibiotics.”

“There is no evidence of benefit at this time for a longer course of treatment … or repeating a treatment course of Paxlovid in patients with recurrent COVID-19 symptoms following completion of a treatment course,” John Farley, M.D., director of the Office of Infectious Diseases, said in a post.

Science is complex!

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Should the COVID-19 injections be renamed to something other than “vaccine”?

by philg

When coronapanic hit and various public health prophets went on television calling themselves “scientists,” friends who are medical school professors said that, when the predictions of these physicians and public health bureaucrats inevitably failed the public’s confidence in medicine would be reduced. They cringed every time Anthony Fauci was in the spotlight, for example.

I wonder if the same thing could be happening with the shots that are currently marketed as “vaccines”. People who’ve had 3 or 4 shots are regularly getting sick with COVID-19. Some are being hospitalized and, in the long run, nearly all of the COVID-19 deaths will be among this heavily-jabbed population. By contrast, the childhood vaccines that we desperately want people to apply to their kids, e.g., the measles vaccine, actually stop humans from getting sick with measles.

Now that we know that COVID-19 vaccines don’t work like “regular vaccines” is it time to rename them so that their ineffectiveness doesn’t tarnish the reputation of the “real vaccines”?

Ignoring any serious harm that the COVID-19 vaccines might cause, the closest analogy that I can think of to the situation is what we call “the flu shot”. Americans don’t usually say “I am vaccinated against influenza.” We say “I had all of my childhood vaccinations and this year I got a flu shot.” The flu shot is put in a “can’t hurt; might help” category. When a person who had the flu shot gets the flu anyway, that doesn’t result in him/her/zir/them or his/her/zir/their social network to lose confidence in “vaccine vaccines.”

Readers: What do you think of the idea? Half of the hardest core Mask and Vaccine Karens whom I know seem to have gotten COVID-19 within the past few months. Wouldn’t the overall image of vaccines be improved if we said “They had a COVID-19 shot, which was good prep for their COVID-19 infection” rather than “They were vaccinated against COVID-19 three times and then got COVID-19 anyway”?

Related:

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Young doctors should move to Florida?

by philg

May is Skin Cancer Awareness Month. What better time to talk about health care in the Sunshine State?

The Great Plains are traditionally the best places for doctors to work when salaries offered are compared to house prices and overall cost of living. But not everyone wants to live in the Dakotas, which, presumably is why a dermatologist can get paid $600,000 per year for showing up.

We’ve noticed that it is tough to get an appointment with almost every kind of doctor in Palm Beach County. Concierge medicine, in which people pay $3,000 or $5,000 per year to a primary care doctor to get the kind of service that was standard in the 1950s (pre-Medicare/Medicaid), seems to be much more common here than it was in the Boston area. Getting in to see a dentist can also be tough, with the high-rated providers backed up for 1-2 months. A physician neighbor who moved here less than a year ago and joined a private practice says that he is already busy.

I’m wondering if the Great COVID Migration has opened up a lot of opportunities for young doctors to establish themselves in Florida. The migration to Florida from the lockdown states wasn’t a randomly selected group. The first element of selection was a love of freedom. Doctors get half of their income from the government and nearly all of the other half is heavily regulated by the government. Doctors get paid more when low-skill migrants are admitted to the U.S. (a larger population leads to larger Medicaid payments, if nothing else). The typical doctor, therefore, is not aligned with “small government” state politics in Florida. The second element of selection was an ability to work from home. It was a lot easier for someone in engineering or finance to move than a doctor who sees patients in person. Finally, there is the question of state licensing and regulation. It is illegal for a doctor to move from one state to another and hang out a shingle. He/she/ze/they must first get licensed in the new state. A dentist friend who might otherwise want to escape Massachusetts says “It is very tough to get a license in Florida. They make it next to impossible for dental.” A cardiologist friend said that it would take her six months to get a license in Florida.

If the above list of selection effects is correct, there should be a smaller percentage of physicians in the group that migrated to Florida from California and the Northeast in the past two years than the percentage of doctors in the general population. In other words, the state has been flooded with new patients but hasn’t received too many new doctors.

What do readers think? Is Florida a good place for a doctor finishing residency/fellowship?

Some inspiration for docs… our minivan (Bugs and Daffy covering the massive holes left by the Maskachusetts front license plate installation) at a nearby strip mall next to a $400,000+ Rolls Royce SUV.

I don’t think that the lady who owns this marvelous (other than the severe door ding from our Odyssey) machine will quibble about $5,000 per year for concierge medicine.

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Pandemic increases the wealth, power, and prestige of doctors and public health officials even when their remedies are ineffective

by philg

I recently finished After the Plague, a lecture series by Simon Doubleday, a professor at Hofstra. The pandemic of the lectures is the Black Death of the 14th century. As with the physicians of spring 2020 who harmed COVID-19 patients by putting them on ventilators (today we realize that most would have done better if they’d stayed home with an oxygen bottle), doctors in 1349 often made plague patients worse and certainly had no effective treatment to offer. As with the fanatical sanitizers of today, public health officials back then tried to stop the pandemic by cleaning up the filthy streets. Ultimately, just as with SARS-CoV-2, the pathogen killed nearly everyone that could be killed despite the best efforts of the doctors and officials.

Professor Doubleday relates that the lack of effective remedies did not reduce public confidence in the experts. In fact, physicians made more money, officials got more power, and both classes of health experts got more prestige even as 50 percent of the population was being felled by Yersinia pestis.

In common with other scholars, Professor Doubleday relates that the reduction in population resulted in a tremendous increase in wages for the survivors (see Immigration is the Reverse Black Death?) due to the reduced supply of labor.

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Massachusetts Marijuana Billboards

by philg

To celebrate World Health Day, let’s look at a state where long-term public health was optimized by closing schools for more than a year while keeping the marijuana stores open. Every retailer of healing cannabis in Maskachusetts requires a permit to operate from the government. These permits are limited and, generally, political connections are required to obtain one. Thus, the dope trade is so lucrative that these shops have outbid Verizon, Apple, McDonald’s, et al. for billboard space on the Massachusetts Turnpike. Our heroic reader/commenter Alex has done a drive-by photo project for us. The following photos are from the Pike, I-91, and some of the “poor mine” towns near Springfield, MA.

First, remember that consuming alcohol and psychotropic drugs 24/7 “is not a choice; it’s a disease.”

(Yet it is a disease that can be cured by giving people money on condition that they stop being diseased? See “Financial Incentives for Adherence: Do They Pay?” (Psychiatric Times 2017) and “California Wants To Become The First State To Pay People With Addiction To Stay Sober” (state-sponsored NPR 2021))

This one might be my favorite, the old religion of Christianity represented by a church right next to a billboard for the new religion of weed:

Dazed and Turning Leaf:

For every 200 billboards promoting the consumption of scientifically proven healing cannabis, there is 1 that is part of a disinformation campaign (in this case, disseminating misinformation that marijuana does not improve driving skills; Facebook Fact Checkers rate this claim “Missing Context”).

The Mercedes logo gets some added class by appearing right next to a weed shop billboard:

The implication is that Mercedes is better with cannabis. This concept is made explicit in the next billboard: “Springfield is better with cannabis”.

Who says that Republicans and marijuana don’t mix? A big portion of the Springfield Republican‘s building will now be devoted to cannabis retail.

The INSA “cannabis for real life” shop, right next to the Basketball Hall of Fame:

A proven-by-Science Theory of Wellness:

Illustrating the challenge of taking pictures while driving….

What if phone camera use leads to an accident? A personal injury lawyer stands ready:

Happy World Health Day to everyone and I hope that everyone stays healthy this year by following CDC guidance (to test and not to test, that is the Science).

Related:

  • “Welcoming Refugees” (Jewish Family Service of Springfield, MA): For us social justice is rooted in the Jewish commandment to remember the experience of slavery and the Exodus from Egypt. … JFS resettles refugees fleeing their homelands in partnership with HIAS (formerly the Hebrew Immigrant Aid Society) and the State Department. In the past five years JFS resettled over 500 refugees from around the world to Western Mass– their new home. Well before a family’s arrival, staff secure housing, furniture, and household items for new families. We then provide comprehensive support, including support for school-aged children, comprehensive employment services, and help navigating their new community. JFS continues to serve New Americans long after initial resettlement — for up to five years and beyond in many cases. [Remember that there is no archaeological evidence to support the Passover victimhood narrative. Despite the extensive body of written history from Ancient Egypt, there is nothing to suggest that Jews were ever enslaved in Egypt, that a large group of Jews lived in Egypt, or that a large group of Jews fled Egypt.]
  • “Poverty in Springfield, Massachusetts” (from Welfare Info): The poverty rate in Springfield is 28.7%. One out of every 3.5 residents of Springfield lives in poverty. … 21.1% of Black residents of Springfield, Massachusetts live below the poverty line. 26.7% of Asian residents of Springfield, Massachusetts live below the poverty line. 13.3% of White residents of Springfield, Massachusetts live below the poverty line. 43.5% of Hispanic residents of Springfield, Massachusetts live below the poverty line. Enrolled in Elementary School(Grades 1-4) in Springfield, Massachusetts have a Poverty Rate of 46.1%.
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A young child killed by a new vaccine

by philg

Averros may find this of particular interest… The Last King of America: The Misunderstood Reign of George III (Andrew Roberts):

On 20 August 1782, the King and Queen were devastated to lose their youngest son, ‘dear little Alfred’, who died at Windsor Castle shortly before his second birthday. He had been taken to Deal by the royal governess Lady Charlotte Finch in the hope that he would recover from a fever through fresh sea air and bathing, but to no avail. The Court did not go into formal mourning as Alfred was not fourteen, but the royal couple were utterly grief-stricken. The Queen gave Finch an amethyst and pearl locket, and a lock of blond hair from ‘my dear little Angel Alfred’. She wrote to her brother Charles two days after Alfred’s death, ‘I am very grateful to Providence, that out of a family of fourteen children, it has never struck us except in this one instance, and so I must submit myself without a murmur.’ The cause was probably too high a dosage of the smallpox inoculation. The King and Queen were staunch advocates of this treatment, which was spearheaded by Edward Jenner, although they believed that Providence still played a large part in medicine.

When Edward Jenner finally perfected his vaccination technique in the mid-1790s, the King knighted him and became patron of the Jennerian Society which advanced the practice. In his enlightened way he did not allow personal tragedy to affect his rational appreciation of the great benefits of science.

If the U.S. had not traitorously rebelled, Americans might have funded a lot more scientific research during the 19th century.

Early in 1751, Frederick and Augusta settled the twelve-year-old George and eleven-year-old Edward at Savile House, adjoining Leicester House. It was the Hanoverian practice to give princes their own establishments early, and Savile House, built in the 1680s, was to become George’s London home for the next nine years. His mini-Court there consisted of a governor, preceptor (responsible for teaching), sub-governor, sub-preceptor and treasurer, with part-time teachers for languages, fencing, dancing and riding brought in from outside. He studied algebra, geometry and trigonometry. He was the first British monarch to study science, being taught basic physics and chemistry by Scott. He was receiving a good, all-round, enlightened education.

(But maybe not, since the British never taxed anyone in North America to fund government operations in England. Any taxes raised in the 13 colonies were spent in the 13 colonies. On the third hand, a British-governed North America led by a scientifically educated king might have funded local research labs.)

And we might have been spared the partisan politics that are often decried.

Contrary to the Whig imperative of minimizing royal power, The Idea of a Patriot King argued that the role of a constitutionally limited hereditary monarchy was important. Bolingbroke fully accepted that such seventeenth-century notions as the Divine Right of Kings had ‘no foundation in fact or reason’, and he believed ‘a limited monarchy the best of governments’. The limits on the power of the Crown, he maintained, should be ‘carried as far as is necessary to secure the liberties of the people’ and enough to protect the people against an arrogant (by which he meant Old Whig) aristocracy. Bolingbroke’s patriot king would revere the constitution, regard his prerogatives as a sacred trust, ‘espouse no party’ and ‘govern like the common father of his people’. A key message of the book was that government by party inevitably resulted in a factionalism disastrous to the state. ‘Party is a political evil,’ Bolingbroke wrote, ‘and faction is the worst of all parties. The king will aim at ruling a united nation, and in order to govern wisely and successfully he will put himself at the head of his people,’ so that he can deliver them ‘tranquillity, wealth, power and fame’.

Circling back to the vaccine… the situation is not directly comparable, of course. George III and Queen Charlotte were trying to vaccinated their child against a disease that regularly killed children.

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Your health insurance and Medicare tax dollars in the Wizarding World of Harry Potter

by philg

We overlapped in Orlando last week with an electronic medical record expert friend who was attending HIMMS 2022, a conference for 20,000 senior hospital executives and the software companies trying to sell them stuff (the first round of digital stuff was paid for partly with $30 billion of taxpayer funds showered on hospitals by the Obama administration). Attendees had to be vaccinated against a 2.5-year-old version of SARS-CoV-2:

Due to the cruel tyranny of the Florida Legislature, they were forced to add a test option:

Our Right of Entry Policies were specifically designed with consideration of relevant Florida regulations. Our policies allow an attendee to voluntarily show validation of their vaccine status if that is their preference (Option A), or to voluntarily show proof of a negative COVID-19 test within one day of badge pick up, if that is their preference instead (Option B).

How about using a saliva-soaked bandana to cancel out the effects of sharing indoor space for five days with 20,000 other people?

Masks are highly encouraged but not required on the HIMSS22 campus.

What happened in practice? My friend: “I didn’t see a single mask.” (Most of these experts on health care and, therefore, avoiding COVID-19, had brought their families to share the hospital-paid hotel rooms and roam the packed-for-spring-break theme parks during the day.)

How rich have hospitals and their vendors become off the river of tax-subsidized health insurance and tax-funded Medicare/Medicaid? They had sufficient $millions to pay Universal to close Islands of Adventure’s doors to the general public at 5:00 pm, clear the rabble out of the park, and run all of the rides exclusively for the HIMMS attendees starting at 7:30 pm. How was the party? “It was awesome! I got on every ride with no line!”

Related:

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Vuity Eyedrops and Americans’ love affair with new meds

by philg

“FDA-approved Vuity eyedrops could replace your reading glasses” (Today):

Just approved by the Food and Drug Administration, Vuity’s new product has been found to take effect in as little as 15 minutes.

“New FDA-approved eye drops could replace reading glasses for millions: “It’s definitely a life changer”” (CBS):

A newly approved eye drop hitting the market on Thursday could change the lives of millions of Americans with age-related blurred near vision, a condition affecting mostly people 40 and older.

Vuity, which was approved by the Food and Drug Administration in October, would potentially replace reading glasses for some of the 128 million Americans who have trouble seeing close-up. The new medicine takes effect in about 15 minutes, with one drop on each eye providing sharper vision for six to 10 hours, according to the company.

“I Swapped My Reading Glasses for Magical Eyedrops” (NYT):

To make matters worse, the whites of my eyes had a pink tinge. Picture Campbell’s tomato soup when you add an extra can of milk. My 20-year-old daughter assured me I did not look high: “But your eye bags are bigger than usual,” she said.

Not only did my eyes retain their bloodshot, rheumy cast during the five days I used the drops, my close-up vision never improved significantly enough to make reading glasses redundant. The drops burned as they went in, too. I’m not talking about an acid kind of pain, more like a lash in your eye, but still unpleasant.

A NYT reader’s comment:

I am an ophthalmologist. This “new” drop is just a rebranding and remarketing of a weaker version of pilocarpine, that we used ages ago to manage glaucoma. The drug is almost never used now to manage glaucoma because of its side effects, including the development of headaches, and, more importantly, an increased risk of retinal detachment. I think this drug represents extraordinary marketing of a very poor idea. The drug was very cheap in higher concentrations, and raising the price for a lower concentration of a drug that isn’t a good idea in the first place is quite extraordinary. I have been wearing progressive bifocals for 20 years. They took about a day to get used to, and provide me with excellent vision at distance near and points in between. and they have no possible side effects.

Is the doc correct? Wikipedia says pilocarpine dates to 1874 (Ulysses S. Grant was president) and, as a friend likes to point out, “If it’s not on the Internet, I don’t believe it.”

Another doc comments:

As an ophthalmologist, I will say that the amount of confusion and general lack of understanding of how eyes actually work that is on display in this article and in the comments here is astonishing. I don’t even know where to begin. To be clear, everyone will eventually experience the effects of presbyopia and cataracts. This is universal, not a “condition” that only some people get. Achieving better vision for near targets can be managed with glasses, contacts, laser refractive surgery (LASIK or PRK) or choice of refractive target when implanting an IOL in cataract surgery. Normal age related presbyopia, as occurs in all human beings, on its own is absolutely not a good reason to undergo surgery, though if there were other good indications to undergo surgery (LASIK, PRK, or cataract extraction) then as I said the near vision can be improved if one wanted through refractive target, though at some expense to the quality of distance vision. Looking through a pinhole aperture can offset some refractive error and enhance depth of focus, but it will reduce peripheral vision and make your vision dimmer. Rebranding Pilocarpine (which we have used for decades to constrict the pupil) seems really ill advised and I wouldn’t recommend it to a patient. But brilliant marketing that they managed to get it approved and have articles in the media calling it a “cure” for the mysterious “disease” of presbyopia. The only cure for presbyopia is for nobody to live beyond the age of 40.

I think that the above is a good illustration of how powerfully we want to believe that the latest products of the pharma industry are safe and effective and that health care = health.

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Measles as a best-case study of how humans stack up to respiratory viruses?

by philg

Nearly two years ago, when public health officials first began talking about “science” in the context of the measures they were taking that would eradicate SARS-CoV-2, the medical school professors whom I know would point out that humans had never beaten a respiratory virus and therefore there was no possible scientific basis for a confident belief that a proposed intervention would be effective.

Influenza is a familiar example of respiratory virus that has laughed at our science and medicine. The common cold viruses are another class that are apparently smarter than us. Measles is a unique case. It has a bizarre-for-an-organism inability to mutate. “Why you need one vaccine for measles and many for the flu” (ScienceDaily, 2015):

The surface proteins that the measles virus uses to enter cells are ineffective if they suffer any mutation, meaning that any changes to the virus come at a major cost.

It’s only possible to speculate why the measles virus would find an evolutionary advantage to being so rigid, but one hypothesis is that measles uses a more complex strategy to get into human cells than influenza. Influenza, for instance, simply requires the binding of one of the sugars that decorate the outside of cells as a means of getting inside. In contrast, measles requires binding to specific cellular protein receptors as its doorway.

Since measles can’t mutate, we have great drugs for treating it and near-100 percent vaccine coverage all over the world, right? Wrong. In fact, measles kills roughly 200,000 people per year (WHO). They’re mostly under the age of 5 so they would have lived at least 50 more years, even in the poorest countries. That’s 10 million life-years lost every year to measles.

How does losing 10 million life-years compared to the killing done by COVID-19? WHO says that 1.8 million humans were killed by COVID-19 in 2020. Unless each one had another 5.6 years to live, which seems unlikely given that the typical victim in Massachusetts was 82 with comorbidities, measles actually took away more life-years than COVID-19. And if we use the British technocrats’ quality-adjusted life year, measles was far more destructive than COVID-19. Measles prevents people from enjoying their healthiest and most vigorous years while COVID-19 chops off the years during which electric scooters are required for mobility.

(The above paragraph raises the obvious question of why hardly anyone in the EU or US cared about measles deaths prior to 2020 or, even now. Nobody would have been willing to spent $10 trillion to save 10 million high quality life-years destroyed by measles.)

Because it is free to mutate, SARS-CoV-2 is a much more elusive enemy than Measles morbillivirus, yet I think our definition of success against COVID-19 is much more stringent than the standard we’ve applied to ourselves when fighting measles. Unless humans have become vastly more capable in just the past year or two, aren’t we setting ourselves up for disappointment?

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Who followed the Elizabeth Holmes trial?

by philg

Who followed the Elizabeth Holmes trial closely? “The Elizabeth Holmes Verdict: Theranos Founder Is Guilty on Four of 11 Charges in Fraud Trial” (WSJ, which is the newspaper primarily responsible for bringing down the company):

At the 15-week trial, Ms. Holmes testified in her own defense, showing regret for missteps and saying she never intended to mislead anyone. She accused her former boyfriend and deputy at Theranos of abusing her, allegations he has denied.

She was found guilty on three of the nine fraud counts and one of two conspiracy counts. She was acquitted on four counts related to defrauding patients—one charge of conspiracy to commit wire fraud and three charges of wire fraud.

The verdict doesn’t make sense to me on its face. If the patients weren’t defrauded with false test results how could the investors have been defrauded? But I didn’t follow the trial, so probably the jury knows a lot that I don’t.

If it were up to me, I would imprison the investors for stupidity in thinking that a young American college dropout knew more about blood testing than the file cabinets full of Ph.D. chemists at Philips, Siemens, and F. Hoffmann-La Roche. I would have been reluctant to find Holmes guilty of anything or sentence this new mom to any prison time.

The man whom Holmes has accused of raping her daily, Ramesh Balwani, goes to trial next. Let’s see if readers, via the comments, can predict the ratio of prison sentence between these two defendants. I am going to guess that the immigrant/accused rapist receives a sentence that is 2X as long as whatever Holmes suffers. This is partly based on “Estimating Gender Disparities in Federal Criminal Cases” (University of Michigan Law and Economics Research Paper, 2018), which says, all else being equal, a person whom the jury identifies as a “man” will be sentenced to 1.6X the prison time that a person whom the jury identifies as a “woman” receives. I moved the needle from 1.6X to 2X because Mr. Balwani is an immigrant and I think both the jury and the judge will be angry that someone emigrated to the U.S. to become a criminal.

(If Mr. Balwani enters into a plea bargain, the above prediction should be revised to 1X.)

Related:

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