Thread by @TheHershmeister

I can't speak to the details of all the pardons and commutations handed out by Trump, but there is one especially heinous one I'm moved to address. It involves #ophthalmology and #RacialEquity in health care.

Come along... 1/21

First, you have to know a little about age-related macular degeneration (ARMD). We have a smart wallpaper (retina) that lines the back of our eyes (the center of which is called the macula), and it turns light into electrical signal to send to the brain. 2/21

Melanin-derived pigment is an important photochemical buffer for absorbing this light over the course of an eye's life.

Macular degeneration, therefore, is a breakdown of this pigment layer of the retina. 3/21

It takes many years to develop (age-related), and almost exclusively affects Whites (~91% vs 3% Blacks, 4% Hispanic, 2% Asian, etc) bc less pigment in the macula = more susceptible to the cumulative damage of light exposure. 4/21

Once this pigment layer breaks down, blood vessels creep through the retina where they shouldn't be and tend to bleed and leak, leading to profound vision loss. This is known as "wet" ARMD. 5/21

The mainstay of treatment is repeated injection of medication directly into the eye to reduce the development of these bad blood vessels. 6/21

While #ophthalmologists go to GREAT LENGTHS to reduce anxiety, pain, discomfort, and trauma from this treatment, it inevitably takes a toll on the patient. There is an accumulation of emotional stress that comes w/ monthly injections. 7/21

To summarize this part: wet ARMD sucks, requires lots of injections in the eye, takes an emotional/mental toll on patients, and affects Whites >>> Blacks, Hispanics, Asians, etc. 8/21

Now meet Salomon Melgen, an ophthalmologist from Palm Beach County, FL. In 2015, he was arrested and charged with perpetrating a MASSIVE ($73M) scheme ranging from garden-variety fraud e.g. charging for tests/photos for 2 eyes of patients who had only 1 eye... 9/21

to sophisticated multi-dose dispensing of expensive medications intended for single-dose use. These were the monetary charges that came at the expense of all Medicare recipients and all taxpayers. Despicable, sure, but not heinous. 10/21 justice.gov/usao-sdfl/pr/s….

Here's that part (from court documents): "Typically, only 10 to 15% of those diagnosed with ARMD have the wet version of the disease. But Melgen’s treatment records told a different story. Of the rather remarkable 97.8% of his pts that he diagnosed with ARMD... 11/21

"... he also diagnosed 75.5% with wet ARMD in at least 1 eye. That included ALMOST ALL of his African-American patients, even though expert testimony at trial indicated that wet ARMD is...almost never present in AA's." 12/21 courtlistener.com/opinion/477225…

He purposely misdiagnosed an implausibly large number of all his patients (and an impossibly large number of his Black patients) with wet ARMD so he could force injections (and lasers) and charge taxpayers. 13/21

He was charged with 76 counts outlining a scheme in which he systematically over-diagnosed the type of ARMD that needs treatment, even to patients that did not need treatment bc they were completely healthy, had dry ARMD, or the eye was blind or a prosthetic. 14/21

The burden of this unnecessary (often emotionally taxing and sometimes even painful) treatment was borne disproportionately by his Black patients, who - again - were least likely to have had ARMD that needed treatment to begin with. 15/21

In civil cases, 4 patients alleged his multi-dose practice led to infection/inflammation of their eyes and permanent vision loss. Which of those were even needed? Which of those pts were Black and not at risk of wet ARMD in the 1st place?! 16/21 palmbeachpost.com/news/crime--la…

And yet - YET! - he was charged only for that which is provable: financial fraud. No criminal assault charges and no gross malpractice charges.

At least he was found guilty of those and sentenced to 17 years in federal prison, right? At least there is some justice? 17/21

He served just *2 years* before being pardoned. The 32-year career DOJ lead prosecutor on the case, who considered this his most important conviction ever called the pardon an "insult and slap in the face." 18/21 nytimes.com/2021/01/21/us/…

So what does that mean for the hundreds of patients (many of whom Black or Hispanic) who suffered medically unnecessary injections into their eyes and the emotional burden they're left to carry? 19/21

What does it mean to once again fail to deliver justice on behalf of medically exploited minorities? To once again violate the trust of the emotionally and medically vulnerable? 20/21

The pardon is plainly reprehensible, and we can't change it. All we can do - all I can do as an ophthalmologist - is commit to be better, to be an advocate for my most vulnerable patients, and to continue to fight for racial equity in health care. 21/21