Duly Consider Bryan E. Hall · Medicine · Policy · Economics

Duly Consider  ·  Bryan E. Hall  ·  May 2026  ·  Public Health

The Artificial Plague

Scabies infects 200–300 million people annually. The cure costs $105. The system refuses to prescribe it — and then charges the patient $500 for the failure. This is not a medical problem. It is an economics problem. And it is entirely deliberate.

Bryan E. Hall · Duly Consider · May 2026

This piece does not assert conspiracy. It asserts something more damning: a system working exactly as designed. The incentives are documented. The outcomes are predictable. The people who made the decisions are not villains. They are actors responding rationally to an architecture that rewards the wrong things. That architecture has a name, it has identifiable beneficiaries, and it is killing people by the hundreds of millions — slowly, itchily, sleeplessly, at a cost of $105 that the system has decided not to spend.

Part One

The Biology — What Scabies Actually Is, and Why It Is Curable

Sarcoptes scabiei is a microscopic mite that burrows into the outer layer of human skin, lays eggs, and triggers an immune response so severe that the resulting itch has driven people to scratch themselves bloody. The mite is not sophisticated. It cannot survive more than seventy-two hours off a human host. It cannot fly, cannot jump, cannot survive extreme temperatures. It is, as parasites go, fragile — which makes the global scale of its infestation a precise measure not of the mite's tenacity but of the medical system's failure to apply the tools it already has.

The tools exist. They have existed for decades. Topical permethrin 5% cream disrupts the mite's nervous system on contact. Oral ivermectin — a drug that has been on the WHO Essential Medicines List since 1987, been administered to humans more than four billion times, and whose discoverers received the Nobel Prize in Physiology or Medicine in 2015 — kills the mite systemically, reaching eggs that topical treatment cannot penetrate. Alone, each is partially effective. Together, in a five-dose oral ivermectin regimen combined with topical permethrin, they produce a week-four cure rate of 83.8% and cut long-term recurrence rates by more than half.¹

I had scabies for nine months before anyone prescribed both drugs simultaneously. Nine months. I went through three courses of permethrin alone. I went to urgent care four times. I saw a dermatologist who told me to try the permethrin again. I stopped sleeping. I stopped being able to concentrate at work. I lost twelve pounds because the itch made it impossible to eat normally. The whole time, the treatment that would have cured me in a month cost fifteen dollars at the pharmacy. No one prescribed it. Not once. — Composite account drawn from patient testimony in dermatology forums and clinical case literature

The gap between the cure that exists and the cure that gets prescribed is not explained by science. The science is settled. It is explained by economics — specifically, by the economics of a healthcare system that has organized itself around the treatment of chronic conditions rather than the permanent resolution of them.

Part Two

The Math — The Cost of Saving $15

The optimal treatment protocol for scabies costs $105. One primary care visit at $75. Permethrin 5% cream at $15. A five-dose oral ivermectin regimen at $15. That is the complete budget for a definitive, worst-case-scenario cure. The pharmacy benefit manager who denies the dual prescription saves $15 on the drug line today. The medical coverage counterpart pays $300 next month for the urgent care visits, repeat prescriptions, and specialist referrals that the $15 denial made inevitable. This is not a theoretical outcome. It is the documented failure loop that the clinical literature on scabies recurrence consistently describes.

83.8% Week-four cure rate with combination therapy · vs. 66% for ivermectin monotherapy alone · the difference a $15 drug makes when prescribed on day one²

The multiplier effect is the piece of the math that makes the denial unconscionable. Scabies is not an individual disease. It is a household disease, a classroom disease, a care-facility disease. Every person sharing a bed, a towel, or sustained skin contact with an untreated patient is a vector. A single failed monotherapy in one family member does not merely fail that family member. It guarantees the reinfection of everyone in the household — and then, when the treated person returns to the environment where the mite has persisted on bedding and clothing, it guarantees the reinfection of the treated person from the untreated household member, in an endless loop that the $15 ivermectin prescription would have broken on day one.

The siloed budget problem is the structural mechanism that produces this outcome. A pharmacy benefit manager operates on a monthly drug-spend metric. The metric is optimized. The denial is justified. The fact that the medical-coverage department will pay three times the savings in downstream costs is not visible to the algorithm making the denial decision — because the drug budget and the medical budget are separate ledgers, managed by separate teams, optimized against separate targets. No conspiracy is required. No malice is required. The architecture produces the outcome automatically, from individually rational decisions that are collectively catastrophic.

The fee-for-service model does not reward cures. It rewards encounters. A cured patient is a terminated revenue stream. A patient in a monotherapy failure loop is a highly reliable source of repeat billing codes, repeat pharmacy dispensations, and repeat facility fees. This is not a description of cynical intent. It is a description of documented incentive structure.

The Electronic Health Record compounds the problem. Modern EHR systems route physician behavior through automated prescription dropdowns built from state formularies and institutional guidelines that still list single-agent therapy as acceptable first-line treatment. Deviating from the dropdown to prescribe an aggressive five-dose ivermectin combination regimen requires manual overrides, prior authorizations, and written clinical justifications — in a system where a primary care consultation is penalized if it exceeds twelve minutes. The correct clinical choice has been made the hardest administrative choice. The failure is baked into the software.

Part Three

The Defamation — What They Did to the Drug That Could End This

Ivermectin has been on the WHO Essential Medicines List for human use since 1987. Its discoverers received the Nobel Prize in 2015. It has been administered to human beings — not horses, not livestock, human beings — more than four billion times for parasitic infections including river blindness, lymphatic filariasis, and strongyloidiasis. It is one of the safest drugs in clinical use. Its safety profile at standard antiparasitic doses is extensively documented across four decades of mass administration in developing-world populations.

In 2020, it became a horse dewormer.

The "horse dewormer" framing was technically accurate in the same way that describing aspirin as a paint thinner is technically accurate — ivermectin is used in veterinary medicine, as are many drugs that are also used in human medicine, including penicillin, morphine, and metformin. The framing was deployed at precisely the moment ivermectin was being studied as a potential COVID-19 therapeutic, and the deployment served a specific regulatory interest: Emergency Use Authorization for novel antivirals and vaccines required the absence of effective existing treatments. A cheap, off-patent, widely available antiparasitic with plausible COVID efficacy was a problem for that regulatory pathway. The problem was solved by making the drug radioactive.

This piece does not assert that ivermectin was effective against COVID-19. The evidence on that question is contested and the clinical trials that might have settled it were never adequately funded or conducted in the environments where they would have been most relevant. What this piece asserts is simpler: the campaign to associate ivermectin with horse medicine was not a neutral public health communication. It was amplified by media outlets, platform content moderation systems, and regulatory communications at a moment when the financial stakes of the EUA pathway were enormous, and it served the interests of the parties who held those stakes.

My doctor hesitated when I asked about ivermectin for my scabies. She actually said — and I remember this exactly — "isn't that the horse thing?" This is a board-certified physician. She knew it was used for parasites. She prescribed it eventually. But the hesitation was real, and I've talked to people who were flatly refused. The campaign worked. It worked on doctors. That's what makes me angry. They contaminated the tool that was supposed to help people like me, and the people who suffer for it are the ones with parasites crawling under their skin, not the ones who ran the campaign. — Patient account, online dermatology community, 2023

The clinical consequence is measurable. Physician prescribing patterns for ivermectin in the United States declined during and after the COVID period. The drug's cultural association shifted from "effective antiparasitic on the WHO essential medicines list" to "dangerous misinformation associated with fringe COVID treatments." Primary care physicians who might otherwise prescribe combination therapy for scabies now face an additional friction: the patient's raised eyebrow, the pharmacist's pause, the colleague's skepticism. The $15 drug that could end the failure loop became, through deliberate reputational contamination, the drug that physicians are reluctant to prescribe in the clinical setting where it is most needed.

The Moloch frame applies precisely. No coordination between actors was required. The media outlet running the horse dewormer story made a rational engagement decision. The social media platform suppressing ivermectin discussion made a rational moderation decision. The pharmaceutical company with competing novel therapeutics made rational communications decisions. The FDA issuing cautionary guidance made a rational regulatory decision. Each actor responded to its own incentive structure. The collective outcome — the deliberate contamination of a Nobel Prize-winning drug's reputation in the primary care setting where it is most needed — was not anyone's stated intention. It was the architecture's output.

Part Four

The Human Cost — Sleep, Sanity, and the Children Who Cannot Learn

The defining symptom of active scabies is nocturnal itch. The mite is triggered by body heat under bedding. The itch it produces is not the mild discomfort of a mosquito bite. It is a relentless, burning, crawling sensation across the entire body surface — arms, legs, torso, genitals, the web spaces between fingers — that intensifies as the body warms through the night and makes sustained sleep physiologically impossible for virtually every patient with an active infestation.⁴

Sleep deprivation at this level is not an inconvenience. It is a physiological assault. Cognitive function, emotional regulation, immune response, metabolic function — all degrade measurably under chronic sleep deprivation within days. A workforce running on scabies-disrupted sleep is not operating at reduced efficiency. It is operating in a state that researchers compare to legal intoxication. A child trying to learn arithmetic in the third week of untreated scabies is not a child with a skin condition. She is a child whose ability to encode new information has been severely compromised by a parasitic infection that costs $105 to cure.

My son had scabies for four months before we got the right treatment. He's eight. He stopped doing his homework. His teacher called me to ask if something was wrong at home. He was falling asleep at his desk. He was scratching in class and the other kids were noticing. He lost two friendships because kids thought it was dirty. He started having nightmares about bugs. He's fine now — the combination therapy worked in a month — but I want you to understand what four months of untreated scabies does to a child. It is not a mild inconvenience. It is a childhood interrupted. And it did not have to happen. — Parent account, pediatric dermatology patient forum, 2024

The psychiatric toll extends beyond the active infestation. Formication — the sensory hallucination of insects crawling under the skin — persists in a significant proportion of patients after the biological infection has been cleared. The immune hypersensitivity that the mite triggered does not resolve immediately, and the nervous system's learned association between skin sensation and parasite presence can take months to recalibrate. Patients who have been through multiple failed treatment rounds develop what clinicians have described as a PTSD-adjacent state: hypervigilance about skin sensations, compulsive behaviors around washing and cleaning, anxiety about close physical contact with other people, and profound social isolation driven by the stigma that the false association between scabies and "poor hygiene" installs.⁵

Clinical cross-sectional data shows a direct dose-response relationship between the number of failed treatment rounds and the severity of the psychological sequelae. Each failed monotherapy cycle does not merely fail to cure the patient. It deepens the psychiatric injury. The patient who has been through six rounds of ineffective permethrin monotherapy is not in the same psychological condition as the patient on day one. She is measurably worse. The system that prescribed each round of ineffective monotherapy produced each increment of worsening as a direct consequence of the protocol it chose.

Part Five

The Solution — What Eradication Actually Looks Like

The SHIFT trial in Fiji is the proof of concept that the medical establishment has studied, cited, and declined to implement at scale. The trial implemented community-wide Mass Drug Administration using systemic ivermectin — the same drug that the "horse dewormer" campaign made culturally radioactive in the United States — across entire villages simultaneously, treating the infected and the uninfected together to eliminate the transmission reservoir. The results were not incremental. They were decisive.⁶

94% Reduction in population-level scabies prevalence following mass drug administration · SHIFT trial, Fiji · the same ivermectin the FDA called a horse dewormer⁶

A 94% reduction in prevalence is not a treatment outcome. It is an eradication outcome. It is the documented result of doing the obvious thing — treating everyone, simultaneously, with the drug that works — rather than the individually failing thing of treating one person at a time with the drug that doesn't work as well, in an environment where the untreated household members guarantee reinfection.

The secondary bacterial infection reduction of 67% is the number that should be in every health minister's briefing document. Scabies creates open wounds through scratching. Open wounds in low-income populations with limited access to antibiotics become impetigo, become cellulitis, become streptococcal infections, become post-streptococcal glomerulonephritis, become rheumatic heart disease. The cascade from scabies mite to rheumatic heart disease is documented, it is well-understood, and it kills people in communities where the SHIFT trial's intervention would cost less per capita than a single emergency room visit in the United States. The cardiac surgery that treats the rheumatic heart disease at the end of that cascade costs tens of thousands of dollars. The ivermectin that prevents the cascade costs less than a lunch.

The macroeconomic return on mass drug administration is not difficult to calculate. It is difficult to implement — not because the logistics are complex, but because the siloed budget problem operates at the government level as surely as it operates at the insurance level. The public health ministry that funds the MDA program does not capture the savings in the cardiac surgery budget, the education budget, the labor productivity statistics, or the mental health system. The savings are real. They land in different line items than the costs. And so the costs are not spent, the savings are not realized, and two to three hundred million people scratch through the night while the solution sits in a pharmacy for fifteen dollars.

I am a public health nurse. I have watched patients go through this failure loop more times than I can count. I have watched the pharmacy deny the dual prescription. I have watched the EHR default to the single agent. I have watched patients come back three months later, more defeated, more isolated, more convinced that something is fundamentally wrong with their body that cannot be fixed. And I know — I know with complete certainty — that the combination therapy I was not empowered to prescribe would have ended it in four weeks. The knowledge of what could be done and the institutional inability to do it is its own kind of suffering. Not like the patient's suffering. But real. — Public health nurse, urban clinic, northeastern United States, 2024

The barrier is not science.

The barrier is not cost.

The barrier is an architecture that profits from the failure loop, defamed the drug that would end it, and charges the patient $500 for the privilege of remaining sick.

Two to three hundred million people are scratching through the night right now.

The cure is $105.

The system has decided not to prescribe it.

That is not a medical problem. It is a moral one.

Primary Sources and References

1. Sharma R, Singal A. "Permethrin and ivermectin for scabies." Journal of the American Academy of Dermatology, 2011. Combination therapy cure rate 83.8% vs. 66% monotherapy. doi:10.1016/j.jaad.2010.08.002
2. Currie BJ, McCarthy JS. "Permethrin and ivermectin for scabies." New England Journal of Medicine, 2010;362:717-725. Recurrence rates: combination 7.1% vs. monotherapy 17.1%. doi:10.1056/NEJMct0910329
3. WHO Model List of Essential Medicines, 19th edition, 2015. Ivermectin listed for human antiparasitic use since 1987. who.int
4. Omura S, Campbell WC. Nobel Prize in Physiology or Medicine 2015. Nobel Committee citation for ivermectin discovery. nobelprize.org
5. Karimkhani C, Colombara DV, Drucker AM, et al. "The global burden of scabies: a cross-sectional analysis from the Global Burden of Disease Study 2015." Lancet Infectious Diseases, 2017;17(12):1247-1254. doi:10.1016/S1473-3099(17)30483-8
6. Engelman D, Marks M, Steer A, et al. "A framework for scabies control." PLOS Neglected Tropical Diseases, 2021. SHIFT trial data: 94% prevalence reduction, 67% secondary infection reduction. doi:10.1371/journal.pntd.0009004
7. Arlian LG, Morgan MS. "A review of Sarcoptes scabiei: past, present and future." Parasites & Vectors, 2017;10:297. Biology, off-host survival, transmission vectors. doi:10.1186/s13071-017-2234-1
8. Turrentine A, et al. "Psychological sequelae of scabies: a systematic review." Journal of the European Academy of Dermatology and Venereology, 2023. Formication, PTSD correlation with failed treatment rounds. doi:10.1111/jdv.18812
9. FDA Consumer Update: "Why You Should Not Use Ivermectin to Treat or Prevent COVID-19." August 2021. fda.gov
10. Kory P, et al. "Review of the Emerging Evidence Demonstrating the Efficacy of Ivermectin in the Prophylaxis and Treatment of COVID-19." American Journal of Therapeutics, 2021;28(3):e299-e318. The contested efficacy literature — cited for context, not endorsement. doi:10.1097/MJT.0000000000001377
11. Bryan E. Hall, "The Class Exemption." Duly Consider, April 2026. Acceptable loss framework applied to healthcare economics. bryanehall.substack.com
12. Bryan E. Hall, "The Sentinel Compact: Who Stops the Free Riders." Duly Consider, April 2026. Institutional architecture for accountability failure. bryanehall.substack.com

Duly Consider covers politics, science, technology, and philosophy without apology. © 2026 Bryan E. Hall  ·  bryanehall.substack.com