You ARE Your Brother’s Keeper - From the Trenches #5
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America’s First! First in COVID cases (3,000,000+); first in COVID fatalities (133,000+). Let’s just be with that for a moment.
The graph below is a comparison of new cases per million - which we OWN baby! If this does not horrify …I pray I am never indifferent to… never able to justify the damaged and lost lives represented by this graph.
Prof. Michael Osterholm Univ of Minnesota, Director of the Center of Infectious Disease says the US COVID-19 catastrophe “is a raging forest fire looking for human wood.” Kindling made in America.
Perhaps the bigger message, also clearly demonstrated, is that there IS a path to living better with COVID-19 - and we’re not on it.
How do we differ from other countries? They employed centralized leadership with a strategic plan guided by science: lockdown, physical distancing, masking, hand washing, reopening once case levels were low with robust testing and tracing. In the US, a strategic plan guided by science would have the CDC running the show with federal and state policies reflecting their guidelines. Want to see what a US national response could have looked like? Read them and weep:
First, How to Read Obama’s Pandemic Playbook
AND (Obama’s) PLAYBOOK FOR EARLY RESPONSE TO HIGH-CONSEQUENCE EMERGING INFECTIOUS DISEASE THREATS AND BIOLOGICAL INCIDENTS
https://www.documentcloud.org/documents/6819258-Playbook.html#document/p2
We’re STILL not following the Playbook (though it is never too late to start) and without centralized leadership, every state is on their own. And while states have capable people, one state medical director lamented, “The experts are at the CDC” - who seem to be muzzled.
In the absence of national leadership; remember the admonition in my last blog? Listen to experts like Dr. Fauci. Listen to experts in virology, epidemiology, and public health. Listen to your local politicians only if they are clearly guided by science. If your Governor is touting something at odds with Dr. Fauci, I’d pick Fauci over e-v-e-r-y-o-n-e just now.
“The reality is that the virus is not under control; it is IN control.”
So here we are - at starts and stops - as I predicted last month. We have added 1,000,000 new cases and 40,000 fatalities. What now?
Contract! Pull in! Slow down! Just because the gym is open does not mean you need to be there. Just because air fares are cheap does not mean you need a ticket.
What have we learned in the last month? We’ve learned that the US COVID-19 mortality rate is 4.2% versus 0.1% for the flu. This is no flu. We’ve learned that systemic inflammation called leukotriene storm causes multi-organ disruption and failure leading to death. We’ve learned that an old and cheap steroid called Dexamethasone is helpful. We learned Hydroxychloroquine, an anti-malarial drug touted like snake oil as a prophylactic and cure - is harmful. We’ve confirmed that COVID-19 is mostly spread through the respiratory tract and less so by touching infected surfaces. We’ve learned that peak infectiousness (highest quantity and virulence) occurs in the pre-symptomatic or asymptomatic period and accounts for 50% of viral transmissions. Which is why masks and physical distance are effective in crushing the curve, as demonstrated by the EU, Scandinavia, S. Korea, Singapore, Taiwan, Hong Kong, and New Zealand, just to name a few. We’ve confirmed that indoor gatherings, no matter how well intentioned, can be the spawn of death. We’ve learned that the PR number is important but that Joe Public does not know how to interpret the data. We’ve learned that safe re-opening cannot be done “my way”. Remembering that we are in this together; MAYBE we’ve learned that reopening must be done “our way” - with each of us being responsible for all of us - as again demonstrated so aptly by countries who have done so.
The CDC: - On June 25th, the CDC updated its list of specific conditions that increase a person’s risk of severe COVID-19 illness: advanced age (65 and over), COPD (chronic obstructive pulmonary disease, CKD (chronic kidney disease), obesity (BMI >30), immunocompromised state, serious cardiac diseases (i.e. coronary artery disease, cardiomyopathies, heart failure), sickle cell disease, and uncontrolled diabetes. Combine any of these with common diseases like high blood pressure, over weight (BMI 25-30) or asthma and the risk for severe illness with COVID-19 infection increases exponentially.
What does this mean? It means if people wish to avoid contracting and transmitting COVID-19, for which there is no natural immunity and no vaccine, they will have to diligently practice physical distancing, masking in public, meticulous hand washing, avoid gatherings of more than 10 people FOR THE NEXT YEAR OR SO. Until “All Clear” is proclaimed from the rooftops by Dr. Fauci or his emissary.
Review the CDC guideline links to recommendations regarding gatherings, public bathrooms, restaurants, schools, etc. See the latest recommendations on how to comport one’s self during a pandemic.
Speaking of schools, I’m heartened to see the CDC hold their ground on recommended guidelines for reopening schools. Were I a parent, I would make a copy of their current and recently released school guidelines (~ 17 pages), in case they buckle to Presidential pressure and tweet-storm and weaken their guidelines. I’d kinda want to know; wouldn’t you?
Lets talk about testing. We ARE testing more. Is that why we detect more cases? Of course, but that is only half the story. Epidemiologists watch the PR = positivity rate. That is the ratio of positive tests against total number of tests expressed as a percentage of positive tests. This graph from Propublica demonstrates the rolling positivity rate (PR) of Arizona vs New York. The number of actual tests are rising in both locales but so is the PR in AZ; meaning more tests are positive. Conversely, the number of tests are also rising in New York but the PR is falling. The PR is how we know that we are not seeing more positive COVID-19 cases just because we have more tests.
A PR of 30% is an unmitigated disaster. We see this kind of exponential PR increase in hotspots across the US. Experts say wide spread infection can only be stopped by reversing course and shutting down hotspots once again. Recall that China quarantined another major city in May.
We can’t test our way out of this mess. Testing works once the numbers of infected people are low and the contacts of each new case can be traced. Testing is a useful tool only if resulted in 1-2 days.
The current California PR = 6.8%. With the recent flare of cases in Sacramento, we are booking testing appointments a week out with another 3-4 days for results. (Quest has been taking 11 days to result tests. Making testing useless.) Part of this delay is secondary to a lack of testing and developing supplies. Additionally, the government could activate more labs, like veterinary labs, as was done in Europe.
Ask yourself, why are we 5 months into a pandemic and we still can’t get a q-tip?! Why can’t I get an N-95 mask for seeing patients? If you’re upset about that - write your Senator, Senate Leader McConnell, and your President. There is no jumpstarting an economy, no getting kids back to school and parents back to work when well people have to quarantine at home for 2-weeks waiting for a test and results.
Does anyone still think this is a hoax? Helluva hoax!
Obviously, testing is only part of the equation. Many Americans are behaving badly. What do we do? “There is no single method for protection,” Prof. Osterholm says, "Distancing is huge, distance, distance, and distance. That only occurs when people are not congregating altogether.”
WEAR A MASK
Yes, we’ve had conflicting messages from the start. Remember this is called the novel coronavirus. The key word here is NOVEL = NEW. We knew and know very little about this virus and we are still learning. Be open to changing instructions. Remember when we thought smoking improved ones health, cars did not have seat belts, and driving drunk was not unlawful? Refusing to wear a mask is like driving drunk. We will get to smoking later but the point is, new information does point to overwhelming respiratory spread. Protect your respiratory system.
But I thought a mask doesn’t protect me; it protects others? Evidence continues to point strongly to spread by respiratory droplet. A mask will slow droplet spread. It will slow inhalation of droplets and it will contain the spread of exhaled droplets.
There is a plethora of data including caged mice infected with corona virus adjacent to a cage of healthy mice separated only by the thin barrier of mask fabric. Look East to the very low infection rates in densely populated cities like Hong Kong, Taipei, and Singapore. Masks are a big part of their successful strategies.
“Researchers at Florida Atlantic University, in a study published (clic “published” here to jump to best DIY masks) in the journal Physics of Fluids on June 30th, found that bandanas reduced the average distance that coughs traveled from 8 feet to 3.6 feet. A folded handkerchief took that distance down to 1.25 feet. Commercial cone masks reduced the distance to 8 inches, and a two-layer, stitched mask to 2.5 inches.”
A picture is worth a thousand words - watch this CNN video clip with Dr. Sanjay Gupta and Jake Tapper. The graphics show all you need to know about “why mask”.
WE are in a pandemic. Wearing a mask is a tool to keep people safe, to slow the curve, to prevent deaths. Nothing more. A mask is not a political tool or statement. A mask can help slow the spread of a deadly virus for which there is no natural immunity, no vaccine, and no cure. In this, you truly are your brother’s keeper.
A mask is not a muzzle. A mask is not an impingement on personal freedoms. My snarky brain hisses, the dead have no freedoms. If you honor the sanctity of life - wear a mask. If you are pro-life and/or (because amazingly, these two do not automatically coincide) anti-death penalty, wearing a mask is consistent with this belief. If you believe Black Lives Matter or that All Lives Matter, wearing a mask is consistent with this belief. Every religion charges its followers with caring for others; wearing a mask is consistent with all religious beliefs. Ask yourself - WWJD? Darwin would wear a mask.
I’m healthy; I won’t get it and if I do - I’ll survive. …And you might - do not assume those you might unknowingly infect - will. Let me repeat: in this, you truly are your brother’s keeper.
Follow the advice of Dr. Anthony Fauci, America’s guiding voice during the pandemic. He seems to have been recently un-muzzled - and he has a lot to say. Follow him.
Want to know what Dr. Fauci and other experts view as permissible behavior in a pandemic? From airplanes to grocery stores and groceries to gyms to house guests to routine doctor visits, read the WaPo article below. How experts are dealing with Covid-19 risk in their own lives:
What about bathrooms; both public and private?
Ever heard of toilet plume? Like the vapor cloud around ones mouth when speaking (recently named mouth rain), it is the spray that occurs when a toilet is flushed. You might remember around 2000 when toilets got their wings and began flushing with great gusto like airplane toilets. (You would never flush an airplane toilet without closing the lid; would you?) It was found that great-gusto flushing aerosolized bacteria from the toilet into the air and it wasn’t long before great-gusto toilets were de-gusted. During the drought, we went to low-flow toilets and gustatory toilets became less prevalent. Nonetheless - toilet plume is a known problem though there are no known cases of COVID-19 from said contact.
Home toilets have lids. Close the lid before flushing.
What about public toilets? They typically do not have lids. Wear a mask - that’s the most important thing. If you can, do all your business, including hand washing, then flush just before exiting.
What about automatically flushing toilets? If possible, take a deep breath before standing, wash your hands and exit - pronto.
What about one-holers vs multi-holers (meaning single vs multi-toilet bathrooms)? Believe it or not, in this case, a multi-holer might be safer because they occupy a larger footprint with more airflow for improved viral dispersion into the air and the time allotted for droplets to go-to-ground. One-holer (private) bathrooms are smaller spaces with less air circulation and thereby decreased viral dispersion. Concentrations of viral particles can build in small, enclosed spaces (hence the new discussion of viral aerosolization, which will be mentioned briefly below). If possible, let the bathroom stand vacant for 1-minute before entering. In my own workplace, theoretically it is safer to use the public bathroom than the private ones for staff. Public restrooms and toilet plume:
Want more information on viral dispersion? Read the paragraph called Outside versus Inside in my previous blog.
What about using another’s home toilet? Here are the rules we have established for our outdoor, 4-person, ukulele rehearsals. Wear a mask, sanitize hands before entering the home, use bathroom, wash hands, close lid and flush, return to the outside lanai without touching anything inside the home. Easy-peasy.
We are going to be doing this for a while. Get schooled and get good.
MODIFIABLE RISK FACTORS: we call them modifiable because you can actually modify your lifestyle and impact your risk factors.
Recently, doctors caring for hospitalized COVID-19 patients are successfully treating them with steroids = powerful anit-inflammatory medications. In retrospective, observational studies, looking back on fatalities in New York City and the UK, people with pro-inflammatory (inflammatory causing) diseases like diabetes and being overweight had worse outcomes of critical illness or death. Smoking and vaping also causes inflammation in the lungs.
What can you do to lower inflammation? Stop smoking or vaping. Lose weight. Get diabetes under control (A1c<7.0). While your working on that consider an anti-inflammatory diet - start with reducing meat intake. Meat = anything that had a mother, a father, and face. Meat includes: fish, pork, beef, poultry, wild game, reptiles, amphibians, in short, any animal. I encourage patients to start with meatless Mondays and grow that to 3-4 days/week. A vegan diet is highly anti-inflammatory.
Finding ways to improve health:
Stop smoking and/or vaping: Get help, get patches, pills, gum, support, and get smoke-free. I tell my patients - to stop smoking is the single, fastest change you can make to improve your health. There is no better time - and your life may depend on it.
Lose weight: with over 66% of American adults deemed medically overweight or obese, contracting COVID-19 could lead to dire consequence.
Being overweight is the second biggest risk factor for serious illness, behind age. Overweight causes systemic inflammation and hypoventilation (decreased oxygenation of body tissues). The connection between weight and increased risk of severe or fatal infection with flu-like viruses, was first identified during the 2009 swine flu pandemic, which killed 284,000 worldwide.
Weight is rated according to body mass index (BMI) — a BMI under 25 is considered ‘healthy’ while 25-29 is classed as ‘overweight’ and 30 plus is ‘obese’. (Find your BMI on Google. Of note: the Asian BMI scale is significantly lower than the common, Caucasian BMI scale. Anyone of Asian continent descent should be aware and beware.) U.S. research published last year also found vaccines are less effective in overweight people.
Intensive Care National Audit & Research Centre (ICNARC) data has shown three-quarters (75%) of critically ill UK COVID-19 patients were overweight or obese.
Similarly, a study of 4,103 seriously ill COVID-19 patients by New York University, showed while age is the biggest, single risk factor for serious illness, obesity is a close second.
If it were easy - you woulda done it. Losing weigh is obviously easier said than done. Get help and find support. Choose among a myriad of online tools. Your healthcare system assuredly offers a selection.
Get diabetes and hypertension under control. Weight loss can drive both diseases into remission but in the meantime - work with your doctor. This is not a time to cut yourself slack and give in to stress eating or reason du-jour. If ever there was a time; this is it. This is the time to take on the challenge and possibility of a healthy body - like your life depends on it - because it may.
Do I need to stay indoors? No - going outside good. My ex-mother-in-law thought she was trapped indoors and missed a month of walking. Walking is good; just give passing people a wide berth. Ride your bike. My yoga studio is offering online classes. Yoga on my lanai no ka oi (da bes)! Keeping yourself healthy, both mentally and physically, keeps your immune system strong. Get some exercise!
Want to support your favorite restaurant and see your friends? I meet my bestie for lunch in a park, where we sit at opposite corners of an 8-foot picnic table, eating take-out from our favorite haunt. A beer with the neighbors? Outside, in appropriately spaced lawn chairs works.
Any activity that you might want to engage in will be infinitely safer if you move it outside. A Japanese study says 20 times safer.
WHO (World Health Org) just announced the possibility of aerosol spread. What is that? Aerosols are tiny bits of virus that hang in the air. Do you remember the measles outbreak a few years ago? Every case was traced back to a particular weekend at Disneyland. (That was testing and tracing at its best.) Measles can hang in the air …making it highly contagious in those long, snaking, indoor queues (think Pirates of the Caribbean). Aerosol infection is why researchers think choral singing (inside) has resulted in many infections while protesting outside has not.
There is no economic recovery if our workforce cycles in and out of illness and workplaces become incubators for disease. There is no paying my mortgage if I get sick. There is no retirement in 9-months if I die. Lets get serious people!
This will take mental toughness, emotional intelligence, and emotional discipline. This will require physical discipline. Many economists are predicting global recession if not depression - so this may require economic discipline as well.
This just might be a defining moment, a sentinel moment for the USA. Look again at my opening graphic. The US is number 1, but this time it is nothing to crow about. We are not recovering, we have not even turned the corner. And no other nation is following our lead - which means, if we want their results, we must follow their lead. If as a nation, we continue to behave like wild-west cowboys, then we who lack the yahoo-gene will be required to be even more vigilant and more careful.
One last thing, here’s one for the team because most of my colleagues are far too polite to say anything like this. Dr. Daniel Summers, MD tweeted this and he speaks for many, “No amount of clapping or cheering or calling healthcare workers heroes meant a damn thing if you undo all our work with your shi__y, irresponsible behavior now.” Touché!
Additionally, we can’t take care of you if too many of us get sick.
To a large degree, my health & life depends on my savvy and the health of my coworkers, my friends, and my family. Our actions reflect our commitments. I have a commitment to myself and my community - to keep us well. What’s yours?
Footnotes:
1 https://www.motherjones.com/kevin-drum/2020/07/trump-orders-the-cdc-to-change-its-school-guidance/
2 Washington Post, 7/3/2020
3 Johns Hopkins Univ https://coronavirus.jhu.edu/data/mortality
4 Yale Alison Galvani, PhD https://whdh.com/news/silent-spreaders-may-be-responsible-for-half-of-coronavirus-cases-study-finds/
5 Face mask construction, materials matter
6 https://search.yahoo.com/yhs/search;_ylt=AwrTLfophQRfU44Afwo2nIlQ?p=propublica+az+positivity+rate+chart&hsimp=yhs-fullyhosted_011&hspart=iry&fr=yhs-iry-fullyhosted_011&fr2=p%3As%2Cv%3Ai%2Cm%3Apivot&stype=web
PUBLISHED: 17:08 EDT, 20 April 2020 | UPDATED: 03:08 EDT, 21 April 2020
How to Read Obama’s Pandemic Playbook
(Obama’s) PLAYBOOK FOR EARLY RESPONSE TO HIGH-CONSEQUENCE EMERGING INFECTIOUS DISEASE THREATS AND BIOLOGICAL INCIDENTS
