Tuesday, July 19, 2022

Keeping safe from COVID: Apparently it's all up to you

The most recent COVID-19 subvariants, currently accounting for at least half of US infections (and probably comparable world-wide) are the BA.4 and BA.5 subvariants of the Omicron variant. The bad news is that they are spreading rapidly, infecting many people. The good news is that a high percentage of those infected are getting milder illness, and the percentage of people requiring hospitalization or dying is lower than for previous infections (such as the original Omicron variant and its first variant from last winter, BA.1). This is explained (see “Family Practice News” article, here on MEdge) by the fact that we have (a bit simplistically) two different types of lymphocyte cells that produce immunity. B-cells produce antibodies (called humoral immunity), while T-cells directly attack invading germs that they have been primed to recognize by prior exposure through infection or immunization, which is called cellular immunity. Essentially, the new subvariants have mutated to avoid detection by antibodies (thus resulting in more infections) but not to resist destruction by T-cells (thus the less severe infections).

The other piece of bad news is that you can still get sick, can still get hospitalized, and can still die from COVID. And, of course, you can still infect other people, whether in public or in your home, and if some of those are more susceptible with lower immunity (say, older parents or grandparents, or those with chronic disease) and are infected by you, they can die. You will have been, sorry to say, the vector for their death. Like a deer who carries a tick that carries Lyme disease. And then there is “long COVID”, persistent serious symptoms lasting for months or years (from the CDC, over 13% at one month, several percent at a year, over 30% in people who were hospitalized). Sometimes getting infected is essentially unavoidable; people do have to go out, and even if they have been immunized, and boosted, and take care like wearing masks and staying reasonably distanced, and not eating indoors at restaurants, they can still get infected. But I have just listed a lot of things that a lot of people could do and many are not doing, and to the extent that they are not, infection is much less “unavoidable”. When you cross the street, you can be careful, cross on the green in a crosswalk, look both ways, and still be hit by a person careening around the corner at high speed who isn’t looking. But if you cross in the middle of a busy street, with no light, trying to dodge cars, you have greatly increased your risk. There is, to put it mildly, a LOT of misinformation about COVID that persists (see cartoon!)


A lot of people talk these days about individual responsibility and not being able to trust the government, and they definitely have some justification. But they often are looking at the wrong problems and coming up with the wrong solutions. No matter how many guns you carry, or how fast they shoot, or how big the magazine is, you can’t shoot the virus. You can do the things I mentioned above (get vaccinated and boosted, try to not be indoors with lots of other people, wear a good mask if you have to be in public, and also a mask if you are around vulnerable family or friends). A note on masks: any mask will help protect other people from you because it is right in front of your mouth and nose. Unfortunately, for you, this isn’t protective if other people are not wearing masks, certainly the norm these days. To protect yourself from others, you need an N-95, well and tightly fitting, since if folks are infected they will have been spewing virus all over.

Government agencies (and they don’t always have their acts together and agree even at the federal level, not to mention all the 50+ states and territories and thousands of local jurisdictions) have generally not been requiring masks recently. The federal government has been sending access to home test kits, and they and local governments have been closing sites that can do more accurate testing. Getting a vaccine is not always so easy, even if you want one. The CDC and FDA and Secretary of HHS Xavier Becerra and Anthony Fauci (whatever his title) often seem to not agree with each other, and often disagree with something else that they recently said themselves. And what agency is responsible for doing and saying what is a mystery to most people. Yes, sometimes the pronouncements of these agencies and individuals change because the scientific knowledge has changed – this is what Fauci is fond of saying, even when he contradicts himself because the science did not change – but there is another major reason, and, sadly, this gets back to you and to me.

Governments make policy and implement it (more or less effectively -- less, in general, for mask mandates) but they are nothing if not political. Political means that they (or those who appointed them) need to be elected and re-elected, and this is their main goal. If they pursue policies (like, say, mask mandates) that people find intrusive and don’t want to do, they can lose votes. And if they pursue policies that keep people from working and shopping and such then businesses lose money, and the politicians can and will lose donations. So they try to walk a fine line between encouraging some restrictions (sotto voce) and loudly proclaiming that things are getting better, that society should open up, that our economy will be growing, and you can go back to work.

So, those of us who are concerned about us and our families getting COVID and maybe getting very sick and maybe dying, and even more likely suffering the continuing problem of “long COVID”, should be very cautious about jumping on the “things are getting better; you should go back to normal” bandwagon. Things are not the “old” normal, but everywhere you go people have taken the “blue pill” (The Matrix, 1999 reference), drunk the Kool-Aid (Jonestown, 1978 reference) or are on soma (Brave New World, 1932 reference) and are not being careful, so you need to be extra careful. There are a lot of places to get infected, and they are sometimes places that you hadn’t though about or planned for. A friend recently went to an outdoor concert with adequate distancing, wearing masks – but prior to entering was in a tightish line to get in. And got COVID. Waiting in the passport control line at an international airport, people were jammed together, and few were wearing masks. Being safe most of the time doesn’t protect you from when you are not safe. [see: Anything. Because something didn’t happen once, or twice, or fifty times, doesn’t mean it won’t happen next time.]

There are a lot of really bad things going on now. Domestically, the Supreme Court (#SCOTUS-6) is doings its best to put you and everyone else at risk, abandoning Roe v. Wade, increasing the probability people with die, allowing almost anyone to walk around with almost any kind of gun, increasing the probability people will die, limiting what the government can do to slow (forget prevent!) global warming increasing the probability people will die, threatening democracy, which will not necessarily direct cause people to die but increases the risk of all the others. They are moving on to making almost anything else that will protect us illegal with one hand, while things that put us at risk are legalized with the other. Plus the world, the wars including that in Ukraine, and world-wide climate change. That is how they get you – how many things can you worry about, fight to change? Well, it has to be all of them. Including the virus causing a world-wide pandemic that could kill you.

Government needs to make easy free effective accurate testing widely available on virtually every corner, not depend on home tests which are not only much less accurate but do not allow accurate data collection. It needs to make it very easy and free to get immunized. It needs to require masks for people gathering indoors. It needs to have a consistent and broad policy on the use of paxlovid and other treatments. It needs to enforce effective protections – only the BEST kind of masks and respirators – for healthcare workers, particularly in hospitals. It needs to, with all the problems listed above, not be distracted by actual red herrings, like refugees and immigrants.

But too much of this will be politically unpopular. Many of us want to stay in the Matrix, at least while we can. Amazingly, the American Public Health Association (APHA) has just announced that masks will be optional at its November meeting in Boston! Can any public health person tolerate this? Do they understand the optics?

So if APHA won’t mandate masks, the government probably won’t take the risk. So you have to take care of yourself and your family. Do what you can, do more, be extra cautious.

Maybe it will help enough.

Saturday, July 9, 2022

More important than our circadian rhythm: Creating a society that is safe and has health care for all

The New York Times, in addition to covering world and local news, has a lot of “feature” type news, generally appealing to educated, urban, and often higher income people, especially in New York, who are a large percent of its readers. Obviously its Arts coverage reflects the enormous NY arts scene, but also frequently seems to be more in-depth, designed to appeal to an even smaller group. Similarly, while its health coverage often includes news and opinion pieces on the social inequities in health care, on community risks (such as gun violence), and on policy issues, it also includes pieces aimed at what might be called “individual health self improvement”, sometimes involving new(ish) research.

An example is the recent front-page piece on “Circadian Medicine”, that reports on research about following our “body clocks” to get the greatest health benefits from how we do things like eat, exercise, etc. It starts with a look at the effort to move toward permanent daylight savings time and how this affects our personal and work lives.  Of course, this is ultimately a sociocultural issue; the amount of light and dark each day is unchanged, but the question is when our particular area decides to do things. Farmers and ranchers, for example, do not work based upon the time it says on the clock. If we wanted to, we could work from 9 to 6 instead of 8 to 5 rather than changing the clocks.

What is actually more important about this piece, to me, is that it goes on to emphasize how individuals can (possibly) improve their health by choosing the correct time of day to do their health-inducing activities. It is thus yet another effort to look at what each of us can (provided we have the education, autonomy, money, and time) do to make our individual selves healthier. Maybe. Such emphasis is not wrong per se (except, of course, when it is wrong, as has been, for example, our obsession with taking vitamin supplements when we are not vitamin deficient, as see F. Perry Wilson on Medscape, “It’s official: vitamins don’t do much for health”). The real issue is that it is a distractor, in that it focuses upon something that is perhaps slightly beneficial for some people (or not) but will not have a major impact upon the health of the public or the populace, taking our attention away from focusing on the very many major serious things that do have a significant effect upon the health of the public, and that we, as a people, could do something about.

 Like what? Let’s start with some data that should be scary: Among wealthy countries, the US is the only one that has seen a leveling-off and decrease in life expectancy, as reported by “Our world in data”. I have reported on this trend several times previously (Lower life expectancy in the US: A reflection of racism, classism, and social inequity April 29, 2022, Decreasing life expectancy in the US: A result of policies fostering increasing inequity, November 29, 2019) and examined some of the various proposed explanations. Case and Deaton, among others, suggest that the increase in the death rate (particularly among less affluent whites) are “deaths of despair”, mediated through the use of substances (alcohol, tobacco, opioids and other drugs). No doubt these are major contributors, but there are also others. One that has many people very concerned, as it should, is the ubiquity of gun violence in the US. This is a major contributor to death rates in populations such as young males, where suicide and homicide are very important causes of mortality. Most of us can reel off the names associated with major episodes of mass shootings, especially school shootings like Columbine, Sandy Hook, and Uvalde, but these are the tip of the iceberg. An interactive story in the Times documents the 63 “mass shootings” (four or more people shot) in May 2022 alone, and there were 65 in June, and 25 in July -- and as of only July 8 when this was published! And this does not count the many more deaths where “only” one to three people were killed! In the wake of Buffalo and Uvalde, Congress finally passed a very weak gun law. It did break an impasse, but in the minimal amount of restriction it places on gun ownership and carrying, it reinforces the idea that “America is a gun”, as in Brian Bilston’s poem. Any other country with only one major mass shooting has reacted much more dramatically and effectively. While articles continue to appear, such as the Op-Ed of Patti Davis describing the reaction (in her) and lack of reaction (in the nation) to the shooting of her father, Ronald Reagan, 41 years ago, we still are in thrall to the gun lobby and to folks who truly believe that they are at risk if they don’t have and carry guns that they make it easy for those who are going to create major violence and death.

And what about when we get sick? We – Americans – are as a group less able to access care than people in those other countries because we don’t have universal health insurance or access. Dr. Aaron Carroll, in an Op-Ed on July 7, emphasizes the impact of health insurance deductibles, noting that it is not just the uninsured but the underinsured, for whom deductibles are a major obstacle (along with other inappropriately-designed out-of-pocket payments) who suffer from not being able to access medical care, especially in time. The numbers that he cites for deductibles, and for co-payments and co-insurance, are amazingly high, as is the impact that it has on the health of those affected. For example, “The good news is that the A.C.A. limits these [out-of-pocket expenses] in plans sold in the exchanges. The bad news is that they’re astronomical: $8,700 for an individual and $17,400 for a family,” and for people in Medicare drug plans “a simple $10 increase in cost-sharing, which many would consider a small amount of money, led to about a 23% decrease in drug consumption.”

The fact that it is the Medicare drug plan (Part D) that is cited here is not coincidental; it, along with both Medicare Advantage (Part C) and the newer REACH (formerly DCE) program implemented by CMS (the Center for Medicare and Medicaid Services) are the portions of the Medicare program focused on providing profit to investor-owned companies rather than health care to American seniors. A recent report by the Urban Institute on Geographic Predictors of Medical Debt, in Health Justice Monitor, shows, unsurprisingly, that those areas with the highest concentration of poor, uninsured and underinsured people, and people with chronic diseases have the highest level of debt. And the lowest level? Those areas with the highest concentrations of people over 65. This, of course, is the only part of the general US civilian population that has essentially universal health insurance, despite the efforts of the programs above to decrease or dilute it. Although this seems worth mentioning, the Urban Institute did not; maybe they thought it was obvious.

But in this country nothing is obvious to most people and needs to be pointed out.  This includes our legislators, federal and state, to whom often the only thing that seems obvious is who is contributing to them. With all respect, we need to be focusing less upon our body clocks and circadian rhythm and more on the things that made a real difference in our nation’s health.

We need to decrease the availability of semi-automatic guns with high-capacity magazines. We need government policy focused upon creating well-paid, good-benefit jobs that will decrease “deaths of despair” rather than maximizing corporate profit. And we need high-quality universal coverage and access to health care for all our people. What we do not need are more programs like Medicare Advantage, Medicare Part D, and REACH that channel public tax dollars to private enterprises as profit.

What we do need, we needed long ago, and we need it now.

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