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.

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.

Abortion is health care. It must be safe and legal.

Quite a number of years ago, before the murder of George Tiller, MD in 2009 (see my post In Memoriam George Tiller, May 31, 2009), the Students for Choice group at the medical school where I worked had a forum with a speaker who was the minister that counseled potential abortion patients in Dr. Tiller’s practice. (Yes, he had a minister to do counseling. He was murdered while acting as an usher in his church. Don’t forget that!) During the discussion, one student stood up to identify himself as a person who was adopted as a baby, and how he was so glad that he had not been aborted. He talked about the wonderful love and support he had gotten from his adoptive parents, and how it had made it possible for him to get to medical school.

I was very happy for him, but it is a specious argument in two important ways. First, one can never know what “might have been”, and who a baby born would have been. In addition, this in no way begins to address the pregnancies with fetuses who have conditions incompatible with life, or the trauma of giving birth to a 12-year old who is the victim of incest, or indeed any pregnant person. A person carrying a baby to term is 14 times more likely to die than one having an abortion, and in some circumstances (Black women in Mississippi) 118 times more likely to die! (cited by Michelle Goodwin in an excellent piece in the NY Times, June 26, 2022, “No, Justice Alito, Reproductive Justice is in the Constitution”).  

The second flaw in his argument, personal as it was to him, is that all children are not guaranteed such an outcome if they are born and adopted. It would be incredibly wonderful if all children had terrific, loving, supportive parents, when biologic or adopted or of any other combination, especially if they also have the financial and emotional capability of raising a (or another) child. But this is far from always the case, for any kind of parent. It is a romantic pipe dream of the  “pro-life” movement that being given the opportunity to be born means anything is possible for the child. This is the position taken recently by, for example, the Cornell Republicans, who tweeted '“Hundreds of thousands of children will now have the opportunity to live life to their fullest potential” (Cornell Daily Sun, June 26, 2002). This is nonsense; having that opportunity requires more than being born. It requires love, and safety, and food, and housing, and education, and nurturance. The kind of things that the medical student above apparently had. The kind of things that millions of children born already do not have access to. And, clearly, the kind of things that many Republicans (and others, likely; I didn’t want to make this about political party, but it was the Cornell Republicans who issued the statement) have completely refused, continuously, to support for children born in the US. The meme that “pro-lifers” love only unborn, not born, life, is sadly, the effective truth. (Note that I do not mean that all, or even most, people who identify as “pro-life” feel this way, but it is the effective practice of those they elect to Congress and state legislatures. Of course, if we were going by what most people believe, over 60% of Americans believe abortion should be legal in all or  most cases.)

People who are pro-choice also use specific examples, individual stories, and they are also gripping. A post making the rounds on FB since the Dobbs decision says: ”Overturning Roe does not stop abortions, it stops SAFE abortions!” and this is absolutely true. As much as the anti-abortion forces would like to prevent all abortions (they think), abortion have been part of human life since...forever. But they have not always been as safe as they have become since the Roe decision, and now they are about the safest procedure that can be done, and even safer when done with medication. I thought I’d include a few of those stories, anecdotes, that accompany these posts because they are each as real as the story of that medical student, written in the voice of one who says that they are not “pro-abortion” but “pro-life” as in:

·        I'm pro-Becky who found out at her 20-week anatomy scan that the infant she had been so excited to bring into this world had developed without life sustaining organs.

·        I'm pro-Susan who was sexually assaulted on her way home from work, only to come to the horrific realization that her assailant planted his seed in her when she got a positive pregnancy test result a month later.

·        I'm pro-Theresa who hemorrhaged due to a placental abruption, causing her parents, spouse, and children to have to make the impossible decision on whether to save her or her unborn child.

·        I'm pro-little Cathy who had her innocence ripped away from her by someone she should have been able to trust and her 11-year-old body isn't mature enough to bear the consequence of that betrayal.

·        I'm pro-Melissa who's working two jobs just to make ends meet and has to choose between bringing another child into poverty or feeding the children she already has because her spouse walked out on her.

·        I'm pro-Brittany who realizes that she is in no way financially, emotionally, or physically able to raise a child.

·        I'm pro-Emily who went through IVF, ending up with SIX viable implanted eggs requiring selective reduction to ensure the safety of her and a SAFE number of fetuses.

·        I'm pro-Jessica who is FINALLY getting the strength to get away from her physically abusive spouse only to find out that she is carrying the monster's child.

·        I'm pro-Vanessa who went into her confirmation appointment after YEARS of trying to conceive only to hear silence where there should be a heartbeat.

·        I'm pro-Lindsay who lost her virginity in her sophomore year with a broken condom and now has to choose whether to be a teenage mom or just a teenager.

·        I'm pro-Courtney who just found out she's already 13 weeks along, but the egg never made it out of her fallopian tube so either she terminates the pregnancy or risks dying from internal bleeding.

The post concludes:

You can argue and say that I'm pro-choice all you want, but the truth is:

I'm pro-life.

Their lives.

Women's lives.

You don't get to pick and choose which scenarios should be accepted. It's not about which stories you don't agree with. It's about fighting for the women in the stories that you do agree with and the CHOICE that was made.

Women's rights are meant to protect ALL women, regardless of their situation!

Overturning Roe does not stop abortions, it stops SAFE abortions!

Abortion is healthcare.

 

It is health care. And it is critical that be available. To all.

Technology and other obstacles to getting health care: it’s capitalism, of course!

I saw this cartoon posted recently on Facebook, and am sorry that I can find neither the cartoonist nor the original site of publication. It is, as is the case with most good humor, both funny and sad, in that it cuts close to the reality of the lives of people seeking health care. This particular cartoon emphasizes the technology obstacles to receiving care, which represent another layer of obstruction beyond insurance, distance, availability of providers, and, generally, a system that favors the corporations involved in health care over the people (also known as ‘patients’) seeking it, or the clinicians who provide it. One of the biggest complaints and stressors (and reasons for physician burn-out) is the Electronic Medical (or Health) Record which consumes enormous amounts of clinician time inputting data (many clinicians report at least a 1:1 ratio of charting on-line to seeing people).

It take so much time and is so onerous in large part because it involves, in addition to charting the note recording what the person was complaining of (“Subjective”), what was found on exam, lab, imaging (“Objective”), what was diagnosed (Assessment) and what was done (Plan), many click boxes have to be filled out to record specific data digitally. While this includes things that are sensible because they enhance easy retrieval (e.g., a flu shot), and things that are otherwise ostensibly documenting preventive care for certain issues (e.g., alcohol or tobacco use), they also include many things that ensure compliance with specific government regulations or insurance companies rules, and extensive and complex documentation and clicking to ensure that maximum reimbursement is received by the employer.

There are benefits to having data stored in a searchable and easily retrievable digital format. However, on balance, patients find their access to medical care, already strained by financial, time,  and distance constraints, further limited by technologic obstacles, and doctors find them terribly burdensome and of less utility,  but yet they proliferate. Patients do not usually want to blame their doctors or other clinicians, most of whom they value and trust, but cannot understand why those obstacles have been put in place.

Let us go back to “maximum reimbursement is received by the employer”. Most doctors and other clinicians are no longer in solo or small-group practices, but rather are employed by corporations (both for-profit and ostensibly not-for-profit) or by large groups that, even when physician owned or managed, have the same incentive to maximize reimbursement, even at the cost of efficient use of the clinician’s (not to mention the patient’s!) time and effort. Of course, for the corporation, the most efficient use of a physician’s time is that which generates the greatest reimbursement, which is not necessarily the same as that which generates the greatest marginal health benefit for the patient. This is an issue I have written about many times before, but it bears repeating. People who are willing to vote against an administration because gasoline prices are high, even though that is a result of corporate greed and is most supported by the administration’s opponents, are not always ready to think deeply. Indeed, physicians and other clinicians retain a great deal of respect and admiration despite the violence done to people in their name (usually not, of course mainly physical violence, although making it difficult or impossible for folks to access health care can certainly result in physical damage!)

People often want to take credit for what is seen as good, and to deflect blame onto others for what is seen as bad. This is a particularly common trait in those called “leaders”, although they are often just bosses, not leaders. It is so common in this group, in fact, that we are often shocked when a person in a position of real authority takes responsibility for their – and their subordinates’ – mistakes, and gives credit to others for accomplishments; this is why Harry Truman’s sign “The Buck Stops Here” became so famous. In the case of health care, such duplicity by the “leaders” often takes the form of the corporation wrapping itself in the mantle of “caring for and about your health”, while actually creating obstacles (including those technological ones) to accessing care, particularly if you are not a high-profit-margin patient, and even blaming those doctors, nurses, and others who actually do provide care for the problem.

In a different context, this theme has been replicated in Mexico, by the government rather than the corporation. Doctors (and their patients) in rural areas are being kidnapped, killed, and otherwise abused by drug gangs, as reported in the NY Times. In a cynical political move to seem to address this problem, the government is talking about bringing in 500 Cuban doctors. ‘“They [that is, the rural physicians] forget about a patient’s primary right, which is to be cared for wherever they are, and it’s because of this that we needed to resort to contracting foreigners,” Dr. Jorge Alcocer Varela, Mexico’s secretary of health, told reporters at a recent news conference.’ Safe in his cabinet office in Mexico City. This generated an appropriate response: ‘The announcement about the Cuban doctors provoked outrage among many Mexican doctors, who said the problem was not a lack of physicians or an unwillingness to work in rural communities, but the life-threatening conditions they must work under.’

The lower your own risk, the easier (but more ignoble) it to criticize those who are at risk. The less value you (as, say, a CEO) bring to the actual provision of health care, the more you can feel free to blame those who do, or who criticize the way that you have organized systems to maximize your profit, not to improve people’s health. Such CEOs love to brag about their great programs that bring highly-reimbursed care to well-insured people, but are rarely willing to spend much on high-value (as opposed to high-profit) care for the most needy.

Healthcare is scarcely unique in having been seemingly overtaken by systems that have the goal of limiting human-to-human interaction and replacing it with often difficult-to-navigate (especially for the older or less computer-savvy person) human-to-machine systems. “They” want you to download their app (after upgrading your operating system), go to their website, and do anything that does not require them to pay a person who can actually help you. Almost no actual people prefer that, but we’re usually stuck. When they can’t force you off the phone and on to the computer, they can sure make you wait – at your doctor’s, at the pharmacy, at the airport – and maybe you’ll give up. It does not just happen in health care, but when stakes are your life and health, it seems particularly bad.

Just remember who and what is at fault; usually not the doctors and other clinicians, who actually want to help you, but corporate capitalism, motivated by greed.

Where has all the caution gone? COVID infection is still common!

Most infections diseases in people get passed from one person to another, although sometimes animals and insects are the vectors. More rarely (as in the case of COVID-19) an ‘enzootic’ infection (one that resides in animals) can ‘make the jump’ to people, although after that the transmission continues to be primarily person-to-person. If there is an outbreak of an infection it can spread rapidly among ‘susceptibles’ (people who do not have immunity through either prior exposure to the infection or from vaccination against it), particularly in crowded conditions.

Many of us are aware of this from our children. In winter, young children in school and day-care bring home infections that can make them sick and often infect other members of the family. Luckily, most of these are minor and transient (the ‘common cold’), but in the past included many serious and potentially fatal diseases such as polio, measles, mumps, whooping cough, rubella, diphtheria, Hemophilus influenza, chickenpox, and others. The frequency of these diseases has gone down dramatically as a result of vaccines that have been incredibly effective. Outbreaks still occur in places and populations where an insufficient percent of the children have been vaccinated to result in ‘herd immunity’. In the US, this is, sadly, most common not in communities which do not have access to vaccinations, but in which large numbers of people have, for whatever their reasons, chosen to forego vaccination for their children.

 

Dave Caverly, Speedbumps

 

The way that outbreaks of any infectious disease, from colds to influenza to chickenpox to sexually-acquired infections to COVID-19, occurs depends upon the route through which that organism is transmitted – sometimes by respiratory droplets (cold, COVID, pneumonic plague, polio), sometimes through fecal-oral contamination (think young children), sometimes through sexual contact involving exposure to blood or other body fluids, sometimes by more than one of these. Respiratory transmission is particularly great in crowded indoor environments, such as schools, concerts, restaurants, clubs, and family gatherings. And gyms, where people working out are breathing heavily. And singing (such as the karaoke sessions enjoyed by the NY State judges before many came down with COVID). Sexual transmission is, of course, less likely to be incidental and requires close and often prolonged contact.

But there is a similarity. This is that we are at risk for exposure not only from symptomatic individuals with whom we have contact, but often from those who are not, or not yet, symptomatic but who have been infected by someone else. In the case of sexually acquired infections, the idea that when you have sex with someone you are not only having sex with them, but potentially anyone else they have had sex with, or the people those people had sex with. Monogamy, is of course, protective, provided, of course, that it is actually practiced. It does not necessarily take many outside episodes to introduce an infectious disease.

In the case of COVID, we are not talking about sex, but about high-risk exposures. And also about what we assume should have been low-risk exposures but were to people who themselves may have taken greater risks. You may be pretty careful, not go out much, wear your mask if you are indoors with groups of people that you do not know, but be less careful if you are with close family members, especially those in your home. But just as a child can bring home a cold from daycare, or a sexual partner can bring home an STI from a relationship that you did not know they had, a family member can bring home COVID from a concert, club, restaurant, airport, social gathering, or other event in which others, who you (and maybe they) do not know were infected, unvaccinated, unmasked. If you happen to be more vulnerable: older, sicker, immunocompromised, and especially (because this is usually fixable) unvaccinated, the outcome can be not just infection but hospitalization and even death.

Minority communities have higher rates of all of these problems – infection, hospitalization, and death. Some of this can be tied to greater prevalence of chronic disease, some could possibly be lower rates of vaccination, and much may be related to having a higher rate of low-income and jobs that require actual presence and cannot be done from home by ‘Zooming it in’. It can also be true that poorer families may be more likely to have multiple generations living in the home, with various sources of infection (school, work, social activities) increasing the likelihood of COVID being brought into the home and infecting family members who are more at-risk.

Most of us want to see and interact with our family members. But if those family members have contracted infection, whether by “choice” (adopting higher-risk behaviors, not wearing masks, especially not being vaccinated) or by bad luck despite taking precautions, seeing them puts us at greater risk. Some of that risk may be unavoidable, but some can definitely be mitigated. COVID is NOT gone, but people are taking more and more risks, including me. I returned from a trip to Europe a few days ago, and while I wore an N-95 mask on the plane and in the airports, it was risky (the line for passport check in the Madrid airport crowded despite ironic signs on the floor asking people to maintain a 2-meter distance, between which were many people, was surely a potential super-spreader event). But I seem to be one of the few people worried about it. In the gym, no one else is wearing a mask, even as they huff and puff on machines which definitely increases the likelihood of spread, and I take no reassurance from their carefully wiping them down, since this is not really how COVID is spread. The front desk has even taken down the plastic barrier that has long been in place.

If all this were occurring because the rate of infections, and thus hospitalization and death, were down, this could be a good sign. Unfortunately, it is not. A recent headline in my local paper, the Arizona Star, on June 3, 2022 is “AZ COVID numbers continue to rise”, and daily published an update on number of cases. Yes, vaccination has definitely reduced the rate of hospitalization and death among those who have been infected, but the greater the number of infections the greater the risk of those really bad outcomes.

Death is now less likely, at least among the vaccinated. Be vaccinated. But COVID is still there, and in many places cases are increasing. Continue to exercise caution, and try to not take unnecessary risks.

 

The Fourth Surge? The Fifth? Guess what: It’s still not safe out there!

The US recently passed a million deaths from COVID-19. There have been a lot of articles marking this dubious milestone, notably in the NY Times as in this Briefing by Jonathan Wolfe, and this Daily podcast.  The Wolfe piece includes two important graphics, one showing the number of new cases by day. It also contains shows hospitalizations and deaths, and makes the several “waves” very clear. And that this Spring’s wave is huge. The second graphic shows deaths, by time and by race/ethnicity in the key non-child, not old, age range of 25-54. A lot of deaths, and while the particular minority group that is most affected varies among the different surges, Blacks and Latinos are disproportionately dying.

A million people is a lot of deaths. It is, as Wolfe points out, more Americans than have died in all the wars in our nation’s history. It is more people than have died in any other country. It remains about 20% of the world’s deaths. I have often written about how the US healthcare system is far inferior to that of many other countries, particularly the wealthy ones that are our appropriate comparison group. It is unfortunate that this area, where we are but certainly should not want to be #1, demonstrates our lack of an effective public health system and the inadequate coverage for healthcare of so much of our population.

 

It demonstrates more than that, as anyone can tell you, regardless of the group that their political position demands be blamed. People are getting out more, mingling more, interacting more, going to physical workplaces more – and getting infected more. Not a day has gone by recently where I have not heard from a friend or relative about something that they did for the first time in a long time – go to a concert, or to an indoor restaurant, or get together with a group of people in someone’s home. And every single one of these stories has ended with someone, the friend or relative or one of the people that they interacted with, getting sick and testing positive (and possibly, likely, others to follow). I have learned more than I ever expected to about the unreliability of home test kits, which have sometimes been falsely negative two or three times in a sick person before the result of a more definitive test came back a couple of days later. The amount of virus (“antigen” if you want to be cool) that you need to make you sick is less than that required to generate sufficient antibody (what your body makes to fight the virus) to turn these tests positive.

It is tempting to say people are behaving badly or stupidly, but what is true is that people’s behaviors – tentative or full-throttle efforts to move back to a “normal” pre-pandemic life – have increased the number of infections. And that the increase in the number of infections leads to an increase in the number of hospitalizations and deaths. These are sometimes, but not always, in the people adopting the “risky” behavior. Sometimes they are in the people (often older, sicker, more vulnerable) that they live with.

Both my wife and I have traveled abroad recently, and it makes us nervous. She went to India, and we both are now in Europe. We tried to be as safe as we could on an airplane where the pilot and staff announce regularly that “you are not required to wear a mask, but please respect the decision of other people to mask or not mask”. I guess that means that there have been at least arguments, and likely fights, on planes over this issue. A federal judge in the US, in the middle of this current surge in infections, ruled that the government could not require people to wear masks on planes, and the administration did not appeal it. Thus, in traveling from India, through Dubai, everyone was masked until my wife got off at O’Hare – and most people were not. There are legal scholars who disagree with this judge’s ruling, but the key point, whether you agree with it or not, is that she ruled that the Constitution does not give the federal government the right to require people to wear masks on planes. She did not rule (and of course, could not rule!) that not wearing a mask was safe. This distinction seems to be lost on many people.

Including judges, of course. We just learned that 70 New York State judges went to a retreat in Montauk, NY, and that (as of May 19) 20 of them have tested positive for COVID, and many are sick. And there will likely be more. The fun of that retreat included a big karaoke party, a really effective way to spread the droplets that cause the infection. And these are the people who issue the rulings about what is allowed and what is not. Makes me feel really secure; how about you?

On a more chilling note, a close relative just told me about a longtime friend who has not been vaccinated,  won’t do it, and refuses to wear a mask. But he does not refuse to travel or to go out and interact with others, even in settings where evidence of vaccination is required. He lies and says he is vaccinated. “Luckily” for him (and, of course, unluckily for the rest of us!) he shares his father’s name, so he uses his father’s evidence of vaccination to access these venues. Think about that. Think about how reassured you are when you are with a group of acquaintances and “everyone” is vaccinated or tested negative. Or are on a plane where “everyone” has had to present proof of vaccination. Do you feel secure? You should, actually, at least feel more secure. The odds are very much lower in these settings. And in private groups, of course you trust your friends and relatives. On the other hand, it might not be everyone. One of them might be this guy. Or one of the thousands, probably millions, like him.

Recently, a ruling by a federal judge has blocked the federal government from ending Title 42, a public health regulation invoked by Trump to keep migrants coming from Mexico out of the US  based upon the possibility of their bringing in COVID, which has been continued until now. But it is not migrants who are spreading COVID; it is infected Americans who have not been vaccinated, will not wear masks, and openly mingle in public (and private) places.

In small villages in India everyone is wearing a mask. At O’Hare, or your local restaurant, or even on an airplane or in a convocation of judges, people are not. Luckily they are vaccinated. Unless, of course, they’re not. Since people’s desire to “open up more” began, early in the pandemic, I have been saying “opening = death”. Vaccines have helped a lot, and there area lot fewer deaths and hospitalizations when folks are vaccinated even when they are infected.

Sadly, there are too many people who are doing their best to try to make it worse.