Friday, May 15, 2020

Thinking "broadly and deeply..." about COVID-19

That's a quote from my colleague, Dr. Ann Swartz, this morning in a series of group messages we share among our nursing faculty. It was a reference to an article she found, Dr. Peter Piot's interview in Science Magazine online. Piot, a virologist who studied AIDS and Ebola, says in the piece, "Finally, a virus got me." Piot suffered from COVID-19 in a hospital in Britain, and while he is better and recovering at home, he is not completely well. He, like many, was walking around with a low grade pneumonia, and low oxygen levels, until it became too much to bear, and he presented for treatment. You can read his description of the experience in the link above.

Also, this past week I posted on my Facebook page a brief piece on a newly emergent pediatric manifestation, "hyperinflammatory shock" is what the authors of this article in The Lancet call it. It seems some kids, eight patients in this report--most of them otherwise healthy, get a generalized inflammation that can appear like Kawasaki disease or toxic shock syndrome. The New York Times reported on cases in New York, where, at the time of their article, it had caused the deaths of three kids. It's serious. These kiddos need to be in ICU. It seems to be an immune hyper-reaction, maybe related to the "cytokine storm" we've seen in adults with COVID-19 pneumonia, just with a different presentation and timing.

With these developments, is it any wonder that many people want to maintain strict limitations on travel and activity?

So California State University announced closure of campuses in the fall--and we're months from that yet. Dr. Anthony Fauci, in Senate testimony warned that the Winter of 2020-21 could be "the darkest winter in modern history."

So it must seem incredibly rash to want to open our society again! Until one starts "thinking more broadly and deeply."

Julia Marcus, a professor of population medicine at Harvard, writes in The Atlantic that "Quarantine Fatigue Is Real" and argues for "harm reducation"--a long-known theory in addictions medicine that admits that 100% adherence to abstaining from drugs or alcohol or sex is not achievable, because we are human beings, not perfectly disciplined robots. During the pandemic, the message we get is that we must adhere 100% to staying at home, not touching anyone, and so on. A lot of us have been able to sustain that, for a time. But Marcus argues that most of us cannot sustain this behavior forever, and not even for many months on end.

Marcus observes that "pandemic shaming" has become a thing, with people shaming others online --often without full context--for appearing to behave in ways that some of us think are shameworthy. I concur. I've been seeing this online as well. Why aren't those people staying safe? What's wrong with them? This has morphed into Why aren't they protecting me?

Individuals are forming opinions about what they consider "good [pandemic] behavior" and bad. Many say they base their opinions on "science"--but that neglects the fact that even the scientists have a point of view, and unrestrained by the strict rules of scientific writing, those biases can inform their public pronouncements. When Fauci warns of "the darkest winter" the image is evocative, scary, and can influence people to do what he wants: limit disease spread, limit deaths, limit stress on hospitals, and therefore achieve one kind of "good." One can't say that limiting these bad things isn't good.

But are there other "goods" that we want, and other "bads" that we wish to avoid? Perhaps. Dr. Dimitiri Christakis, director of the Center for Child Health, Behavior and Development at Seattle Children's Hospital and the editor-in-chief of JAMA Pediatrics, argues that we need to start thinking about the mental health of children, and balance that with our efforts to mitigate coronavirus, in this article at NPR. Christakis argues that social development, mental health, risk for child abuse, and risk for hunger are all increasing as the lockdowns continue and the economy crashes.

The author of the NPR piece shares examples of children who are depressed, angry, irritable, and who are starting to say things like "I don't care if I die." If I was that parent, that would certainly freak me out.

As I said, I've been seeing this tug-of-war between people who argue that we must continue strict distancing, lockdowns, and school and business closures; and people who argue that all of this is an "overreaction" or that the virus "isn't that bad" or that the "cure is worse than the disease." This is entirely expected, as people en masse tend to dichotomize issues between extreme choices, but I am thinking that these extremes are a false choice. There are others.

I'm doing ok. As a professor, I still have a well-paying job. It's not that difficult for me and my wife, a musician, to stay at home on our lovely property and wait this out. In scanning my feed on social media, I have begun to note that many of the people who argue for continued strict isolation also have the good fortune of working in the knowledge economy where they can work from home. They're still employed...or retired and thus not in danger of losing their lifestyle.

I also notice that many of the people arguing for opening up faster are people who are furloughed or laid off entirely, their jobs never-to-return. Or they're students who face declining educational and social experiences, and future financial uncertainty as the lockdowns start to push into the fall (like this student suing my employer over the spring closure--I'm not sure I disagree with him).

As I thought about what I have been seeing, I began to see that strict lockdown may be a luxury for some, a curse for others, and the inflection point of that divide seems to me related to the balance between competing goods that are individually determined and individually focused. Put another way, rather than asking "what is good for all of us? (even if that comes with risks)" we seem to be asking "what is good for me and the people in my circle?"

I think this pandemic has become an unintended emblem for our times: us against them. The "us" and the "them" simply depends on one's point of view, but in the aggregate these tiny points of view coalesce into shapeless extremes.

Between March and May, the Earth caught fire--"corona" a crown of fire around the Sun--a very apt metaphor for how swiftly and terribly the virus has overtaken us. We have to control the fire, and little fires are probably going to burn on for many months or even years. But we can't let the fire completely overtake our common sense of humanity, and the many needs that humanity requires. We have to change the conversation from "this versus that" to how can we build toward the better things for all of us--even if they aren't individually the "best" things for each of us.

Monday, April 27, 2020

Updates, and "New Normals"

Here's an update of the graph shown on April 10th, with an end date of April 26th:
Graph: Author
The growth of new "test-positive" cases of coronavirus infections has continued its trend downward to reamain consistently less than 5%. In the next graph, check out the purple line, which represents the number of new cases day by day.
Graph: Author
Note that it has been flattening out since about April 2nd. The anticipated "peak" for Pennsylvania was at that time April 15th. On that date I checked and the peak was moved to the 18th. Whatever the case, the trendline from April 10th to date is flat to slightly negative, and that means we're coming out the other side. Of course, these changes are sensitive to how much we're testing, which has gone up and down daily, but averaged about 5,200 new tests reported per day.

New Normals?
In a press conference, Dr. Deborah Birx announced that social distancing would continue through the summer. A journalist on NPR speculated that things like telehealth would become the norm, even beyond the epidemic. These bits, and more this morning just teed me off and I switched of the radio!

There were protests in a number of state capitals last week, including in Harrisburg. A minority of people want some of the restrictions to end, and for more businesses to be allowed to open as long as precautions to limit disease spread are put in place in their workplaces. Georgia has started to allow a number of social-contact businesses (eg, barbershops) to open. Most Americans, according to polls, say it's too soon to do so, and many in those opening areas plan to keep their distance from others anyway. No one ever promised that social distancing and lockdowns would stop the virus; the intent was to "flatten the curve" so as to avoid overwhelming hospitals with very sick patients.

Sweden is an experiment that studies a different approach. The BBC reports that the Swedish government has not locked the country down, rather allowed people to continue to mix, with recommendations for keeping distance, and Swedes have mostly gone along with this. The policy is broadly popular, as is the government's epidemiologist, Dr. Anders Tegnell. Sweden is in the top 20 for deaths, and most of those are very old folks in nursing homes, but the death rate is a concern to the government. It has been suggested that Sweden is seeking to improve herd immunity through this policy.

So how is this going? Here are the deaths in four countries in Europe, compared to Sweden:
Graphic: BBC
What's interesting to me is that all of these graphs appear similar, that Norway and Denmark have fewer weekly average deaths, but Britain has more--and Prime Minister Boris Johnson took a lot of heat for this, and coincidentally got COVID-19 himself!

Herd immunity is something we've all heard a lot about, and a number of folks I know have publicly mused about it. What can we expect? We don't know yet, but if the virus--SARS-CoV-2 is similar enough to its brother, SARS-CoV-1 in 2002, then immunity after exposure probably lasts about 1-3 years. So maybe it'll be more like the flu than chicken pox, which confers life long immunity. A vaccine is likely to come into the equation in the next 12-24 months.

So what's the deal with Sweden, and why are so many countries so different from them? I suggest that both the protests here in Harrisburg and elsewhere, and many people's expressed desire to continue some social distancing despite an imminent opening up of society, are two touch points for understanding what is going on.

Swedish scientists knew there was no stopping the virus, and they also knew that no matter what was done, people would die, although most of those deaths would be among people who were quite frail, and who would die of something soon in any case (flu, a bad cold, bacterial pneumonia, urinary tract infection, etc.). It's a risk-based management strategy, and to some probably seems cruel, but in fact it simply reflects the reality of the situation. It does not ignore that younger people and health care workers would also die, but it frames all of this in a context of building herd immunity. It depends on the natural tendency of individuals to avoid danger; many Swedes are exercising a complex personal calculus that includes their own risk tolerance, and they practice social distancing voluntarily for this reason. Sweden's death rate is high, but their herd immunity after this passes may exceed 50% of its population.

Interestingly, the Swedish government has allowed schools to remain open. Special needs students still get in-person services. People are out exercising, "It’s good for their physical and mental health," says Johan Carlson, head of Sweden's Public Health Agency. Their hospital beds are not full to capacity. They have not run out of ventilators. There's evidence that Sweden's economy has not been hit as hard. Shops can still do business--less business--but keeping the doors open. In short, Sweden's approach may be more sustainable and lead to less disease and death--of all kinds and all sources--than may be the case where strict lockdowns have been instituted. Time and study will tell.

From this I think it's reasonable to conclude that we could open up the country more quickly, and rely on individual risk estimation, continued, aggressive testing, contact tracing and selective quarantine to allow people to begin to transition to a real "new normal. What's that look like?

Who knows? It irritates me when journalists, policy makers, and talking heads breathlessly speculate extremes (as I mentioned above). But I think a few things are likely:

  • Some people, but by all means not all people, will decide to keep employing some distancing behaviors indefinitely. But evidence from other epidemics (Spanish flu, Ebola) don't point to people en masse giving up on handshakes, hugs, and sharing a tasty dessert. People haven't changed that much in 10,000 years.
  • Telehealth will become more common, and be better paid for, but it will not become the "new normal" since talking to a patient on the phone or via Skype is only a "second best" way to really evaluate health and disease. I speak from experience. Just because a health system decides it's more efficient to "see" patients on Zoom, doesn't mean it's a good idea. Look for a generation of lawsuits to emerge over cases that should have been seen in-person.
  • Funding for public health, disease surveillance, and stockpiles of medical gear, and calls for changes in health care system design, are likely to be demanded by the public as a means of forestalling a similar crisis in the future. We got caught with our pants down once. I doubt people want that again.
  • Tolerance for "lockdown" in the US will begin to fade very quickly in the next month, but even then individual behavior is likely to moderate what society looks and feels like to people. When, and if, we see another outbreak of this new virus in the fall or later, the response to it will be different, less intense, more modulated to local conditions, and reframed to a risk model that looks more like Sweden's. 
  • Public health scientists have become heroes of a sort, but I think that fame has led to a kind of desire to keep the power that heroism confers--maybe for the "best" of motives, but still one-sided. I don't wish to indict anyone in particular. I just understand how people are. That power will fade, because it will be moderated by other considerations: you can't keep an economy on hold forever, and at some point people will begin, on their own, to engage in the same complex decision-making that Sweden already has, and that we've seen in other parts of the world, like Africa.
I really think that the suddenness, the surprise at the numbers of deaths, and the realization that we had really neglected disease surveillance, led to what we're seeing now--and its economic fallout. So I know everyone's hungry for predictions of the future, but I would caution: be patient. Understand that we're figuring this out together, and as such we do have a voice in the conversation, and we're not just to be herded into our pens. I was neither in favor of the protests, nor was I critical of them. It's just another part of the conversation that needs to happen.

Otherwise we'll spend the next 20 years isolated in our closets, waiting for inevitable death.

Friday, April 10, 2020

How are we doing today?

According to modeling at National Public Radio yesterday (the site is here, just scroll down and click on the blue "SHOW ALL (ORDERED BY PEAK DATE))", Pennsylvania is due to peak April 15th. This accords strongly with my own data from the PA-HEALTH case website:

Graph: Author

This shows that our daily new case rate has dropped below 10% (yay). I just came from the grocery store, where most customers and about half the staff were wearing masks. Wearing masks does work to prevent the spread of influenza-like illnesses. According to the CDC "Most experts think that flu viruses spread mainly by droplets made when people with flu cough, sneeze or talk. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. Less often, a person might get flu by touching a surface or object that has flu virus on it and then touching their own mouth, nose, or possibly their eyes." This reach extends about 6 feet. (Hence, all the yellow tape marks 6 feet apart on the store's floor!)

However, with the novel coronavirus, this is less clear. The World Health Organization still lists this virus as being spread by droplets and contact. They are aware of some studies that suggest it can be breathed out, even while talking, but also note that this research is still in progress and is not conclusive, and they stress that personal protective equipment is in short supply, so masking by ordinary folks might not be a good use of that PPE.

Of course, the directive from the Governor's Office that all people should mask reflects the thinking that "Well what if is does turn out to be airborne? Why not be careful?" Urging people to "make their own" masks--sewing them, or wearing scarves or bandannas--addresses the PPE issue. The idea is not to be protected from inhaling COVID-19, rather to avoid breathing it out.

My graph above displays a consistent decline in new cases since the outbreak began and some precautions were started, and a continued decline since social distancing and stay-at-home orders were rolled out. It's possible that that masking directive will lead to an even sharper decline, but it's also possible it won't.

There are several reasons for this:

  1. It's possible that most transmission is not airborne, even if some is. Statistically, it could be difficult to impossible to see this come through the numbers.
  2. It is likely that little things, like picking up things at stores, which can involve contact with stuff that settled out of the air, is a cause of transmission, but again, statistically that would be hard to see in the numbers.
  3. It may be that there isn't any airborne expression of virus, except when someone coughs or gets a COVID-19 test (which involves sticking a swab up the nose--really far!), or gets a respiratory procedure like intubation. This would mean airborne transmission mainly happens in hospitals, but not the community.

When I was out just a while ago I saw many creative masks! It's a fun way to do something that may or may not help, so why not? On the other hand, I found it hard to feel critical toward the people I saw not wearing masks. Masks can be hot. They fog people's glasses. And they aren't 100% effective in controlling the expression of very tiny aerosol particles. They are fairly ineffective at keeping those very tiny particles out.

I also think there's something else going on. I think masking creeps some people out. It visually reinforces our fear of one another. I did see a lot of fear in people's eyes in that store--both among the people wearing masks (afraid of the virus), and those not wearing masks, afraid of what we are becoming--perhaps a society of individuals, separated permanently from one another, driven by a fear of our instinctive social, "touchy" nature.

So looking ahead, I will be watching for this. Are we to become a society of germaphobes, living in fear of one another, forever bathing in sanitizer? Looking back over the last 20 years and the proliferation of germicidal hand soaps, wipes, and a commercial emphasis in TV ads on being absolutely clean, I have every reason to believe that the trauma of coronavirus on our collective mind will lead to exactly that.

Interestingly, as I have discussed elsewhere in this blog, there's good reason to suspect that this obsession with "sterile-clean" home environments has been partially responsible for the explosion of auto-immune diseases like rheumatoid arthritis, ulcerative colitis, and other conditions.

What will happen? Too soon to tell...but when we begin to know, you can be sure I'll be talking about it!

Do what you need to do to be comfortably safe!

Tuesday, April 7, 2020

(Another) COVID19 Update

We're not out of the woods yet.

On the other hand, there is hope. I have been compiling data from the Pennsylvania Department of Health from the first day of regular reporting, March 4th. It was the first of two days which would report no cases. The clouds were still just coming over the horizon then. Today, we had the second highest daily increase in deaths, 240, or 32.5%.

Rest their souls.

It may be darkest before the dawn, and that's what I wanted to share tonight. This is the main graph, which shows the number of total (cumulative) number of cases to date (red), cumulative deaths (orange), and the daily death rate (pink).

Figure credit: Author

The average death rate is 1.10, although today it really spiked a bit. I don't expect that to continue, but it is hard to be certain. What is encouraging is the declining upward curvature of cases. There is an interesting correlation with the graph below, which is the rate of change of new cases--or, day by day, is the number of new cases higher or lower, and how does this compare to the previous day's number?

Figure: Author

For example, March 20th and the 26th weren't so great, with pretty big spikes in new cases. Look at the trendline--the black line--from the beginning of full reports with coronavirus testing, the overall trend is for slower growth.

The first closure order was March 16th, but it was advisory, and limited in scope, and this may account for why, from March 18th to the 23rd it kind of bounced around 27%, then spiked on the 26th. The hard order for the urban counties was on that date, and then the line really starts sinking. Interesting the highest numbers are in urban parts of the state (at 155 cases and 1 death, Dauphin County doesn't quite qualify).

The message: "Social distancing" is working--although I still prefer the far sunnier "healthy distancing."

The learning: I wonder what this would look like if we had tested more aggressively? This we will only be able to speculate about using modeling after the whole thing is over.

Finally, what's this mean for all of us? It means that we're not out of the woods yet!--but there is a light over the hill. Stay strong and let's hope that we get over it soon. (And if any of you feel guilty about making an extra grocery trip just to get out of the house, take heart: we're all just human).


Monday, March 30, 2020

An Epidemic and The Psyche

Much is being made to night of this photo, and others like it, as the people of New York City gather to watch The USNS Comfort glide into New York Harbor.
Credit: New York Post
I write this because I am dismayed at the responses I've seen in the press--from Reuters to Breitbart to the Post--that these "bone headed" people are ignoring social distancing rules. I don't know how many ordinary people, who aren't internet pundits, feel.

Then I saw this on the evening news tonight, and I have to say I was moved at the spectacle of help on the way to a city that is literally (and perhaps justifiably) freaking out. Can you imagine, living in such a concentrated hub of humanity, thousands of cases, hospitals filling up. And then a white ship of hope arrives.

Hospital Ship USNS Comfort Arrives in New York | National Review
Credit: The National Review
Is it any wonder people broke out of their self-imposed isolation for a moment to welcome the help? I fear it is a peculiar disease of mankind that criticism comes easier than kindness. There has been kindness aplenty, and that feels like something healthy. This collection of masked and fearless New Yorkers is seen looking on, an old man grasping the barrier as if he were looking out of prison bars. 

I don't know. I just couldn't muster up any criticism of these people, clutched in this malignant grasp.
Hospital Ship USNS Comfort Arrives In New York To Ease Coronavirus ...
Credit: WBFO

The Pandemic, So Far

Speaking of malignant forces, how's this virus doing? I have reviewed the statistics from various locales and so far there is a consistent 1 to 1.4% mortality rate. There are outliers like Italy and Louisiana, but most experience run to about 10 to 14 people in 1000 will die. This breaks down to maybe 4 people older than 80, 2 or 3 aged 65-80, maybe 1 or 2 from my age group, and the rest lightly scattered in the remaining groups. 

Of course, we still don't know how many people get the virus and never get sick. They are carriers in many cases, but how would they know when testing is in such short supply? I think once we can estimate the number of people infected but not sick, plus those plausibly afflicted and perhaps tested, the illness rate and death rates will be lower. It's the contagiousness of this thing that got us discombobulated. Contagiousness is thought of as "R-naught"--R0. I've seen R0 rates of 1.4 to 3.7--that is, one person can infect 1.4 to 3.7 people, with the average settling in at about 2.5. Now this can come down if people, don', congregate. But baseline, its R0 is higher than the flu (which we have a vaccine for, so, just sayin'). People who want to bring this thing under control want the rate to be less than 1 (then the number of cases will go down).

Social distancing is an imperfect tool to limit any epidemic. South Korea used a better tool: aggressive testing, selective quarantine, and contact tracing as a means of limiting the damage. Another shortcoming of social distancing and general area lockdowns is the social isolation it can lead to. Just because it is an imperfect tool, doesn't mean it shouldn't be used, especially if the better approaches, well let's just say it's too late for those. 

So one has to wonder: who should we really be pissed at? Our fellow, desperate citizens? Or the people who govern them? It is said that the people rule, but: leaders must lead. Our politics these days doesn't seem to lend itself to that. So the morgues get a little bit fuller, the dying die without family, we grow farther apart in both space and mind, and once again we're humbled by the power of Nature to impose her brand of reconciliation on a careless species. This can be expected to focus our attention.

Maybe the catastrophe is being pinned on the wrong culprits.  
Wash your hands and touch your face :)

Tuesday, March 24, 2020

Coronavirus Update

So it's been a while, because I teach a very intensive course until Spring Break. What better time than now to dive back into the blog?

I won't rehash the usual advice or news, since there's a constant fire hose of these all day long. I'm sure any readers of this blog are up to speed on hygiene, and of course what coronavirus is, and why people are worried about it. There's a lot of speculation out there: When will it peak? When will it decline? How many people may die of COVID-19? When can we go back to back to "normal" (whatever that ends up looking like)? But speculation is mostly a waste of time. Most experts will be wrong, either by a lot of a little. A few will say they "called it," but mostly they'll have just gotten lucky.

If it sounds like I'm a bit jaded by this experience, I am. In the middle of the chaos, there's no time to ask the deeper questions that need to be asked. Those deeper questions are what interest me the most, though, perhaps because I am only mildly inconvenienced by this catastrophe. There are many folks who are a lot worse off than just "inconvenienced," so I've mostly kept my thoughts to myself.

So, in no particular order, I'll go ahead. Perhaps it's time to share.

The Silence of an Early Spring
This was the parking lot at Target. On a Tuesday. At 11 AM.
Credit: Author
My spouse desperately need a new computer in order to teach from home, so we went forth. Nothing available. Here's what we found inside, at the Starbucks entrance inside Target.

Credit: Author
This is certainly the most closed down we've been since 9-11. Maybe more so. So far it's been difficult for people, but I haven't heard about any adverse health effects, such as suicides, homicides, relapse of depression, violence, or health problems directly attributable to the closing down of America. Perhaps my readers have, and perhaps I'm not paying enough attention. I am hearing about a lot of people turned away from hospitals, ERs, and doctors' offices because of the perception--I think--that it's just too risky to do your job in a time like this. 

The counter-argument: It is too risky to see anyone but the sickest COVID-19 patients right now!

But it isn't.

According to NPR, a Dutch researcher found that many health care workers were already infected with the novel coronavirus. So a lot us may already have had it--and not known it. No symptoms. Yet it's changing how we work. Just today a colleague of mine had to take her husband back to the hospital for readmission, because he was discharged--just days ago--"too soon" with a major kidney problem, because of the collective organizational worry about what's coming. 

I get it: How bad can it get? is the question that troubles hospitals, who are trying to create capacity for anticipated thousands of very sick patients, even though these acute shortages are only being really being seen in major cities. In the rest of Pennsylvania, the numbers suggest that while growth is geometric, some of this owes to increased testing. Deaths remain modest, with 6 out of 644 cases as of 2 PM Monday (most in the Philadelphia area), 1%, twice the rate death from the flu, but the flu has caused 128,000 cases and 100 deaths in Pennsylvania so far, and the season isn't over yet

So one question that I look forward to answering after we all head back to the Starbucks, when this is over, will be: What was it about this thing made it seem like a coming apocalypse? We don't take flu, or tuberculosis, or HIV seriously enough to devote efforts to limit their spread (or we'd already have enough masks and gloves in a stockpile somewhere). Why this?


This is an antimalarial drug, but it's also used for autoimmune diseases like lupus and rheumatoid arthritis. A nationwide shortage of the drug now exists because prescribers are hoarding the drug for themselves and their families. I have a family member with lupus who is on this drug, and although I haven't heard from her yet, I have heard about numerous cases in which people with these serious diseases cannot get it, because it's been hoarded by the very people charged with helping the sick.

Perhaps the shortage of personal protective equipment has led to this behavior. Maybe not. Perhaps it's just self-centeredness, a doppleganger of the "self-ism" of many of our societies  in the West, in which individual "freedom" is believed to eclipse the common good.

Anyway, I found it interesting that in just a few days of this behavior, several people have died from taking this drug. (The link is just a couple of the cases reported so far--maybe this will cause people to rethink taking medical advice from a real estate developer.)

If you are considering, I would not recommend it. I myself would use a homeopathic remedy--at least the cure won't kill me.

Panic Buying

Or is it something else, maybe boredom? After all, we're pretty much left with just the grocery stores for outside entertainment in the presence of others of our kind. Here's an example:

Credit: Julie Moffitt
The pasta aisle at a local supermarket. I do hope none of this ends up in a landfill when it's too stale to eat. Maybe people will donate to food banks, especially with all the unemployed now coming online.

I understand. We're freaking out. But why? Should seem obvious, one could say. Deaths, lockdowns, mysterious, invisible invaders among us (sound familiar?), and all sorts of disruption with no clear end date. If I examine the real data so far, I can conclude that we have a serious health problem on our hands that mostly afflicts people 50 and older, that it seems alarmingly contagious but modestly fatal--the vast majority live when circumstances allow, such as healthy food supplies, clean water, avoidance of well-known bad habits (In China 52% of men smoke), and exercise some healthy behaviors, the fatality rate seems a modest 1%--and will probably be lower once we have a real denominator. We don't actually know how many people even are infected with the novel coronavirus.

Today I began to wonder Did we need something to happen? Were things too easy? Were we somehow bored? Did we need "a kick in our complacency," as Jean-Luc Picard put in Star Trek?
Things were not great for a lot of people, but we were tolerating it. This communal freak out accomplishes laying bare the inequities and poverties of many parts of the world, thus to inspire better discussions about how to fix those inequities. 

I mean, people are gettin' an education about their "health insurance". Am I right?

I'm not sure that I would say that people are somehow "causing" this. But this epidemic was probably influenced by the growing power of Chinese agribusiness, which like America's, forces the less wealthy to find other means of support, when they see a market to over-exploit.

In other words: systems move as an interconnected wave. It's not possible for me to imagine that this is objective decision-making in the face of limited data; rather it is the collective psychic seizure that for a moment frames everything into such relief, it can no longer be ignored. So...
  • We should have been better prepared for this.
  • Politicians politicizing catastrophe should be publicly flogged.
  • Individuals should have been better prepared, both by equitable wealth-structures and personal effort.
  • We need to have a real conversation about what's possible and what's desirable, real soon.
So that's going to mean new discussions. I kinda hope it upends the current political stalemate. That's what I'm thinkin' about. How about you?

Special Thanks: to Julie Moffitt. I love bouncing ideas around with you. Inspiration.

UPDATE 3/25/20: COVID-19 cases in U.S. 55,000; deaths, 801. From the CDC: "CDC estimates that so far this season there have been at least 38 million flu illnesses, 390,000 hospitalizations and 23,000 deaths from flu." Context.

Tuesday, January 28, 2020

What is Dementia?

I ran across this on Facebook:

"One man turned nursing home design on its head when he created this stunning facility."*

It unsettled me. It's sad, it's hopeful. Mostly it endeared me. I have worked with many people living with dementia. Many times they seem blank, distant, unreachable. Occasionally they are irascible, combative, silly, or rude. They can be hilarious and good-natured. They can grope, throw food, or repeat the same word for hours.

They can stare at you like you are the last real person they will ever remember, just because you were there at a particular time.

I have often observed such people to display hallucinations, or speak as if to spirits, or describe the world in detail as it was 50 years ago, but to them it feels like today. I've wondered, "Is she just lucky to have such a pleasant hallucination?" when one has seen many appear to be having pretty frightening delusional experiences.

But then what is "delusional"?

Is it delusional to attempt escape of a fragile and painful body, immobile, perhaps fetid, through the agency of a flight of fancy that seems so real? Or perhaps it's an unsurprising that such a person could find themselves in a fearsome funhouse full of unfamiliar sights and sounds and strangers.

So I read this and found myself really liking the concept. Give in to the delusion. Why fight it? Too often we fight against Nature. There is no winner inasmuch as we all will die. Some believe they will go on to another life...but...why the rush? So much are we tuned into our embodiment of ourselves--our actual bodies--that it becomes hard to imagine actually leaving this mortal life. I feel that way. I like this life. This causes me to wonder if others, whose lives perhaps weren't so lucky, would actually be served by a magical delusion that seems so real.

Except when we interrupt it. Suppress its expression.

There's been a movement in geriatrics that aims at not trying to reorient our memory-challenged elders when they are having a delusion. I've seen this begin to spread in health care, and in fact our own students benefit from this research. So it's getting around. A good idea.

This gives me hope that we are really beginning to put aside our assumptions and lean into Nature. Without that lean we're just regarding things at a distance, struggling with our ignorance, and perhaps robbing people of a sort of restorative humanity they may need in their final days.


* Although I did not verify this story, it's plausible, and seems like a pretty good idea in any case.

Sunday, January 26, 2020

Is The End Of Homeopathy Near?

The short answer is "no."

Over the past couple of years the US Food and Drug Administration has been reviewing the regulations governing homeopathic medicines. Mostly they have been trying to get at the issue of new medicines marketed over-the-counter for consumers.

In general I have been supportive of these regulations, since there is evidence that homeopathic remedies, used improperly, can cause harm. It's like I tell my students:

If it's strong enough to cure you, it's strong enough to kill you.

Well, "kill" might be an overstatement. I've never seen a remedy kill anyone! But I have seen some harms, such as when people repeatedly take high potency remedies that were not carefully prescribed. Dr. Hahnemann himself wrote in the Organon of Medicine that strong remedies in high potency leave their mark on a patient. I have referred earlier to an FDA recall of Zicam because of such problems.

Lately, I've been getting a lot of hysterical email blasts from various homeopathic advocacy groups, and a few emails from patients who are alarmed by these reports, which claim the FDA is trying to gain the authority to recall homeopathic single remedies, which are used in classical homeopathy for complex, constitutional cases, acute problems, and other maladies.

This is not true. For support I'll share this very well written report from the American Association of Homeopathic Pharmacists, here in its entirety in the link. But I'll direct the reader's attention to the crux of the report, as I see it:

"AAHP also believes that the greatest existential threat to the industry today is not FDA but rather manufacturers and distributors marketing products not in compliance with current Good Manufacturing Practices [emphasis mine]."

People who access "natural medicine" are often unaware that the manufacturers of such products still live and work in a capitalist world where the object is to make money. It may be many believe they're also doing good...but, they still have to make payroll! I've talked here many times about Big Pharma and how allopathic drug makers are often corrupt, greedy, and frequently develop drugs that are expensive yet have marginal effectiveness. One must not assume that because a product is herbal or nutritional and outside of the pharmaceutical regulation system, it's "okay." In fact it is because these products are lightly regulated that nefarious intentions can lead to economic opportunism. 

If one wishes to contact the FDA about these draft regulations, one of the best things you can tell them is about the benefits of homeopathic single remedies to your health, and the importance of their continued availability. Expressing support about existing homeopathic medical practice reinforces with them that there's a constituency that values access to homeopathic single remedies.

Be well & stay warm!

Sunday, December 1, 2019

Vaping Illness Cause Found

The Centers for Disease Control has reported on the cause of vaping illness nationwide--and it confirms my original theory: a chemical contaminant.

Vitamin E acetate
From Alibaba Market Website.
Vitamin E acetate is "generally recognized as safe" (GRAS) by the US Food and Drug Administration if you consume it by mouth. It's actually pretty bad for you if you heat it up and vaporize it to be inhaled, turns out. This was known prior to the vaping illness outbreak, but I guess it wasn't known to the hundreds of basement chemists and homegrown vape-hackers cooking up juices published on internet discussion forums, or sold in the grey market through online stores. I found this at Alibaba, a China-based worldwide online seller equivalent to Amazon. It's not a substance that we can just stop selling or your vitamin E capsules would cost $100!

As I have mentioned previously, this is what happens in a market that is growing in an atmosphere of conflict between two sides. On one side you have free-market innovators aiming to make a buck and provide a low cost alternatives to tobacco use to people who either wish to quit smoking or to people who would like a safer alternative to nicotine use. Without any guidance or regulation, this vaping illness caused by a chemical made toxic by inhalation was bound to result.

I'm pretty sure that people cooking up new recipes for vape juices (like "Beer" and "Peanut Butter"--I mean really, who wants to inhale the flavor of beer?) aren't also looking to poison people to death. But absent leadership from health experts, researchers, and government agencies, what did you think was going to happen?

On the other side, you have these three players--health experts, researchers, government agencies--and basically all they have done is freak out about people getting addicted to nicotine, tried to ban flavorings, and aim to ban vaping outright. This is not productive, but it reveals the true character of many in the public health field who believe it is their right to legislate their idea of good health behavior.

Trump supporters expressing 
their views on the prospect 
of a vape-flavor ban. 
This has led to a peculiar recent political phenomenon as Trump voters began protesting an anticipated federal ban on flavored vaping products.

As I have argued previously, nicotine is not itself especially harmful. Finding this information in official medical databases isn't easy but is possible, and this article from Forbes provides a nice summary. I have also argued that, despite the fact that vaping is not completely harmless (what is harmless? breathing clean air!) it is way less harmful than smoking. So for people trying to quit using tobacco, and for those who don't intend to quit but who would like to reduce their level of harm, it is a reasonable alternative (further research may modify my stance on this, but so far, so good).

Harm reduction  is the approach to managing the instinctive human drive to seek pleasure, often from various substances such as drugs. Measures that would reduce harm in this case include a partnership between government and industry--including small-scale industry and not just Big Tobacco companies--to develop a list of safe ingredients for vape juices; enforced bans on both retail and internet sales of vaping products to young people (whether this ends up being 18 or 21 or somewhere in between); research that avoids the biases against nicotine, and against human pleasure; and perhaps a real conversation about how it is we wish to regulate adult behavior in pursuit of pleasure.

No matter how you feel about the President, he is paying attention to the wishes of a lot of ordinary people, and he seems to understand this libertarian streak, as the ban has been placed on hold for now. It is reasonable to ban behaviors that place the public at great risk, especially when that risk extends to people who don't wish to engage in a behavior but are affected by it. Think, the ban on civilian use of hand grenades, or tightly regulating highly addictive drugs like morphine that can be dangerous even to bystanders when mis-used.

It is reasonable to enforce a ban on children having access to dangerous products-of-pleasure, such as alcohol or the free use of motor vehicles. Kids need time to grow into effective decision-making. It is reasonable to require warnings, or training, or licensure for things that can wreck society around us. But it's not reasonable to pass rules that only satisfy a particular, scolding constituency, or create a more dangerous black market, or end up hampering a potentially harm-reducing phenomenon like vaping.

One might argue about the public health costs of vaping, but I would note that we don't yet know what the costs are and indeed, the benefits in reduced combustible tobacco use might outweigh the less costly harms of vaping. We just don't know yet, so why assume? Furthermore, we must admit that there are cultural and political dimensions that come with evaluating vaping,  because these are the same dimensions that come with considerations of alcohol, tobacco, and now marijuana. On a scale of known harms, alcohol is more harmful than vaping, at least the preliminary evidence strongly suggests. We tried banning alcohol. See where that got us? We need a more honest discussion in our society about personal responsibility, community responsibility, and human nature. This discussion wouldn't focus on a "yes/no" or "us versus them" polarity. Rather, it should be willing to admit human prerogatives in a free society, the limitations of assigning a monetary value to every human decision, and the fact that people aren't perfect, not can we make their lives "perfect"--if we even know what that would be.

Sorry it was so long in writing--it's been a pretty busy semester--but Thanksgiving break has provided a window for me to catch up. So let's all give thanks at this giving time of year.

And now, I'm going to give my students their grades

Sunday, September 29, 2019

Vaping Illness Update

This matters to me because I have found evidence--both in my clinic and in the scientific research (mostly from Britain)--that vaping is 1) less toxic than smoked tobacco, and 2) a means of achieving harm reduction in smokers.

Most people have heard about the 800+ Americans who have suffered from a mysterious lung illness, a kind of pneumonia that doesn't appear to be caused by some germ. It's an "inflammatory pneumonia" and some who have it have gotten so ill they've ended up on breathing machines, and a few have even died. The FDA and Centers for Disease Control have suggested that--until a cause can be found--vaping should be avoided.

What is vaping?  
A vape-pen and vape liquids.
Photo: U.S. Dept. of Defense.

For the unfamiliar, "vaping" is the use of electric vaporizers to heat a liquid so that the resulting vapor can be inhaled. "Vape juice" is usually based on some combination of vegetable glycerin and propylene glycol, a sugar alcohol, and this somewhat thickened base mixture is then flavored to recreate flavor experiences like "tobacco", "cigar", or novel flavor profiles like fruits or candies, or spiced profiles like menthol or clove. Vaping began with nicotine added to recreate the drug experience that tobaccos users seek, but in short order it was obvious that other drugs could be added, mainly THC from marijuana, to create a smokeless product, without the tars, carcinogens, and carbon monoxide of actual smoking.

History and Use

Tobacco smoking has been in decline for the last few decades. Smoking's out of fashion. So-called "e-cigarettes" were developed about two decades ago but never caught on. With time, the technology got better and e-cigs started to gain traction among consumers. Some used them as a some-time alternative to cigarettes. Some used them as a transition to quit. Others tied them but went back to tobacco. In the last 5 to 7 years their use has grown, especially among teenagers, who are attracted to the flavors (examples: "bubblegum" "pina colada" etc.) and then get hooked on the nicotine.

A lot of people don't know that vaping can be done without nicotine added. But then you ask, "why would anyone do that?" It's simple: it's an activity. It's a thing people can do together--sit around and puff out vaporous clouds, clouds that taste like cherry syrup or cinnamon donuts or Froot-Loops!

There's evidence that nicotine isn't great for teenage brains. And really, is 16 old enough to start making decisions about trying addictive substances? So there's one problem: regulation and control of the industry. But then there's a flip side. With more regulation and control, an industry consolidates, and when it does, it tends to be big players with lots of money who dominate, forcing consumers into a narrower array of product choices, and encouraging others to black market products that are cheaper, or that come in flavors and such that the big companies don't produce.

Public Health England, a research group in the UK, reported that e-cigs/vaping was 95% safer than smoking and could help smokers quit. The researchers admit that data are preliminary, but enough has been accumulated to make some early arguments that vaping should continue to exist and that it should be regulated for safety.

So What's the Problem?

Over the last several months, as doctors started to notice these weird cases of lung disease and their connection to vaping, reports mounted, leading to public health investigations. This article from Buzzfeed News in September suggests the 5 best theories that explain the current crisis. In reporting from the CDC we're now up to just over 800 cases and no single factor explains them all. The CDC has seemed to focus heavily on accounting for the active drug, and THC vaping has been implicated in over 3/4ths  of cases. However no single flavor, drug, or brand is marked in all cases.

My own theory? I think it's a contaminated or poor-quality ingredient, and researchers have reported that vitamin E acetate has been found in a very high number of the suspect vape juices they tested. Maybe heating up vitamin E acetate and getting it into one's lungs is a problem. What hasn't been reported on yet is how heavily the people afflicted with this illness vaped. I also wonder if it's a combination of factors.

After all, Americans have been vaping for over a decade. Millions have done this, and we're only really seeing this critical mass of cases now? Why doesn't smoking cause this illness? Is it that some people may be genetically predisposed to suffer from vaping illness? There is a gene group that could explain this, and it's one we've known a little about for a long time, but in the last five years we know a lot more about it. Is it the unregulated market? The internet is full of recipes for vape juices, and the ingredients are largely uncontrolled chemicals such a glycerin and propylene glycol, both used widely in foods and pharmaceuticals. Isn't it possible that with the vast array of do-it-yourselfers and entrepreneurs out there, and the equally vast array of ingredient sources, and the near-limitless combination of possible ingredients--both drug and flavoring--that there would be an outbreak of illness from contamination at some point?

What to do?

For many of my readers, this may not be an issue. A lot of my patients and readers don't smoke and don't vape. But what if you are a smoker and wish to vape to reduce or eliminate your dependence on cigarettes? What if you quit tobacco, but are habituated on vaping? Well, first off, the percentage of cases in the overall number of people who vape is small. Reputable products from above-board suppliers are causing a tiny minority of cases of vaping illness. Second, in no way is vaping as bad as smoking. If you've quit cigs but still vape, you are still far better off than if you still smoked. Third, why not use nicotine substitutes like patches or gum to wean yourself off? If you can, that's great, but vaping addresses a behavioral aspect of the habit of smoking that some people are as attracted to as the nicotine or THC itself--I hinted at this above when I noted that some people vape without any drugs in their vape juice. So if vaping satisfies that "puffing behavior"--often social or contemplative--and you would just go back to smoking cigarettes or cigars to avoid vaping illness while keeping the behavior, I think that's a bad idea.

Stay tuned, because at some point we're going to figure this out. I hope it doesn't lead to the widespread banning of vape products (it would just become a black market industry anyway, and then anything can happen!) Above I mentioned "harm reduction"--this is the drug management philosophy that argues that people are going to use drugs, no matter what. It's what we do (even if you personally don't), so why not make the thing as safe as possible? Encourage people to quit, but also give them a safer alternative to the worst effects of the use of a drug or behavior. 

Image result for how many people vape in the us
Cited in: BBC

If there are an estimated 42 million users worldwide (and the US has the vast majority of users) then this means even at now-800 cases, it still amounts to a risk of 0.0019%--or about 1 case for every 52,500 users. So the message: it's ultimately safer to not vape, but it's pretty safe compared to tobacco smoking, in which the numbers look much worse (I've noticed that acute pneumonias related to tobacco use haven't been mentioned in any of the press coverage!)

Interested in a longer discussion? From CBS News with public health expert David Abrams I share this video.

A Final Word

This article is not intended as medical advice, as all of my articles are educational in nature. If you vape and notice chest pain, increasing shortness of breath, or you require additional assistance, seek medical advice from your own provider.