Sex, Drugs, and Public Health

       One of my more memorable patients, Mrs. X, was an eighty year old woman who always arrived impeccably dressed, smelling of perfumed soap with carefully arranged hair. Her skin was smooth and almost translucent, like that of a woman twenty years younger. But I always had the sense that, beneath it, her bones were as thin and brittle as Irish crystal. She should have made wind-chime sounds when she moved.

         Irish, she was not. She allowed me to speak to her in Spanish, but her daughter – a woman of similarly classy dress and polite formality – insisted on English. She always stood close to her mother, ready to prevent any stumble or fall.

         Mrs. X’s problem was her lungs – slowly failing, increasingly limiting. But when I asked a specific question about that in her past medical history, the patient suddenly fell silent. Her daughter straightened in her chair. Felt like a rattlesnake coiling.

         “That has nothing to do with my mother’s problems.” A warning.

         After three or four visits, my clumsy Spanish (or something else) led to her story leaking out. Mrs. X had been diagnosed with tuberculosis in her 20’s. “They” came to her house and took her away. Away from her husband and children. Up into the mountains outside Mariposa to a place called Ahwahnee where they kept her captive for several years. They said it was to protect her children and community. She cried daily over losing so much time with her children during those years.

TB is a disease I know more thoroughly than any other. I was in charge of TB control in Merced for ten years and was president of California’s TB Controllers for a while. In the era of Mrs. X’s illness – the 1940’s and 50’s, there were not yet available medicines against TB. There were some therapies – several too bizarre and irrelevant to discuss here – but cold, clean mountain air was considered necessary to the cure. Thus the nation-wide system of Sanatoria like Ahwahnee, frequently located in dry climates, with houses for the patients and medical staff, a hospital, kitchen, dining room and a school for children with TB.

         The only tools at the time to prevent its spread and to protect others from this disabling and often fatal disease were Public Health measures. This included removing infectious patients from the community. A loss of individual freedom? Absolutely. But the public demanded protection. And  if we allow contagious people to wander free among us, we have impaired a much larger number of people’s Freedom – freedom from disease.

         Mrs. X was one of the lucky ones. She survived the disease into the era when we could give her anti-TB drugs and she returned home to her family. But more was scarred in her than her lungs.

         A parallel story was that of an Irish cook who worked for many families in the New York city area. She always left to find another job when typhoid fever broke out in the home. Once Public Health authorities identified her as the common variable in each outbreak, she was hospitalized. She had refused to give specimens for exam, so the hospitalization was involuntary. Specimens from her proved to be teeming with typhoid bacteria. She refused to co-operate with medical folks, escaped, and was responsible for the infection (and several deaths) of more people. Eventually Typhoid Mary was tracked down and isolated for the remainder of her life – the only remedy available in those days to protect the public.

         Protecting the Public’s Health does, sometimes, require limiting some individuals’ “Freedom.” Restaurant owners are not “free” to serve contaminated food. People with untreated Whooping Cough are not “free” to go to school or to wander thru the grocery store.

         You want your physician to do everything he / she can to keep you well.  For Public Heath physicians, the Community is the patient, and believe me, that patient wants the same consideration. Public Health officials and the laws giving them Police Powers exist because people want to be protected from individuals who pose a threat to their health.

The point? Making the minimal adjustment in our lives to wear a face covering and maintain distance when we’re in public is NOT an impingement of “Freedom.” It’s not at all similar to being isolated in a sanatorium or to spending the rest of your life at a facility on an island near New York. But refusing to do these simple things impairs everyone else’s Freedom from disease. We’re seeing the results of refusing to wear masks and distance now as Covid case numbers skyrocket. As morgues overflow. As ICU’s get packed. As Health Care Workers die.

Public Health has not exercised its full power to contain this epidemic in this country, hoping people would do the right thing when given accurate information. Eventually, the Public may demand such action.

As Mariposa says, almost every day on Facebook, “wear the f-ing mask!”

QUESTIONS:

         Is there a problem in the hospitals?

                  Remember “Flatten the Curve?” (After Thanksgiving, I could probably flatten it just by sitting on it). Now rural areas, previously only minimally impacted, are experiencing big outbreaks. Check out the Dakotas, Wyoming, Minnesota and New Mexico. Heck, check out Mariposa County. ICU’s are full in many areas. Morgues are overflowing, requiring the use of refrigerated trucks. Over 1700 Health Care Workers have died in the U.S. We’re running out of people to care for the most seriously ill. Some hospitals are preparing to triage: to decide which patients get ICU level care, based on available staff and equipment. Some people who need such care won’t get it because we’ve overwhelmed the hospitals with our irresponsible behavior.

         The curve is not flat.

         Wear the f-ing mask!

         Do masks really work?

                  The state of Kansas ran a real-world (but accidental) study.

         Multiple other studies, worldwide, have proven the same.  Masks reduce the spread of droplets which contain viruses and they reduce the inhalation of them, also.

         Why do some do just fine and others end up in the ICU?

                  Do you recall the nickname for Covid generated by Millennials in the Bay Area? “The Boomer Remover.”

         Ouch.

         But also, misleading. Kids get sick from Covid. Die from Covid. Not as often as older folks or people with pre-existing conditions, but here’s what we are learning: scientists recently reported finding antibodies in a significant percentage of the most seriously ill. These antibodies attacked the body’s own Interferon – a crucial part of the immune system, weakening the immune response. These are much more common in males (of all ages). Among women with Covid, there is a higher percentage of the “Long Covid” syndrome we discussed last month.  So we’re finding that genetics plays a role. That will help us identify people at risk for serious complications, improving treatment.

         Also, pre-existing conditions that increase the severity of disease are not confined to adults. In Mariposa County, 26% of seventh graders were reported to be overweight or obese per the State and 29% of those in grades 11 – 12 were smokers.

         We’re probably more susceptible to Covid here than we think. And a misplaced concept of “Freedom” is no excuse for jeopardizing the community. So – – –

         Wear the f-ing mask!