Sex, Drugs, and Public Health

April 2, 2021

EPIDEMIOLOGY

Filed under: Uncategorized — cbmosher @ 2:28 am

Retired !

Now what ?

Luckily, many of my patients over the years were in the same predicament cat-bird seat. So I have seen the models.

Model # one involves a couch, a TV, and lots of beer. Initially. Later, it’s lots of vodka. I’ve seen the blood tests on these folks, so – – – no.

Model # two involves cruise ships, tour guides and sunscreen. Also, vodka. But instead of taking pictures of people in foreign lands, I prefer to live with and talk to them. So, again, thanks anyway.

Model # three involves making other people’s lives better. A proven way to feel useful. But – – – Covid. What can you do for others when stuck here?  Well, step one could be De-bulking. Stop acquiring  crap  stuff  things and begin getting rid. Helps the kids with the clean-up after – – – you know.

Step two is get the mail. Chances are fair that, mask on and hand sanitizer in pocket, I’ll be stopped at the Post Office. “Hey, Doc. Can you look at this thing on my forearm?” or “Oh, Doctor. I hate to bother you, but they just diagnosed cancer and I don’t know if I should do Chemo. What do you think?” Actually, after empathizing, the correct answer to most of these situations is “get an appointment with your doctor (or a second opinion).”

Step three uses the miracle of electronic communication. Via e-mail, Zoom and What’sApp phone calls, we’ve been able to continue work with two Foundations. The Mariposa Community Foundation has helped some non-profit agencies weather the Covid –related financial impact. And another Foundation called FAKS (Functionally Active Kids) has kept some children in Guatemala and Honduras walking. Here’s a picture of Mario. 

He was born without a foot. One additional strike for a kid living in a country wracked by chronic poverty, political upheaval and violent crime. FAKS Foundation helped his family obtain a modern prosthetic at a fraction of the cost in the U.S. The result: Mario’s in school, and he’ll be able to support himself without begging. He’s even playing soccer. We’ve been able to stay in contact with Guatemala during Covid, communicating with the local Rotary club.

Step four – turns out, retirement doesn’t erase your career from your dreams or occasional, unsolicited thoughts. If I thought retirement would be Epidemiology – free, well, like some wild animal virus, it tracked me down. Those Post Office consultations have become increasingly centered on the Coronavirus. Both in individuals and in the population. Figuring out answers for a new disease involves knowledge of Medicine, of Physics and of Statistics.

Medicine – are we observing the effects of infection by a virus or of the body’s immune response?

Physics – is the virus transmitted thru the air by droplets or by aerosol?

Statistics – are the deaths we’re seeing “excess” deaths over and above the normal population death rate? Are the control measures decreasing transmission and subsequent infection?

All these aspects – and more – go into the Epidemiology of a disease. Which, by definition, is the study of the behavior of a disease within a population and its control. So, if you were asked to define the epidemiology of the new disease called Covid, how would you approach it?

  1. Count it.  Find out its frequency. For the disease of Covid, the U.S. has the highest case count in the world at over 30 million. You can also by calculate the disease’s Incidence. That is, how many people become new cases over a time period? Or how many become ill? Or die?
  2. Find the pattern. Which groups in the population are most affected by the disease? Most diseases are not distributed uniformly thru a population. Some don’t get infected. Some get infected but not ill. Some get ill and recover completely. Some get ill and remain crippled. Some die from it.
  3. Find the Determinants (AKA Risk). What causes the disease? What influences in the environment or society facilitate it? Protect a group from it? With Covid, the cause is the virus and we quickly learned that close contact, especially indoors, was a major determinant. However, medical conditions and age were also powerful determinants.
  4. Studies. With this unknown disease, we needed information. Fast. Hundreds of studies looked at virus behavior, immune response, clinical syndromes, treatments, prevention measures, vaccines, and the effectiveness of environmental / social preventive measures.
  5. Prevention. All the information generated thru Epi investigations is worth very little if it can’t point to preventive measures. Very quickly with Covid, we implemented what we learned. Face coverings. Distancing. Screening (AKA testing). Vaccination.

The other Public Health epidemic in the news has been with us longer than Covid, but flares into the headlines periodically. So let’s see how Public Health applies epidemiology to Firearm-Related (FAR) deaths.

         1. Frequency: in the U.S., the death rate from this disease is 12.2 per 100,000 per year. That’s more than any other high-income country in the world. The number of FAR deaths in 2020 was the highest in 20 years at 44,000 deaths.

         2. Pattern: the data available (there isn’t as much as we need – see “Studies” below) shows that U.S. FAR deaths include suicides, homicides and accidents. The death rates vary greatly among the states.

3. Determinants: Many people believe that having a gun close by makes you safer. A few studies (too darn few) have been done on this topic. But the clue of differences among states helps. The Rand Corporation spent two years looking at available data and found that (A) a lot more studies are needed on FAR deaths and (B) states with the most permissive policies on gun ownership had higher FAR death rates than states with more restrictive policies. Some studies have shown that households with guns suffered more FAR deaths than those without. There are more guns than people in the U.S. (120 per 100 people). No other country has such a determinant.

         D. Studies: in 1996, congress passed the Dickey Amendment which ordered the CDC to NOT spend any money on studying FAR deaths. This shut down most investigation on the issue, relying on private funding (with the potential of biased studies).

         E. Prevention: a hot topic. In spite of polls from 1990 to now showing a higher percentage of Americans favoring “gun control” than those opposing, very little action on prevention has occurred. Moreover, an Association which represents gun manufacturers is a perennial voice in legislator’s ears.

What does “gun control” mean? Should we outlaw assault weapons except for police and the official U.S. military? Should we apply testing and licensing as we do with the privilege of driving a car or truck (the cause of 38,800 deaths a year)? Should we screen for high risk individuals (those at risk for suicide, for violence, for poor anger control, for situations ripe for accidents)? Like we screen for Heart Disease, Cancer, Covid?

         As with most diseases, more studies will produce more knowledge  which leads to better decisions. If we don’t study a disease, if we don’t apply the proven principles of Public Health, if we don’t act to prevent death-causing diseases, the problem will never go away.

         Next time, it may not be someone else’s child.

March 6, 2021

The New Abnormal

Filed under: Uncategorized — cbmosher @ 3:46 pm

“Hospitals are dangerous places.”

         This observation was all the more shocking to me because of who said it: one of the best physicians I’ve ever known. He was a soft-spoken cardiologist in Fresno. Someone who, like me and all U.S. physicians, was trained in and worked in hospitals.

         Many lives have been saved (or “prolonged” if you’re philosophical) in hospitals, of course. Babies have been born there, making everyone smile. And dramatic technological advances occurred inside their walls (face transplants, limb implantation). But all of us who work in these specialized facilities know that there are also dangers. Methacillin Resistant Staph Aureus (MRSA) was initially a hospital-acquired infectious disease problem before the organism escaped into the community. That’s why we have “Infection Prevention” (the newer, gentler phrase for “Infection Control”) programs in every hospital. The U S Health Care system rumbled along, providing care when people’s medical problems had progressed to the point of being intolerant or life-threatening. Meanwhile, the system did its best to monitor for unwanted errors and institutional infections.

         Early in the U S Covid epidemic, New York was hard-hit, you may recall. There, a prestigious hospital – just a few blocks from my Med School – fitted their physicians with Go-Pro cameras. Review of the videos was alarming. Harried doctors and other staff blew right past boundaries between Covid patients and others in their frenetic work. This glaring defect in Infection Prevention was rectified when a consultant group put doors, bright warnings and a place for donning and doffing PPE between the Covid ward and the rest of the hospital.

That’s just one example of how this epidemic in the U S (still the worst outbreak in the entire world) has uncovered weaknesses in our Health Care system. And it is my hope (and many others’) that this crisis will precipitate major changes to the system that almost all of us know is dysfunctional.

         I have lived, worked in and / or seen many countries smaller and poorer than the U.S. where health care is more accessible, higher quality and far less expensive. 

Many people in the U S use Emergency Departments for primary care. This is especially true in poorer neighborhoods (where, ironically, many Health Care Workers live). Travelling from home to a hospital – sometimes a long distance – for what ends up being a 20 minute exam is horribly inefficient. Especially if the wait in the E D is five hours. During which time you could be exposed to a communicable disease.

         Lots of people figured this out during this year, and avoided the E D.  but that’s potentially dangerous too, ignoring a medical problem (chest pain? numbness?) It’s also a financial blow to the hospitals, most of which depend on their E D’s for admissions.

         So what might the “New Normal” for the U S Health Care system look like, post-Covid?

  1. A lot more telemedicine. Specialists directing care by video. Can you say “Zoom?”
  2. 911 calls may be triaged, and some calls redirected to telemedicine. Not every 911 caller needs an ambulance or even an E D visit.
  3. Extending from that, EMS responders will grow beyond radio contact to video / telemedicine, beginning triage before the patient arrives at the E D.
  4. With this enhanced pre-hospital triage, less critical patients and those you want to protect from complications like infection, will be cared for in non-hospital facilities closer to home. Childbirth could easily fit in here.
  5. These neighborhood Health Centers will also provide on-going care to Covid “Long-Haulers” whose symptoms recur and persist for months.
  6. Architectural design of these neighborhood Health Centers will include more sunlight, gardens and informal, less clinical social settings. For an example, check out “Maggie’s Centers” for cancer therapy in the U K.
  7. Higher Tech (and far more expensive) hospital care will be provided regionally. These tertiary care “motherships” will be connected to neighborhood Health Centers by telemedicine and will oversee quality of care.
  8. Hospitals will be constructed with glass doors on patient rooms, whether in the E D or on the floor. This will allow controlled air flow to prevent spread of pathogens, yet Health Care Workers will be able to see the patients at all times.
  9. Non-ICU and non-patient care rooms in the modern hospital – places like the lobby or conference rooms – will be designed to be convertible to ICU space if needed during a surge such as the Covid onslaught.
  10. Each of us will be able (if we choose) to wear health monitoring devices. Advanced Fit-Bit, as it were, which can not only monitor our health, but warn us if we are near someone with an infectious disease. This tech has already been developed for Covid.
  11.  Physicians and HCW’s will get their early training in neighborhood Health Centers, not hospitals, since this is where most will ultimately practice. Country X has been doing this for over 30 years.
  12.  Medical training will emphasize Preventive Medicine. Success in patient care will be measured by keeping patients out of the E D or hospital.
  13.  Most importantly – actually, this is critical – insurance companies will no longer be involved in financing Health Care. Which means they will no longer be ripping off 18 to 20% of your health care dollar. More money available for care. You won’t hear “your insurance won’t pay for the test your doctor ordered” anymore. We may not be able to achieve the cost efficiency of Country X (where Health Care costs are half of that in the U S, as a share of GDP), but any improvement will be good for the patients.

Covid has killed a half million Americans so far. It has crippled an estimated three million with “Long Hauler” syndrome damaging their bodies, and has been a gigantic pain in our economy and our butts. However, it has also pulled back the curtain from our dysfunctional Health Care system and has given us a once-in-a-century opportunity to re-build a better, more user-friendly system. 

I, for one, will do everything I can to see that it happens. 

What else has Covid taught us?

We’ve learned who our most essential workers are. Health Care heroes, for sure. As here in Mariposa County. But also, grocery clerks, agricultural workers, postal workers, and extended family members (now known as “teacher’s aides”).  NOT Wall Street investors, bankers, or corporate CEO’s.

Covid isolation has held up a mirror for us. Perhaps you have asked some of the same fundamental questions we explored in our 20’s. Like “what is basic and valuable in Human Nature?”

The way I wrestled with this is to compare us Humans to other animals to find what’s unique to us. My list:

  1. we can see and enjoy Beauty
  2. we can create Beauty
  3. we can feel the pleasure of Love
  4. we can feel the pain of injustice
  5. we can believe in things that are so abstract that you can’t see, hear, feel or taste them. Things like Nationhood and Money (no, that’s not “money” – it’s a piece of paper with printing on it).
  6. On the negative side, we can also believe lies. The consequences are obvious.
  7. We can convert the Beauty of animals, plants and rocks into those little pieces of paper with printing.

So how about this for the post-Covid New Normal?

  1. People leave the cement and glass world of cities to move closer to Beauty and work by electronic connection.
  2. Wi-Fi is widespread, fast and free (as in many other countries).
  3. Education is provided in significant part, by electronic connection.
  4. We will withdraw from our encroachment and destruction of the parts of this planet where animals live. And where communicable diseases await.
  5. We move rapidly from fossil-fuel based energy to renewables to enhance the Beauty and to de-rail the Climate Catastrophe (which will be MUCH bigger than Covid).

December 29, 2020

Freedom !!

Filed under: Uncategorized — cbmosher @ 8:37 am

       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.

In early July, the Governor issued a statewide mask order, but was forced to let counties opt out of it under a law limiting her emergency management powers.

 

Only 20 of the state’s 105 counties enforced the order, which required residents to wear masks in public. Those 20 counties saw half as many new coronavirus infections as the counties that did not have the mandate in place.

 

         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!

 

        

December 23, 2020

FREEDOM !!

Filed under: Uncategorized — cbmosher @ 8:19 am

 

 

            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.

In early July, the Governor issued a statewide mask order, but was forced to let counties opt out of it under a law limiting her emergency management powers.

 

Only 20 of the state’s 105 counties enforced the order, which required residents to wear masks in public. Those 20 counties saw half as many new coronavirus infections as the counties that did not have the mandate in place.

 

         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!

 

        

October 5, 2020

The Vax – Scene

Filed under: Uncategorized — cbmosher @ 4:50 am



The party was invitation only and had a theme. When everyone was comfortably seated and served beverages, the hostess passed around an ornate ceramic china bowl. Each guest took one of the small flat discs to eat.


Not mints. Not bon-bons.


These were scabs from a Smallpox victim. The Renaissance-era guests were attempting to immunize themselves from that disease with its 20 to 30 percent mortality rate. (I apologize if you’re eating dinner). This story appears in some Medical History books, but not in others, so the details may be apocryphal. But in China during the 15th century , they performed “nasal insufflation,” inhaling dried, aged, powered scabs. And in Africa, a mother would visit the house where a child was ill with the disease and tie a cloth over the child’s arm. She would return home to tie the cloth on her own child’s arm.


Such processes, called “variolation” (named for the Smallpox disease) all show that people had observed how someone who experienced a mild case would be protected later from the severe form of one of mankind’s most devastating plagues.


The name of the process changed when a physician in the late 1700’s observed that milkmaids who became ill with cowpox were protected from developing Smallpox. He scratched liquid from cowpox lesions into the arms of people, found them to be subsequently protected, and called the process “vaccination” in a nod of gratitude to the cows.


“Vaccination” worked so well over the decades that World Health Organization officials decided to attempt something historic. I saw evidence of it in South America in the early 1970’s. Even in the most remote towns of Bolivia and Paraguay, there were posters offering cash rewards for reporting a case of Smallpox. The efforts to chase down every case and vaccinate those around them was the final stage of Smallpox eradication.
For the first time in history, humans had exterminated a deadly disease.

GOOD VACCINES: following the Smallpox example, we created vaccines against viruses. Some contained killed viruses, others used attenuated (damaged) viruses. With these, we had good results against Polio, Rabies, Measles and Yellow Fever among others.


SO – SO VACCINES: due to the biology of the pathogens and of human immune systems, some vaccines only protect for a while. The Tetanus shot – a vaccine against neither viruses nor bacteria, but against the toxin that this bacteria produces – requires periodic re-vaccination. And with Flu, the virus changes so much each year that we need a new vaccine every Autumn.


DIDN’T-WORK-OUT VACCINES: over the course of six years, a friend of mine worked with Jonas Salk trying to create a vaccine for AIDS. But that never panned out. The test to see if someone is infected with HIV is detection of antibodies. Thus, the antibodies produced by the immune system just don’t kill that particular virus.


So not all vaccines are the “Silver Bullets” we hope for in Medicine.

The HIGHLY UNUSUAL RACE FOR A COVID VACCINE:
Have you ever seen a movie of the Oklahoma Land Rush? Hundreds of hopeful candidates (on horse or wagon) line up; a gunshot; people screaming, horses galloping, great billowing clouds of dust. That’s the vision that plays when I hear the term “Operation Warp Speed.” As many as twelve pharmaceutical companies are rushing to bring to market some of the more than 100 candidate vaccines being developed word-wide.


There are two masked riders galloping among them: Excitement and Skepticism.


EXCITEMENT: there’s some new technology going into this vaccine race. Let’s sort out the different approaches. You really need to know this.


1. WHOLE VIRUS: as with the historic viral vaccines, the technique is to use either attenuated live virus (none of the Covid candidates are doing this) or killed virus (the Chinese are using this).


2. SPIKE PROTEIN: the “corona” (crown) on this virus is composed of protein spikes which attach to human cells and gain entry. The virus then uses the human cell’s machinery to make babies (new viruses). Several labs are working to make vaccine from this spike protein or pieces of it, priming the immune system to attack that part on the virus as it tries to attach to a cell.


3. VIRAL VECTOR: this is interesting. Labs take a common Cold virus (Adenovirus) and splice in the genes for manufacturing the Spike protein. This “vector” virus is injected, enters human cells as it usually does, but makes coronavirus Spike protein because of the modified genetic material. The immune system then builds antibodies against the Spike. Companies using this approach include Merck, Oxford and some Chinese companies.


4. RNA / DNA VACCINES: even interestinger. The virus’ genetic material which produces the Spike protein is synthesized, then injected. No need for a vector virus. Human cells take up the genetic material and produce Spike protein for a while (until the body rejects the foreign genetic strands). Immune system responds. Names of labs using these two approaches (either DNA or RNA) you may recognize are Moderna, Pfizer and Inovio. Here are some interesting points about this new technology of vaccine manufacture:
• This avoids any accidental infection with whole virus
• The RNA vaccine requires two injections
• The RNA vaccine requires special shipping and handling
• Early results show good production of antibodies
• There have been significant side effects reported
• No RNA vaccine has yet been licensed for humans


IN GALLOPS THE SKEPTICAL RIDER:


• Antibody production from some of these (all are still in development or testing) varies from 60% to 90%. None, so far, approach 100%. Unless that changes, not everyone who gets vaccinated will be protected.


• Covid is still new. We don’t know if antibodies will, in fact, neutralize the virus and protect humans. Remember the lesson of the HIV / AIDS vaccine attempt. And if it does protect, we don’t know for how long.


• Politics # 1: China has offered a one billion dollar loan to Latin American nations to purchase and use their vaccine.


• Politics # 2: Pharmaceutical companies see an opportunity to sell their product to a large majority of the world’s population. Billions of dollars to be made. They usually want to rush such a profitable product to market. In the U.S., we have a system to protect the Public from un-safe and/or in-effective vaccines and drugs. The F.D.A. requires rigorous proof that a pharma product meets these goals. That process slows the rush to profit, protecting the Public.


But with this Covid Pandemic, those tables have turned. There has been political pressure (including pressure on the FDA) to speed up the vaccine as the election process gets underway. This is, unfortunately, undermining public confidence. Surveys report that only half the U.S. population currently states they would take the vaccine. Not enuf to attain “herd immunity” and slow the disease. In an unprecedented move on September 8, several CEO’s of Big Pharma signed a very public pledge to meet every standard before releasing a vaccine. That’s usually the FDA’s role.

• Herd Immunity: in Public Health this means a large enuf percentage of a population is immune – from either recovering from the illness or from vaccination – that the virus has a hard time finding susceptible victims and the pandemic becomes controllable. Experts estimate that this number is about 5.6 billion worldwide, 200 million in the U.S. and that manufacturing enuf vaccine, educating the public, and distribution could take years.

TAKE AWAY MESSAGE: vaccines have saved millions of lives over the centuries. We have a mechanism in place to assure safety and effectiveness (the FDA). The technology of vaccine creation is evolving with the development of Coronavirus vaccine. You need to keep a sharp eye on how this progresses to understand how to balance the value against the risk when vaccine is finally ready.
Trust the Scientists. Ignore the politicians.

QUESTIONS and ANSWERS


Q: Will a vaccine prevent me from getting infected?
A: No. The antibodies are inside you. They go to work AFTER you ge infected. Hopefully, they keep you from getting very ill.

Q: Is there anything that will prevent me from getting infected?
A: Yes. Adhering to Distancing and Face Covering guidance has been proven to work. Continue this, even after you get vaccinated. If the vaccine is 75 to 80% effective, you could be in the unlucky 20% group.

Q: How many people would die if three fully loaded 747’s crashed?
A: About the same number of people who die of Covid each day in the U.S.

Q: Where is Covid surging in the U.S?
A: Rural locations – the Dakotas, Utah, Oklahoma, Arkansas, Texas, Florida.

San Francisco has one of the lowest case rates and the
absolute lowest death rate among large American cities.

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