Sex, Drugs, and Public Health

            A friend who has had a flamboyant career as a print and T V journalist over the past six decades – – – (Oh, no! Am I THAT old? Yes. Finish your thought) – – – tells the story of a well known CBS reporter’s first day on the job.

            Boss (Editor): “Does your mother love you?”
            New (Cub) Reporter: “Of course.”
            Boss: “How do you know?”
            Cub: “[?]”
            Boss: “Ask her.”
            So Cub calls his mother at home and asks her. She confirms that she does, and Cub reports back to his new boss.

            Boss: “Now you KNOW.”

            The Cub now had a FACT.

            Also decades ago, in Med School, I was trained on how to “present a case.” When asking for advice or referring a patient to another physician, we must start with the Chief Complaint. What it was that brought the patient to us initially. It should always be phrased: “the patient STATES that – – – .” Because, until the investigation is done, we don’t know the FACTS of the case. We can’t report the patient’s complaint as a medical Fact.   

            A case illustrating this “Does your mother love you?” and “patient states” search for Facts was the middle-aged man who came into the ER where I worked. He was accompanied by his wife.

            “He just has indigestion,” the wife shrilled before the guy could say anything. “He has it a lot. I told him not to bother you, Doctor. Give him some antacid and we’ll leave. He has work to do at our store.” She glared at me with eyes both icy and burning with fury. She had given me the diagnosis and an order of what to do. Her priorities, where her husband was concerned, were obvious. And terrifying.

            There followed an uncomfortable and bizarre discussion wherein it was impossible to get much info from the patient – his wife answered for him every time – and wherein the wife refused to wait outside while we cared for him.

            He was, of course, having a heart attack.

            Point is – you can’t report accurately nor make an accurate diagnosis without getting accurate Facts.  Accepting what you believe, or what someone else believes, may lead to being wrong. In some situations, that can be catastrophic.

            Public Health tools :

            In the clinical situation, my stethoscope, otoscope, EKG machine, lab tests and X-rays are crucial tools. These help me gather Facts and avoid the pitfall of accepting a diagnosis which was wrong. In Public Health, one of our best tools is statistics. I know that’s off-putting to many. After all, statistics are math. And, for many, boring. But it’s a crucial tool for quantifying Facts as Data. With Data, we can arrive at an accurate Public Health diagnosis of a population – a community. Might as well use Covid as the example.

            We are currently at a fascinating and critical turning point in the Covid pandemic. And it’s a perfect example of the long and winding road Science must travel to pursue Facts. Unfortunately, it’s also an example of flawed Public Messaging.

            On May 13, the CDC Director said that Americans who were fully vaccinated could go without masks or physical distancing in many cases, even when they are indoors or in large groups. This caused a whiplash in behavior and confusion with the Public. Many mis-interpreted the message as meaning that all restrictions were lifted. That the pandemic was over.

            While that CDC message – if correctly interpreted – was relatively accurate based on data at that moment, the virus wasn’t standing still. And now the Delta variant has shown us how wrong the Public’s mis-interpretation of the CDC’s massage has been.

            What went wrong?

            Mostly, it was our powerful desire to get back to “the way things used to be.” Not unlike our heart attack victim’s wife who wanted things to be unchanged. Or our Cub reporter who wanted to believe his mother’s love without checking the Facts.

            The Scientific Method:

            Humans have wrestled with this problem since forever. In the face of a society-upsetting disease, we want simple answers and want them quickly. Since Nature doesn’t work that way, the door is open to Quacks and Liars, as depicted in paintings of the Black Plague epidemic. You’re seeing the same thing going on right now. Not knowing how to differentiate between what’s true and what’s not can cause fear, insecurity and a tendency to follow someone who promises simple answers quickly.

            That almost never works out.

            Thus, during the Renaissance, humans developed the Scientific Method to uncover the Facts about how Nature works. You know, gravity, the sun’s daily rising, DaVinci’s vision of flying. Applies to the science of Medicine and Public Health, too. Goes like this:

1. Observation
2. Hypothesis (of how a specific thing works)
3. Test hypothesis with Studies
4. Obtain Data
5. Revise hypothesis if new observations or data crop up.

            We act on currently available Data as the best Facts we have until new information challenges the hypothesis.

            COVID’S Curveball :

            The Observation was that Covid is caused by a virus. The Hypothesis is that this virus, like almost all viruses, can be combatted by antibodies which vaccines can stimulate. Tested with studies, first during vaccine development, and now with data from millions of vaccinated people out there. Here’s some of that Data:

            Vermont is the most vaccinated population in the U S at 67.4%.  That State’s Case Rate is just 3979 per 100,000 people so far.

            Mississippi is the least vax’ed at only 34.3%. Case Rate is a whopping 11,541 per 100,000.

            Of all recently hospitalized Covid cases, 97% are un-vaccinated.

            The hypothesis has been tested in the real world. The best Facts are that vaccination works. Thus the CDC’s May 13 announcement that the Vaccinated won’t need masks.

            Oops. Along comes the Delta variant (a mutation of the original Coronavirus). Science brings new Data:

• 75% of new Coronavirus infections in Singapore are among the Vaccinated
• Massachusetts testing reported on July 4 shows that the Vaccinated shed viruses as do the Un-vaccinated.
• A study posted July 12 from China reveals that Delta has a shorter incubation time and faster replication in the body, producing up to 1200 times as many virus particles as the original virus. Explains its increased transmissibility.
• A study of the Pfizer vaccine showed effectiveness falls after six months from 96% to 84% (reported July 28).

            So, while it’s true that Un-vaccinated folks are primarily driving the pandemic, there’s more infection – and possible transmission – occurring among the Vaccinated than we previously knew. You can almost think of it as a new disease.

            The Good News is – – – vaccination is still effective against severe disease and death. Most of the cases of infection in the Vaccinated referred to in the Singapore and Massachusetts studies were found on testing in people who had no symptoms or just mild cases.

            So Science did not fail us. It did exactly what it’s designed to do – modify the hypothesis based on new Data. Now we have more Facts to drive our decisions. Thus the CDC changes its recommendations to reflect the new Facts.

            We’ve been learning about this virus at the same time as we’ve been fighting it. We’ll continue to learn new Facts as we go. The Coronavirus looks like it’s not going away anytime soon. Just because we may not like the Facts that Coronavirus hurls at us doesn’t mean we should believe the Quacks and Liars.

            Just like the Cub reporter, we have to check our beliefs against the Facts from time to time. Science will do that for us.

            And, hey. Call your mother.

         In 1890, an American cancer surgeon discovered the case of Fred Stein, a German immigrant with a rock-hard lump in his neck. It was an inoperable, malignant tumor – a sarcoma. In addition, the poor patient developed a skin infection caused by the bacterium Streptococcus. Doctors were flabbergasted when Stein’s deadly tumor disappeared after the infection. Dis-satisfied with standard treatment of malignant sarcomas at the time, the surgeon experimented on hundreds of patients with terminal, inoperable tumors, injecting bacteria or bacterial products. A large percentage of the patients showed complete tumor regression. 

         In 2017, while walking on a warm and sunny beach in Country X, I wandered away from the scattering of bikini-clad European tourists, into a cluster of palm trees. There I ran into two natives of the country who were at work with rakes and plastic bags, keeping the beach clean. After hellos, they burst into an enthusiastic expression of national pride. “Do you know about the vaccine we created? It cures cancer!”

         On a level not immediately obvious, these two events are connected. As are the Coronavirus vaccine and modern cancer treatments. Let’s dive in.

         When I entered Med School, Medical Science had progressed from Gross Anatomy (what your eyes can see in the dissection lab), down into increasingly smaller components of our bodies only visible in a microscope. And we were teetering on the verge of an exciting new, much deeper world with the electron microscope. With it, we could observe the interior of our cells in much greater detail.

         Also at that time, most cancers were considered very difficult to treat. As an example, the most common childhood cancer, Acute Lymphoblastic Leukemia (ALL), was considered incurable.

         The progress bequeathed to us by Medical Science since those days has been stunning. ALL is now curable in 90 to 95% of kids. We treat most cancers with surgery, radiation and chemotherapy. I think of these therapies as blasts from a shotgun, sometimes hitting the target of cancer, but often causing a lot of collateral damage to normal tissues. As someone once described chemo to me, “we hope to kill more cancer cells than normal cells.”

          But now, we are again teetering on the verge of an exciting revolution in both prevention of infectious diseases and in cancer treatment. This progress is due to our having gone deeper into the human body than even the electron microscope could take us. Down to the level of molecules.

         Molecules, you may recall, are the chemicals that are composed of atoms. Like water (composed of hydrogen and oxygen) or table salt (sodium and chlorine). The molecules which are the building blocks of Life are larger and mostly carbon-based. And with all the dizzying activity required to keep living organisms like us going (turning food into energy, turning an egg and sperm into a person, repairing our bodies when we damage them) there are two molecules that keep it all from descending into chaos. You know them: DNA is the keeper of all the codes that govern how the body functions; RNA is the workhorse that turns the codes into action.

         Think of DNA as a string of pearls. Each one of the pearls along the string is responsible for giving one very specific message to your body, with it’s own set of instructions. Each pearl is called a gene. This priceless string of pearls remains deep inside our cells, protected within the nucleus in the center of the cell, like a princess behind the fortress wall. RNA takes orders from the DNA by making the proteins, allowing the DNA code to be implemented for our bodies.

         Scientists can now find the exact make-up of the DNA code in our cells, and of RNA which carries out the orders. Taking that information, they have created maps of the genes. Going further, scientists can cut out certain unwanted genes or insert needed genes. We are now even able to build a piece of RNA to use to our benefit. This is “genetic engineering.” 

         You’ve already experienced it.

         Vaccines: 

         When you got a Covid test, the lab searched your nasal swab for the exact RNA in Coronavirus. And when you got the m-RNA vaccine, it consisted of a small piece of engineered RNA, made to look just like the gene which the virus uses to make the “Spike” protein on its surface. The vaccine RNA never got into the nucleus where your DNA is. Beating the virus to the punch, this RNA directed your cells to manufacture a protein identical to the “Spike” which the virus uses to infect you. The vaccine RNA was then destroyed, and your immune system began creating antibodies against this Spike protein, ready to repel the virus.

         Cancer:

         Recall that, back in Med School days, we perceived cancer as an attack of a hoard of abnormal cells that couldn’t stop multiplying. Our current concept of cancer is that it starts with a single error in the DNA of a cell. As that cell reproduces, the offspring may accumulate more errors in its genes. At some point, your immune system should recognize abnormal cells and destroy them.

         However a few abnormal cells may survive because changes in their structure helps them evade immune attack, even though the immune system has many different ways to kill cancer cells. 

         Think of this like what happened with bedbugs. The same species of this pest can be found in Florida and New York. But studies reveal that the New York bugs have quickly evolved mutations to protect them from pesticides. They are many times more resistant than their Florida cousins.

         Cancer, too, evolves, but on a microscopic scale.

         Sometimes, the immune system needs help in this fight. What we want is some sniper rifles instead of more shotguns. Well-aimed bullets instead of chemotherapy and radiation with all the collateral damage. We might be able to specifically target cancer cells by strengthening the immune system.

         Cancer Immunotherapy:

         This is the rapidly expanding field of harnessing the body’s own immune system to successfully attack a tumor. Lucky for us, tumor cells have targets on them. We start by finding the genes and molecules that cancer uses. Let’s focus on three: first, many tumors have genes that produce Tumor Antigens (molecules) which are displayed on their surfaces. A lot like Coronavirus Spike proteins on the surface of the virus. Second, scientists have found genes in tumors that control multiplication of the cells, spread of the tumor, and resistance to the Immune system. Third, tumors use various external molecules as Growth Factors. Examples include hormones that stimulate growth of prostate cancer or breast cancer.

         Knowing this, we can now help the Immune system target a tumor specifically, and reduce damage to normal cells. Here’s how:

1. One unique treatment – some have called it “a living drug” – involves incubating cancer cells with normal immune system cells (B cells) in the lab. The immune system cells make antibodies against the cancer cells. Then the gene for making these antibodies is snipped out and inserted into the patient’s own immune system T-cells (Killer cells). These T-cells are multiplied in the lab, then are injected into the patient. When they encounter cancer cells, the antibodies they carry from the lab help them recognize the target. Like well-aimed bullets, they attack and kill the cancer cells.
2. In cancers that depends on external Growth Factors, one method of reducing these is to develop a vaccine which will direct the Immune system to destroy these molecules. That’s what Country X did with its CIMA-Vax . Another approach is to use antibodies against the Growth Factor as a treatment.
3. Using bacteria in a lab, scientists are working to create RNA vaccines that can force production of Tumor Antigen. The body’s Immune system would then learn to build antibodies against that antigen to lead the attack. Pretty much like the m-RNA vaccines for Coronavirus stimulated antibody production. See how that works? 
4. Emerging information shows that some bacteria can enhance or diminish tumor growth, most likely by producing specific molecules activating the Immune system. One example currently in use is the administration of modified Tuberculosis germs into the bladder to treat bladder cancer. Immune system cells stream to the bladder to kill the TB, and then also attack the cancer. So our sarcoma doctor in the 1890’s was doing cancer Immunotherapy, even though he didn’t realize it.

         As with any scientific efforts, there will sometimes be setbacks with vaccines or cancer therapies. But the goal is always to do much more good than unintended harm.

         Science, including Medical Science, advances both by serendipitous  discoveries like the 1890 observations of our sarcoma doctor, and by building upon the foundations established by preceding scientific work. As did Country X. We are now exploring the detailed complexity of the human Immune system at the molecular and genetic level, and already reaping benefits for protection against pandemics and against many kinds of cancers.

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.

“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).

       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!