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.

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!

 

        

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.

 

            February. The height of summer. A snowflake drifts down to land on Earth’s largest desert. He is joined, slowly, by dozens of others. They accumulate to hundreds and, over time, to trillions. Our snowflake and the air around him is buried beneath the trillions of others and crushed into an ice crystal with trapped air.

            He becomes part of the vast dome of ice that covers Antarctica’s mountains and active volcanos. An ice sheet up to three miles thick, composed of snowflakes millions years old.

             Someone decides to ask that little snowflake a question, so they drill deep into the dome and pull out a cylinder of ice and trapped air. Like reading the rings of a tree, researchers can discover the snow’s age at various depths, and the amount of carbon dioxide in the air at the time it fell. Readings now go back 800,000 years, which helps us understand the cycles of cooling and warming: periods of glaciation and inter-glacial periods of warming caused by increased carbon dioxide in the air at the time.

            These readings are a big part of why researchers are so worried about what’s going on now, as wildfires of California grow bigger and more frequent. And as hurricanes become more fierce.

            Carbon dioxide levels fluctuated from 180 PPM (glacial periods) to as high as 290 (warm periods) in eight cycles since 800,000 years ago. Current CO2 levels have soared to 414. Much higher than documented for hundreds of thousands of years before our industrialized society existed. The associated warming is melting Antarctic glaciers faster (my daughter and I saw this), thawing the northern permafrost and setting heat records (104 degrees in Siberia this year).

            What evidence for this do we see in Mariposa County?

            Cal-Fire reports that, of the 20 largest fires going back to 1932, 17 have occurred since 2000. The Second and Third largest are burning right now. Veteran firefighters say that the speed and ferocity with which our current fire complexes have spread is unprecedented.

            Fire season is becoming longer. Summer lightning storms ignite drier fuels as temperatures rise (a record set in Death Valley this month). It is so dry that previously burned areas are burning again, sooner than expected. Fires in and around Yosemite impact our economy. As mentioned last month, fire insurance is getting harder to obtain. And water is increasingly more rare and valuable, especially to the Central Valley. They may start eyeing foothill water.

              The rapidly changing climate is also bringing humans and wildlife into closer proximity. Grazing deer and turkeys may be cute, but mosquitos carry diseases. And Covid, we believe, came from wildlife.

             Bottom line – Climate Change is a massive Public Health problem. Which will attack our health and, like Covid, is only beginning to show all its impacts on us.

 

Precautionary Principle:  Even if you choose to believe that this is just part of a natural cycle, we DO have the power to slow down its rampant destruction.

 

 

                                                                                                                                  (photo by Sarah Mosher)

            The Virus, happily camped out in someone’s respiratory tract, gets dislodged by a laugh. A hearty guffaw perhaps, from a guy everyone likes. A guy with a good sense of humor. The virus shoots like a circus “human cannonball” into someone else’s face. One inhalation, and the virus has a new home.

            Thereafter, like all homeowners, the virus upgrades its digs. Deeper into various organs. Begins to raise its family in a cul-de-sac of the lungs, in the heart, in the kidneys. Eventually the cops arrive in the form of various segments of the Immune System, ordering eviction. But, from what we know so far (see prior articles) this virus and the response it triggers cause damage well beyond the lungs and for a much longer time than many other viral illnesses.

              The Immune System is much more complex than most shoppers of “Immune Boosting” vitamins understand. It includes antibodies (some circulating in blood, others fixed to cells), various cells including “white” granulocytes, B-lymphocytes, T-lymphocytes, macrophages (“phage” means to eat), and several organs including the spleen, lymph nodes, bone marrow, tonsils, thymus, and some mucous membranes.

               Sometimes the Immune System we depend on for life can become over-active (shall we say “boosted?”) or mis-directed, attacking the body itself and causing disease. For instance, Rheumatoid Arthritis, Lupus, Multiple sclerosis. It’s beginning to look like this may occur as a reaction to Covid also, which is why an immune-suppressing drug like Decadron can help.

               It remains to be learned what someone becoming “re-infected” with Covid means. Very preliminary information suggests that the re-infection doesn’t cause much illness. That would be good. But is the re-infected person a risk to others by transmitting? More study is needed.

              The FDA is the agency that protects our health by making certain any new drug, medical device or vaccine meets two standards: it must be safe; it must be effective. This takes a while – at least 18 months, Dr. Fauci told us. To accomplish this for us, the FDA must remain free of political pressure. As we anxiously await the arrival of a safe, effective vaccine for Covid, danger signals are cropping up. The FDA suddenly reversed its position on using convalescent serum (other people’s antibodies) against warnings of medical experts at the National Institutes of Health. It is reported that there was political pressure to make it available as an “Emergency Use Authorization” before completing the FDA process. At this point, such plasma may be safe, but its effectiveness is unproven.

               A similar thing happened recently with the CDC. Their recommendation for widespread testing (a proven method of getting control of the outbreak which has worked in many other countries) was suddenly modified to recommend not testing asymptomatic people, even if they’ve been exposed. We know you can be infected but not yet have symptoms AND that many cases have come from exposure to such people. This about-face, which medical experts called “potentially dangerous” was reported to have been directed by “the highest authorities.” Even though the decision was walked back, a pattern of political interference was obvious.

                The approaching election is increasing pressure on politicians. The FDA’s mission is to protect the health of Americans by vetting any vaccine thoroughly. If politics contaminates the FDA for the purpose of waving a vaccine in front of voters before it has been proven safe and effective, it could not only harm individuals, but also undermine confidence in the safety of many FDA-processed drugs and vaccines. So keep a sharp eye on the events surrounding a Covid vaccine.

                  There are currently nine Covid vaccines in testing in eight countries and another nine coming on-line. The World Health Organization and some public-private partnerships are facilitating the distribution of approved vaccine to ALL people, world-wide. The only way to control a Pandemic.

                  Back to Antarctica for Good News:  a psychologist at the University of Tasmania interviewed several Antarctic scientists who’d been in cooped-up isolation on the frozen continent. They reported an early phase of frenetic activity, a second phase of enjoying the peace and free time, and a third phase of loneliness, withdrawal and fantasies of wringing necks. Nevertheless, the subjects reported that, as bad as it got, they’d go back there again.

               Why?

               Because there is a fourth phase: going thru the process of Antarctic lock-down resulted in positive personal growth. After the trauma of it, men reported becoming less insular, more willing to request help. Women became more self-confident. Interpersonal relationships improved.

               Chief among the reported effects were “a feeling of self-reliance,”  “I developed new interests” and “I discovered that I am stronger than I thought I was.” Some reported a Spiritual / Existential change such as “I have greater clarity about life’s meaning” “I feel more connected with all of existence” and “I have a stronger religious faith.” Moreover, this positive growth was long-term – perhaps, permanent.

            Food for Thought Time:

1. Extrapolating to our Covid isolation, could we be approaching the phase of Personal Growth? A growth which, as with Antarctic scientists and astronauts on the space station, may be long-lasting. It’s certainly likely that the way we work, shop and go to school will be different. Will it be better?

2. Why do few people squawk at Mandatory Evacuation Orders during a fire, but many foment rebellion when asked to cover their faces to protect their families and neighbors?

3. If someone mingles in a public place (grocery store, Post Office, Farmer’s Market) with no face covering because of “medical reasons” are they less of a risk to you than a mask-less person who has no “medical reasons?”

 

         The phone jangles me up from some pleasant dream. The nurse in the Emergency Room has a man with chest pain and an abnormal EKG. At that time, we community physicians covered the E R for the hospital, so I get up, tip-toe from the bedroom, get dressed, and drive down.

         The guy is very uncomfortable, sweating and scared. His wife, a thin, angry-looking person, scowls from a corner. I explain to them that it could well be a heart attack and he’ll need to stay in the hospital.

         She interrupts me with words like razor blades. The guy has just started a small one-person business and they can’t afford for him to stay in the hospital. She refuses to believe it’s a heart attack and insists that her husband get back to work. I’ll spare you the prolonged efforts to educate them, to warn them of bad outcomes, interrupted frequently by the wife. She marches out, her husband behind, wincing in pain, sucking air thru his teeth.

         Acute Heart Attack and signing out Against Medical Advice are a lethal pairing. Such displays of individuals in Denial making bad decisions are common in this business. But when a sizable chunk of an entire country does it, the impact is massive. Recall that in February, our national leader called criticism of his handling of the Covid epidemic a “new hoax.” A significant minority of the country has followed suit (like the man following his wife from the E R) including politicians at all levels and an angry, mis-informed portion of the populace. So, let’s see how this “hoax” is going.

         Everybody grab a crowbar and we’ll pry the top off the old Denial box.

         Wow. Look at all these countries. 195 of them. Let’s see now, where is the U.S.? Ah, right here. On the bottom. No other country has as many cases. Or as many deaths.  Pretty powerful hoax.

         What are these? Cobwebs? Drifting clouds? Oh, they’re dreams.  From Harper’s magazine:

         “Every time I picked up an item to place it in my cart, it coughed or sneezed.”

         “I began dating a wonderful woman. She was going to break up with me unless I got a decent haircut. It was impossible!”

         “A friend and I were sitting on the veranda, overlooking a big field with trees and flowers. The flowers whispered to me that we had died from the virus and would return in the spring as red flowers.”

         Awake, we may choose Denial.  But asleep, our brains know what’s really going on. Apparently, they exude Anxiety. Where did that come from?

THE PICTURE’S GETTING CLEARER:

         As we learn more each day, it currently appears that Covid comes in at least seven different flavors. (1) Asymptomatic – infected but not (yet) ill. But more than half these folks have abnormal lungs on CT scans.  (2) Long Haulers – folks who are not sick enuf for the hospital, but have headaches, “brain fog,” dizziness, fever, heart palpitations, anxiety and exhaustion for up to four months. So far. We’re still studying them. Many are young – 18 to 34 years. (3) Hypoxemia – people who don’t feel short of breath but whose oxygen levels are dangerously low.  (4) Respiratory Failure – people on ventilators  (5) Blood Coagulation Disease – strokes, heart damage, kidney damage, amputations.  (6) Pediatric Inflammatory Syndrome – resulting in critically ill children with many organs involved.  (7) Cytokine Storm – persistent fever and over-active immune system function which can be fatal.

         No wonder our Health Care Workers are burning out. Are anxious as they see their PPE supplies running low. And lots of them are getting the disease. In a study of 545 Irish nurses who became infected with Covid and “recovered,” 91% of them were still experiencing some Long Hauler symptoms for months. If you don’t die of Covid, it is nevertheless causing a lot of damage.

Certainly not “the Flu.” Not “sniffles.” Not a Hoax.

THE BIG EXPERIMENT

         Wow. Look at all those kids in our box. Your kids. Your grandkids. They’re all participating in the experiment some of our politicians want to run with schools. Thing about a Pandemic is, the disease is worldwide. Let’s see what we can learn from other countries. The most respected Medical journal in the U.S. reports that many European countries (Netherlands, Denmark, Finland, Austria) have had opened schools since April without worsening the epidemic. But with reduced class sizes and social distancing. And they didn’t open until they had already achieved low levels of transmission (fewer than two new cases per day for every 100,000 people), and they continued those control efforts. The U.S. currently is cranking out 22 new cases a day per 100,000.

         On the other side of the Great School Experiment is Israel. After opening schools in May with crowded classrooms and minimal precautions, there was a resurgence of cases.

         How could the U.S. open schools SAFELY? According to Medical and Public Health experts, it’s pretty much the same approach we need to save our exhausted and stressed Health Care Workers: close non-essential indoor workplaces, 100% compliance with personal distancing and face covering in public, widespread testing. Experts believe that, if we started this NOW, we could open schools by October, as long as we apply these same precautions in the schools.

FACE COVERING DENIERS

         Look at all those people with uncovered noses and mouths swarming over everyone else in our box. Without their Denial-driven behavior, the epidemic in the U.S. would be more controlled. Whether they realize it or not, these naked-faced folks are projecting their disdain for everyone around them: hard-working store clerks, public servants in the Post Office, their neighbors, their families, the most vulnerable among us. If 100% of humans were reasonable and considerate of others (you know, like Jesus taught), then everyone would do the right thing. Like not exceeding the speed limit (to decrease injury and death on the highways). But there are always jerks going 85, shooting for 100. That’s why society needs Highway police.

         In my Public Health experience, I’ve had patients with TB who refused to remain isolated, and carriers of typhoid who refused to stop cooking. As with the speeders, Enforcement of the laws protecting the public is sometimes needed. Many people have told me that they believe we are at that point with face-covering- refuseniks. They jeopardize others in the setting of a worsening Pandemic. The society’s health requires an agency with the appropriate training and staffing to enforce the Public Health laws.

O M G !

         What’s that coming from the bottom of our box? Looks like smoke. We dig deeper. It’s Fire! And no water to put it out.

         There are still some Deniers of the impending Climate Catastrophe, but let’s see who doesn’t deny it. “Climate Change is an urgent and growing threat to our national security, contributing to increased natural disasters, refugee flows, and conflicts over basic resources,” reported the Pentagon to Congress. In 2015. Who else? Insurance companies that analyze the increasing frequency of fires as enuf of a risk to cancel home owners’ policies. What’s your major asset (house) worth on the market without insurance? Who else? While I served as chairperson of the California Health Officers’ committee on Environmental Health, we fought the State’s grab to take control of health-related water issues. I saw State officials (who were listening to corporate farmers demanding access to more water) discuss the process of accessing data on water production of private wells in the Sierra. Connect the dots. Who else? Public Health folks who are aware of the medical impact of increasing heat, worsening storms, catastrophic fires, disease-carrying mosquitoes moving to higher altitudes, and food crop impacts of the changing climate. We are also seeing the ominously accelerating process of wild animals interacting with humans. This sets up a route for viruses to jump from animals to humans. Like, you know, Covid.

         If Covid is the Green Mamba bite to Public Health, Climate Change is the metastatic cancer attacking Public Health.

         Close that Denial box !!!

 

 

         In early 1900, a merchant ship under sail neared the Golden Gate. It was proceeding from Hawai’i and had sailed from Asia before that. As it approached, it raised a yellow flag under order of Dr. Kinyoun, Chief Quarantine Officer of the U S Marine Hospital. An order that many businessmen and women of the city detested. The ship remained at quarantine until it was determined that no one on board was ill. It docked, according to some reports, very near the outflow of Chinatown’s sewer.

         On March 6, a 41 year-old man living at a hotel at the corner of Grant and Jackson streets in Chinatown, developed a fever. His condition rapidly progressed and several of his lymph nodes swelled, and became exceedingly painful. After his death, samples from his body were sent to Kinyoun’s lab on Angel Island.

         The first case of Bubonic Plague in the U.S. was diagnosed.

         The Third Pandemic of this ancient, terrifying disease had begun in Asia in 1855. Forty-five years later, it had sailed into San Francisco harbor.

         As the disease spread, two factions broke out. The first group recognized the disease and tried to launch a control program against it. This included the City Government, City Board of Health, many physicians and the U S Marine Hospital.

         The second faction, led by the State’s Governor Gage, fought against even acknowledging that Plague was present. Besides the Governor, this group included many S F business people, some physicians who were politically aligned with Gage, and many Chinese concerned about racist attacks.

         As the disease spread, battle lines were drawn. Kinyoun’s lab confirmed that it was Plague; Gage worried about the economy, denied the diagnosis, and defamed the scientist, Kinyoun. The U S Surgeon General empaneled a commission of experts, who confirmed the diagnosis; Gage denounced the findings, closed the U C Berkeley lab to the Federal scientists, and threatened funding to the University. The Surgeon General ordered Chinatown quarantined; Chinese brought a lawsuit which, shockingly, historically, they won (14^th amendment). Cases of the disease piled up; Gage accused Kinyoun of injecting cadavers with plague to falsify deaths, censored media on the topic, launched a P R campaign calling the outbreak a “fraud,” replaced the members of the State Board of Health with his supporters, and cut funding to the City Board of Health.

         Ultimately, the Case Fatality Rate was 98%.

         Also, ultimately, Gage lost the 1902 election to an ex-Oakland mayor and physician.  Immediate reforms changed the city significantly: a Citizen’s Health Committee was formed, laws were passed, a Plague Hospital built, understanding of the mode of transmission led to a rat control program, a new sewer system was built, stables were required to have cement floors, public sanitation improved, and screening of citizens was instituted.

         By the way, Plague is still with us, endemic in the rodent population of California (including the Sierra). Some believe that might have been prevented had Gage not delayed the early control.

         Lessons for us:

1. Although we can’t eradicate it or make it disappear, we CAN control an infectious disease epidemic. Been done before and we may still have time on this one. We just need to listen to the scientists.

2. The Health Officer has “Police Powers” for a reason – in order to fulfill his / her responsibility to protect Everyone, the Health Officer educates citizens, gives guidance, and depends on them to do the right thing. But there are always a few who will rebel, act stupidly, and jeopardize everyone else. Just as we need police to enforce the speed limit so some yahoo doesn’t do 110 MPH and kill others.

3. Bacteria (like Plague) and viruses don’t care about our religion, skin color, politics, good works or evil actions. They attack the Human Family. Therefore, each person’s actions either endanger or protect that Family. What others do affects you; what you do affects others, and not just in your household.

4. There will be changes to society after a shake-up like a major pandemic (or war). Just as Plague re-made San Francisco in 1902-1904, WW II caused the creation of England’s National Health Service for all. How will our society change post-Covid?

Will we prepare ourselves for the next gigantic Public Health threat (which is already looming)?

Will we re-structure our Health Care system so everyone has access? So 24 hour Urgent Care clinics are close to even the most remote populations? So that sophisticated Medical Technology is concentrated Regionally to maximize quality? So that Tele-Medicine can bring specialists to anyone?

Will we increase work and school from home?

         Will we re-assess how we process meat?

         Will we find a way to protect our unemployed from financial ruin?

         Will we reduce the excessive consumerism we thought was “normal?”

         Will we finally see the error in the axiom that government should be run like a business? (The false-ness of this one has been obvious to me for decades as I did both – private practice and public service. They are two institutions with completely different – indeed, conflicting – goals. One tries to make a profit. The other serves people’s needs).

         Will we re-discover the value of Art?

Big Science.

         We’re learning about this new disease as we go.  Medical clinicians and researchers from all over the world are sharing their information (a normal procedure in science). From autopsies, we’ve seen that the lung damage in Covid is different from that in Influenza. It includes damage to the blood vessels that carry oxygenated blood, not just damage to the lung tissue itself.  Damage is also seen sometimes in the kidneys, liver, heart and brain.  Blood clots form and can cause strokes. And you’ve probably heard of a rare blood vessel inflammation in some children and adolescents after a bout with Covid.

         All this information helps us know the disease process better and, therefore, treat it better. We can anticipate issues that may come up in a patient rather than being surprised. It will hopefully help us develop targeted therapy and vaccine.  It’s crucial to maintain open communication among all the countries of the world so that this information can grow.

Big Numbers.

         The U.S. has 4.5% of the world’s population. All things equal, and if we had mobilized the Pandemic Response resources we built up over the last decade, we should have had no more than 4.5% of Covid cases and deaths.  That would be 265,500 cases and 16,290 deaths.  However, the truth is, we have almost seven times that.

         No country has more Covid than the U.S. even though there are other countries with more population than us. We’re Number One.

         So we have a lot of work to do.

Remember that 98 % Case Fatality Rate of Plague in San Francisco? Here’s some good news:  when Plague returned to S F in 1907 (a second wave), they were better prepared and willing to address the issue with honesty.  As a result, the Case Fatality Rate was cut in half.

We know the right things to do to control Covid. We can’t change how contagious it is, but we can slow its spread, giving Medical Scientists time to learn the disease, work on prevention, and develop therapies. With Personal Distancing, face coverings when in public, and avoiding un-necessary exposure, we can bring this disease under our control.

And let’s also begin building the post-Covid society for us, our kids, and beyond.