Play Ball

Playing Ball in 1977

Kids love to play.  Growing up, I would spend hours in the hills near our house with our neighbor friends creating all sorts of fictional worlds to conquer.  We made lean-to forts.  We had our own "Sherwood Forrest" in a lot next to our home.  We played soldiers constantly. Every pine cone was a grenade.  Tree branches became machine guns.  Our favorite was when we created our very own backyard Olympics complete with weight lifting, wrestling, high jump, races and more.  We made our own medals and sang the National Anthem. We played all the sports, all the time.

Today's kids still love to play. Their fictional worlds are more virtual. The violence that we hinted at In our games is laid out in graphic detail on the screens of today.  What saves our children is their interaction with other kids through athletics. There is a huge void in that regard right now.  It is not healthy to keep our children locked up too long. Their bodies need to move, their hearts need to pump fast and their lungs need to be expanded. It is well documented that our children are the least affected by the virus and are not likely to even become severely affected by COVID-19, let alone die from it.  Why must we restrict them so severely?

The answer of course is that they all have grandparents whose risk is so much higher.  Children are incredibly efficient germ spreaders.  They are not good hand washers.  They are still learning how to cough into their elbows and the little ones put everything into their mouths.  One of my patients came in a few years back coughing, hacking and with a fever.  I simply asked, "when did you get back from Kansas City?"  She was dumbfounded. How did I know that she had been to Kansas City?  I responded that she always got sick after visiting her grand kids.  We called it the "Kansas City Crud" from then on.

Our numbers here in St. Louis have looked pretty good, overall.  Our community quickly banded together and took the social distancing requirements seriously. Our  COVID-19 curve was absolutely flattened.  The number of the sickest patients in the hospital has been decreasing and society is starting to open back up.  One of the questions on people's mind is, "how and when do we let the kids back to play?"  In regards to the type of activities that I described above, I hope that families have been kicking their kids off the screen and out of the house to play outside all along.  I love seeing siblings out throwing a ball or just horsing around.  In regard to youth sports, I do feel that it can be done but precautions should be taken.  None of us really know the best way to do this. We have never been through such a pandemic before. The Washington University Orthopedics Department has released guidelines for resuming youth sports. (Click here to be linked.)  I feel that they are well thought out.  Some key take away messages are to stress the importance that all of us should stay at home if we have any concerning symptoms.  Sanitizing hands after contact is important.  Lastly, crowd control is key.  Spectators are much more likely to spread the disease than the participants. If we are smart we can let the kids loose and “play ball.”

A Bitter Pill

Today I went through fit testing.  No, I didn’t have to run a mile for time.  The fit test is to make sure that the N95 medical grade mask is working for my particular face.  My wife thought I was having a mask formulated just for me.  Nope, not that either.  It is to make sure the masks that we are using work for me.  Let me explain the process.

I first don this lovely head shield without a mask.  A canister is attached and a saccharine aerosol is injected inside.  Apparently, my taste buds don’t light up with this substance so instead of detecting a sweet substance, I received the alternate, bitter canister.  After determining that, yes I do taste/smell the aerosol, I cleansed my mouth and the process was repeated again but this time after donning the N-95 mask.  A larger dose of aerosol was injected into the hood and I was asked to nod up and down, then move my head side to side.  Lastly, I was asked to read a page of prose.  No bitter taste! I passed.

The aerosol is manufactured to be between 5-20 microns in diameter which matches the size of the tuberculosis bacillus as well as the SARS CoV2 virus.  If it fits well enough to keep out the bitter, it will keep out the nasty Coronavirus as well.  I felt comfortable using this mask before but now even more so.  Perhaps this was something that should have been done two months ago, but I am happy that I was able to do it now.

This whole shut down his been a bitter fit test for all of us.  Sometimes we have to go through the bitter to appreciate the sweet.  Because there have been so many who have been careful, we are now able to carefully open up.  Like a N-95 mask that protects a health care worker, our societal guidelines are protecting everyone.  May we all be fit and ready to move on to the next phase of opening back up.

Pandemic Paychecks

I read today of man in Florida who posted on Facebook that his God was stronger than any virus and there was no reason to fear.  He changed his tune when both he and his wife came down with COVID-19. He was hospitalized for two weeks. His wife is still on a ventilator and has made no improvement.  They were both self employed but the loss of their income seems insignificant to the very real struggle to just survive one more day.  The road to recovery before him is long and will be hard.  My heart aches for him and his wife.

I know of two people who showed up to work with cough, fever and shortness of breath.  The first was detected quickly and found to have COVID-19.  That person was able to be sent home rapidly but there was a very real risk of infecting many others.  The other works at a large box store.  Initially the person refused testing for COVID-19 saying that it was just a sinus infection.  Thankfully a fever was present and the employer wouldn't allow the person to come back to work until there was an evaluation. That COVID-19 test is pending but I would be surprised if it were negative.  In both instances, these two individuals needed their next paycheck to stay afloat.  Missing work, even with sick days was too big of a risk financially.

In my own office we have 20% of our staff that have been sent home, "furloughed."  We are now being encouraged to open up to seeing more patients but have fewer staff with which to do it.  As we see more patients, we actually may need more support staff to make sure we maintain appropriate distancing, keep the waiting room to a minimum number of people and screen those that come in for symptoms.  There is a tricky balance of always doing the right thing for the patient and still staying financially sound.  At the hospital, nurses are being used to cover the duties of med techs and phlebotomists who have been furloughed.  They are also being asked to care for more patients than before due to the cutbacks. 

Obviously, I am concerned about how financial stress will affect our ability to keep our patients and community safe.  That said, I am not immune to financial pressures myself.  Amidst these cut backs it was announced that the doctor's compensation system would remain unchanged.  This may sound good on the surface but we get paid according to how much we do.  If our productivity drops by 40%, our pay will drop by the same amount.  There is a lot of pressure to do more and see more, especially right now.  I am grateful that in my office the other providers and myself have agreed that we will not see older adults for routine visits during this first phase of opening up.  Acting responsibly now will pay bigger dividends than chasing a higher paycheck.

I think as a society we all are making similar choices as the economy is allowed to resume.  The financial strain cannot be oversimplified.  There are many who are hurting badly. The old saying about being penny wise and pound foolish seems to apply here.  We will all do better and be healthier by making the right decisions for all of us.  Let us cautiously move into our next phase, never being too hasty.  We all have our part and we need to play it together.

Antibody Testing

Wouldn't you love to know that you are immune to COVID-19?  For me and my colleagues this would be very valuable information. It wouldn't make me careless in my approach to taking care of patients, but it would take a lot of the fear and anxiety out of it.  I would be more apt to volunteer to work in our respiratory clinic to help spare other providers who are not immune.  I asked my partner how it would change his life.  He quickly responded that if he knew that he and his family were immune, his kids would be allowed to throw their arms around Grandma and Grandpa and give them a big hug.  Our public service workers could do their jobs easier, more safe and with less restrictions if we knew for sure that they were immune. 

The easy response is, "well let's get the antibody test done on everyone."  It sure sounds good on the surface but it is not as cut and dry as it may seem. Here are some points to consider:

1. Quality of the tests: The FDA has loosened the usual quality assessment requirements for labs to develop the test.  Those control measures have not yet all been validated. They are starting to be done now, but we are not yet sure who has the most accurate results.  

2. False negative tests: No one is advocating using this test as a means to diagnose active infection with the SARS CoV2 virus. Antibodies are developed by our immune system to fight future infections but the process takes 3-6 weeks to occur.  If blood is drawn within that time, the test may be negative but the infection may be present.  For example, if I see a patient who was stuck by a bloody needle at the hospital, I will order antibody tests for hepatitis and HIV. The reason to do so is to document whether or not that patient already has those diseases to begin with.  I will then order another test in six weeks to see if that exposure resulted in infection. Therefore, a negative test has three possible interpretations. It can indicate a new infection, an inadequate immune response or someone who has never been exposed to the virus in question. 

3. False positive tests: This is the more concerning of the scenarios.  If some has a positive test and feels that they are immune but are not, they may put themselves in higher risk situations.  In our current situation, there is concern that there could be cross reactivity to the other corona viruses that have been in the community for many years but cause mild disease.  More studies need to be done to determine the specificity of the new tests for our current strain. Until those studies are done, it does not do much good to perform the test. 

4. Experimental application. The one scenario that is currently being studied where the test will be useful is in individuals who were known to have COVID-19 and have recovered. If they have a positive antibody test, their serum might be used as a treatment for others with severe disease.  Studies are ongoing at Washington University. If anyone would like to participate, here is the contact information:

Email: IDCRU@wustl.edu or call 314-454-0058.

As much as we would all love to know our immune status to this virus, it is best to wait till more information is available. In the meantime, I protect you be being careful, just as you protect me. We are in this together. 

Influenza vs COVID

I am seeing repeated claims that the death rate for our SARS CoV2 virus is not so bad, that we have been mislead. "Really, it is no worse than influenza." “What is the big deal?” “Did we really need to shut down society?” I have been trying to think about this critically and have dug into some of the published numbers. Here are some of my thoughts on the matter.

1. Influenza comparisons. I understand the desire to compare these two viruses. Influenza is the virus with which we are more familiar and with which we have a history of pandemics. The 1918 pandemic had a far higher mortality than what we are seeing now. These is no comparison. It was felt that 40 million people died world wide from that disease. Historians looking back on that pandemic theorize that the vast majority of deaths occured due to secondary bacterial infections. It was in the days before antibiotics. Likely, if that same disease were to strike again, much fewer would die due to our enhanced ability to fight those secondary infections effectively.

That said, the comparisons being made now are not with the pandemic years but with influenza from recent years. Overall, the mortality rate from influenza has improved markedly through the 1900's due to the factors stated above. Widespread use of the influenza vaccine began in the 1980's. Repeatedly, studies have consistently shown that the vaccines save lives. I spend a considerable amount of energy every year encouraging my patients to get vaccinated.

Three years ago, the vaccine that was developed was not a good match for the strain of influenza that hit our communities. It was a busy year. Our hospitals were full. I lost at least 10 patients that year, all of which were elderly. My colleagues had similar experiences. It was not usually a direct effect of the influenza but if someone was weak from other chronic conditions such as heart disease, lung disease, etc they weren't able to have enough reserves to recover. It was a hard year. My point is that influenza should be taken seriously also.

The COVID-19 disease is not the same disease. The potential for secondary infections is present but has not been seen nearly as much. The respiratory failure that we see comes as a toxic effects from the virus itself as well as an overactive immune response that is generated. Decompensation can be precipitous.

2. Death Rates. Yes, the published death rate from COVID-19 is decreasing. This comes as no surprise at all. In the beginning of our surge in this country our testing capability was extremely limited. Only the sickest patients were being checked. As such the death rate will appear artificially high. It is now estimated that up to 20% of those infected have no symptoms at all. The more we test, the larger the denominator and the lower the mortality rate will go. This does not diminish the number of patients that flooded the hospitals in New York and nearly overwhelmed their capacity. Death rate is not the same as total number of deaths. 

Our current mortality (death) rate in the US is 25.7/100,000 people. Belgium is the worse at 77/100,00. Two countries with some of the lowest rates are South Korea and Taiwan. Their rates are 0.5/100,00 and 0.03/100,000 respectively. That is a huge difference. It is interesting that neither country completely locked down their societies. What they did do was to aggressively test, contact trace and enforce strict isolation on positive results. China too has been aggressive.  Just yesterday it was reported that Wuhan had an “outbreak” of six new cases. The government response is to test 4 million people in that region. These countries show us the way out of our mess. Unfortunately, I fear that our inferior infrastructure and our unwillingness to give up civil liberties will hinder our ability to do so.

3. "Only the good die young." Death rates vary by age. In Italy, those above 90 years old with COVID had a 10% chance of dying. Those younger than 50 have a much lower rate of death. The number of deaths reflects how heavily a certain population is infected as well. In Bergamo Italy it is estimated that 66% of the entire population has been infected with the virus. It has taken a huge toll on their elderly population. Since such a large proportion of their population has been affected they are starting to develop "herd immunity" which protects those who have yet to be exposed. In New York City, by contrast, there have been many more infections in younger people. The reason is that their population is younger. Even with a low death rate the number is high because of the high number of people in that cohort. If New York’s population were older, their situation would be even worse. Both New York and Italy stand in stark contrast to other cities, such as Los Angeles, which is estimated to only have 2% of the population infected.

It does look like the death rate for COVID-19 is higher than influenza. It certainly has a higher capacity to cause critical illness.  Even if younger people live through their illness, they may need to be hospitalized and ventilated for weeks. Personally, though I am concerned for both influenza and COVID-19, if it is left to run rampant in high risk populations, SARS CoV2 has the potential to overrun our health care systems, overwhelm our public health workers and max out the morgues. Influenza hasn't done that for a very long time.

I do agree that we can’t stay in lock down forever. The bottom line is that we can and should relax restrictions safely. Ideally it should be done in the manner we have seen in Taiwan and South Korea. We must protect the most vulnerable. Nursing homes are especially dangerous places and we will need strict guidelines for isolation for a very long time. Multigenerational homes are another potential hazard. How families act that have children and grandparents living in the same place will be crucial. As we lift restrictions we must protect ourselves and all those around us by continuing to maintain a six foot radius, liberally cleansing our hands and using masks. These measures will help regardless of which infection we are dealing with.

Coming Out of COVID

Good news from the COVID count this morning. The St. Louis task force released the latest numbers and they are continuing to come down. After an initial plateau, seeing a definite decrease last week has been good to see. If this trend continues for the current week, society will likely start to open up more fully next week. "Life as we knew it" is not likely to ever be completely the same again. Our long term success in maintain the health of both our bodies and our economy will depend on the decisions that we make in the next few weeks. Here are some of my thoughts.

1. When and how should I access the health care system? In my office, we are seeing patients with acute problems that are best served by an evaluation in the office. In order to keep our office as safe as possible for the patients who come, anyone with respiratory symptoms are seen in an affiliated, "respiratory clinic." We are not yet seeing routine visits but will start next week by seeing those under 65 without serious medical issues. If the numbers in the community continue to come down, we'll start seeing more.
We, like other industries, are trying to rethink our usual operating policies. How do we limit the number of patients in the waiting room? How do we space out visits to reduce too many people coming together at the same time? What is the best way to draw labs? perform X-rays and other tests? We are finally figuring out how to check patients in remotely. Labs are being done by a "drive by process" at the hospital.
2. What is the best way to shop? Now those of you that know me well may laugh that I am being audacious enough to offer any such opinion. Certainly on line sales will remain robust. Curb side pick up will likely be here to stay as well. It cuts out those that like to simply browse while they shop which sounds good to me! (Sorry Mom). The bottom line is to find ways to reduce groups while still allowing commerce to happen.
3. Will we ever be able to gather again in large groups? Of course we will, but not in the short term. If 50,000 people gather in a stadium to watch a baseball game, there will be asymptomatic carriers of the virus who touch the same door knobs, use the same bathrooms as all the others. Touch-less doors will help as well as similar towel and soap dispensers. The risk will never be zero, but I can foresee it being low enough to make such events possible.
4. Can we ever expect children to truly self isolate as they go back to school? Not really, no. This is perhaps the more difficult scenario to control. It is not the kids we worry about, or even their parents, it is their grandparents. To me, the only way to move forward is to have good community testing. If we can quickly identify a hot spot, schools can be shut down quickly in the area that has been identified. We have learned that on line studies can be continued. Even better is to have such good tracking so that discrete exposed families can be isolated without shutting down the whole school.

Above all else, we need to develop a culture of personal accountability and honesty. We had a patient show up to our office yesterday without an appointment who had cough, fever and shortness of breath. There is a high chance this person was infected with the virus. The patient was asked the appropriate screening questions at the front door but must not have been completely honest. Thankfully, there was no one else in the waiting room at the time and was quickly given a mask and sent to our respiratory clinic. If individuals do not stay away from gatherings when ill, our system will be overrun again. We can and should get out of this lock down but we need to do things a bit different. Let's all be strong, let's all be safe.

Mothers

While we may think that the SARS-Cov2 is the "mother of all viruses," it will have its day and life will go on.  A day like today is a good time to take a break from all things COVID and step back and remember the good things in this life and for the rich blessings we have received. Of those nothing is bigger than the love and sacrificed bestowed upon us by our mothers.  Every single one of us arrived in this life via a mother.  I will never know what it is like to carry an infant in my body, to have that living soul grow and develop inside of you.  From two cells that merge into one, it grows and develops into millions of differentiated units. Our development may be programmed by DNA but it is dependent on the environment in which we are raised at our mother's hand.

My arrival came one month earlier than planned.  This is not a big deal with today's medicine and technology but in 1966, I spent a few extra days in the hospital struggling for each breath.  My mother was not sure that I would survive.  She poured her heart out in prayer to God and has always instilled in me that my life was spared for a purpose, that my life was a gift from God.  Mom and I had the typical ups and downs that is typical but deep down, I retained that lesson instilled from my infancy.  I don't ever question her love. She has always made me feel special.

I am one of the fortunate ones to also have the loving influence of my mother-in-law. I met my wife in my first year of college.  I left for two years to serve as a missionary for my church and on returning, I planned a trip to St. Louis to meet this cute girl and her family.  Another boy who was interested in her caught wind of my trip and sent a dozen roses to her home the day before I arrived.  Gina's mother promptly took those roses and threw them away even before Gina saw them! If that wasn't a clear sign that this was a family I wanted to be a part of, I don't know what was.  She has accepted me as one of her one from day one.  We have been fortunate to live so close to Gina's parents through the years when we raised our children.  She taught all of them the piano.  Music has been a loving gift that will continue to live on in our family.

Thirty years ago this week, Gina and I became parents for the first time.  We were young parents for sure but we have never regretted starting our family early.  Karalee has been and continues to be such a blessing to us as have each of our children.  Watching my wife become a mother is a sacred experience.  She is a fierce protector of her brood.  She watches over them without hovering, cares for them without enabling.  All of our children learned to do their own wash, make their own lunch.  She delivers just the right mixture of self reliance while maintaining unquestionable love and devotion.  Now, seeing her as a grandma is the best.  She may have been able to say "no" to her kids but not those grand babies.  Right now we are not able to travel to see them and it is killing her.

I also would like to give a shout out to our Mother Earth.  The same world which delivers earthquakes, famines, death and disease also give us birth, blossoms, mountains, and beaches.  Sunrises and sunsets still take my breath away.  I love being outside.  I love learning about nature, biology and especially the human body.  It is all a miracle to me.  Just as I preach taking care of our human body, we also have a stewardship to care for our mother earth.

Lastly, in our theology we believe that God is our Eternal Father and that we are his children.  As such, the pattern we know on earth is mirrored in heaven.  We believe that we also have an Eternal Mother.  We know very little about her, but I am sure that she embodies all that is good, loving and caring.  I have faith that she knows about the details of our lives. My we honor all the mothers in our lives and be grateful to them all.

The Cuts Run Deep

This week is officially "Nurses and Hospitals Week."  Usually it is celebrated at the hospital with banners, a barbecue and other festivities.  Obviously, group gatherings are not appropriate right now but some sort of gesture would be nice, especially to the ones who have been on the front lines of this pandemic.  Instead, a systems wide email was sent to all BJC employees from our CEO stating that furloughs would be instituted, hiring is being frozen, construction projects will be halted, retirement matching plans will not be contributed to and executive salaries will be cut. It is the harsh reality that the very industry involved in taking care of the sickest of this pandemic is feeling the financial hurt as hard as other commercial industries.  To the credit of our CEO, he absolutely acknowledged the poor timing of this announcement.  I also credit him for sending the email and signing his own name to it.  He easily could have hid behind "an executive committee" decision as so many do. 

Our system is certainly not unique across the nation.  A recent Washington Post article outlines in detail how health systems are struggling and the effect this has on the economy as a whole.  Two large factors have been put into play:

1. Cessation of nonessential medical care. Most systems put a halt to elective procedures and services.  If a surgery can be put off a few months, it is being put off.  Therapy services are curtailed for all but the most important issues.  Dentists have been hit especially hard, having to cancel all but urgent cases.  For myself, much of what I do lies in prevention.  We are not seeing patients for their annual exams.  Routine follow up of stable conditions such as high blood pressure or diabetes is delayed or done through telemedicine visits.  Our ability to see patients using technology is great but it is a fraction of what we would normally be doing. 

2. Fear of contagion.  Patients do not want to access the healthcare system right now for obvious reasons.  They do not want to be placed in close proximity to those taking care of the sickest patients.  Anxiety is a powerful motivating stimulus.  During normal times, the fear of certain symptoms will drive people to come see me for further evaluation. During the pandemic, the fear of contagion is higher than the fear of these symptoms.  This can be especially dangerous if serious conditions such as heart failure, heart attack, stroke or other serious diseases are delayed. 

I do not cast judgement on either of these factors.  They are both very appropriate under the current situation.  It is the reality in which we must function.  For myself, I get paid looking back twelve months on the work that I have done and that is recalculated every three months.  My salary right now has not dropped but as time goes on it most certainly will and it will stay that way for well over a year.  I have much to be thankful for. Being a primary care physician who can practice telemedicine and see urgent patients, my job is safe and always will be.  My heart aches for those who will lose their job. It is expected that 20% of those in my office will be affected. 

The key for my industry as well as all others in our economy is how we open up services in such a way as to maximize health and safety of patients as well as ourselves and our staff.  It will require thinking about how we deliver care in new ways. It will also require a step wise approach.  Our medical group has proposed three phases of retuning to productivity.  The first phase is starting now.  We have essentially removed all the chairs in the waiting room. Patients will be registered possibly remotely.  When a patient comes to the office they will remain in their car until they are called up.  They are screened when they enter the building to make sure they do not have a fever or symptoms that are suggestive of COVID-19. When they enter the office, they will be taken back to the exam room immediately.  Both staff and patients are wearing masks and we make sure they leave out a side door to minimize contact with anyone coming in. 

The efficiency in which we see patients is decreased but can be supplemented by the ongoing use of telemedicine as well.  We'll need to continuously evaluate our process and make changes as needed.  It has been a very collaborative process in my office.  I am encouraged by the willingness of everyone to pitch in and help out.  I am blessed to work with an amazing group of people.  In the meantime there are too many whose livelihood have now been placed in jeopardy through no fault of their own.  I am grateful for governmental, community, religious and familial safety nets.  We must all be on the look out for those who need our help and do what we can. 

Last night I was on a roof cleaning out the gutters for a dear friend who lost her husband a few weeks ago.  Once a month in our church we have the opportunity to give an offering to help those who have fallen on hard times.  With me last night was a man who had received this type of help for his rent.  He and his wife were more than happy to give their help to this widow in return.  It was a beautiful example of a community taking care of each other.  To get through this we'll need to see and do more of this in all areas.  Coming together, we are stronger than any of us alone. 

COVID Contentions

My mind last night was greatly excited.  Just prior to going to bed, I was looking through my Facebook feed.  I am well aware that there are a wide variety of opinions to be found in its pages and I feel like I am good at skipping across radical views or positions that are meant to simply inflame.  My concern came from a fairly pervasive theme voicing the concern that the response to the COVID-19 pandemic has been overly aggressive.  I feel the strong need to share my voice from my perspective as a physician, one who has been trained to not only treat a specific patient that presents for care but to also consider the broader context of the community in which we all live.  I would like to illustrate the concerns that I have seen expressed and address each, one at a time starting with the least rational and moving to the more reasonable.

1. COVID-19 is a hoax and was invented as a political scheme from the left to make sure that Pres. Trump is not reelected.  I am not sure how to even respond to this. In medical studies, mortality is considered the ultimate “hard endpoint,” because “dead is dead.”  It is not left up to interpretation.  This is a world wide pandemic affecting all nations.  No one can “fake” this news.

2. COVID-19 is truly not worse than seasonal influenza.  The response to the virus has been manipulated for political gain.  This is the more reasonable conclusion from the first example.  I don’t buy it either.  I have seen recent claims that the CDC is reporting that the hospitalization rate is leveling off and that those over 65 have the highest rate of hospitalization, similar to the rate of such hospitalization during a high severity flu season.  I went to the CDC site and did not find evidence to support this claim. I even downloaded the whole 42 detailed summary and reviewed the whole document.  What I did find is that in the summary it says that influenza illness is tapering off and in the next sentence it says that SARS-CoV2 infections remained similar (not to influenza but to the previous week's SARS-CoV2) or decreased.  There was not anything to link those two statements.  They did include the following graph showing mortality from any respiratory condition now compared to the last two years.  It is easy to tell that the numbers are much higher currently than past years.

3. The death rate from COVID-19 is so low that it does not merit the drastic measures that are currently employed.  This argument is more of an opinion.  We all place value on life itself but also on livelihood.  Where one person may draw such a line will be different than another’s.  I just want to  make sure that the information that one is basing their conclusion on is based in fact.  Looking at the numbers here in St. Louis, projections were made as to how many cases we could expect having learned from the experience from New York, Washington State and around the world.  In the following graph the upper (gold) line is the worse case scenario if no social distancing was performed.  The lower (grey) line was the best case scenario. The light blue line is the actual cases over time.  Prior to March 30th when widespread stay at home orders were put in place, the trajectory of our cases was worse than what was being predicted in the worse case.  Since isolation mandates have been enforced the curve has indeed flattened, even more than thought possible. Though they have flattened, the number of cases has not yet clearly decreased.

This does not mean that the disease is not as severe as it was thought to be but is rather a reflection of how well the social isolation has been working.  This is exactly what we hoped would happen.  What we are doing is saving lives and is keeping the health care system from being completely overrun, which would happen in the worse case scenario.

An appropriate question is to ask, “Is this the only way to achieve the same outcome?” How can we mitigate against this virus and yet keep the country open?  I may go into this in more detail in future blog posts but the short answer is only through aggressive testing and contact tracing.  If we can effectively quarantine those who have the virus or who have been exposed to it, we don’t have to quarantine everyone else.  Until our capacity to do so is ramped up, societal closure is the only option.

4. Because of mass quarantine Measures, we are weakening our immune systems which makes the pandemic worse.  There are diseases where it makes sense to “just get it over with” so that you will be immune.  My generation’s parents routinely had “chicken pox play dates.”  Mothers would bring all of their children to the neighbor’s house so as to inoculate them all at once.  It was bad for a bit but then the family didn’t have to go through it again.  COVID-19 is not such a disease.  The mortality rate is far too high.  Also, the whole population is naive to the virus.  Everyone’s immune response will be impaired due to never having seen the virus before.  I would love to be an asymptomatic carrier who is now immune but that can’t be guaranteed.  An effective vaccine would be a game changer but that can’t be counted on.  Prevention remains our best option.

Having a difference of opinion is not a bad thing. I find myself changing my mind not infrequently. The key is that we base our opinion on the most accurate knowledge possible. I have no problem disagreeing with someone if they can sincerely tell me why they feel the way they do. I have such discussions with my patients in regards to influenza vaccination all the time. Many of them do not want to receive the vaccination. I will let them know my feelings and explain to them my reasoning. Many will then accept the vaccine. Some do not. That is all right with me as long as they understand my thought process. I am only satisfied when someone’s opinion is based on logic and accurate information.