Imagine a place where school children are taught that their government rules by “the will of the people,” where government officials are chosen in “free and fair elections,” a place where Supreme Court judges are elected as non-partisan umpires of the rule of law and guardians of the people’s will. In such a place, the State of Wisconsin, I was born, brought up, and schooled. Such were the civic ideals I was taught in those Wisconsin schools.

Last week in Wisconsin the date of the important, long-scheduled April 7 primary election fell during a worsening, deadly pandemic. The state issued a stay-at-home order and closed non-essential services as of March 25 to slow the spread of the virus. As the election date approached, many poll workers, unpaid volunteers and members of a high risk group, were so scarce that in Milwaukee, Wisconsin’s largest city, there are only enough staff to open five of the usual one hundred and eighty traditional voting locations. The Elections Commission and the U.S. Post Office were so hobbled by the pandemic that many voters who requested absentee ballots didn’t received them by election day. Fearing their vote won’t be counted, these people were faced with a stark choice: expose themselves to the virus, standing for hours in long lines at the few open polling places, or stay home, stay safe–and have no voice. 

Trump issued national pandemic guidelines on March 16 “including closing schools and avoiding groups of more than 10 people.” In obvious violation of his own national guidelines, on the day of the Wisconsin election, Trump called out to his supporters in Wisconsin “Get out and vote NOW.” Why would Trump weigh in? After all, this election was mostly about the Democratic presidential contest between Joe Biden and Bernie Sanders, wasn’t it? Well, no. Mr. Trump exhorted his followers to go to the polls to vote for Wisconsin Supreme Court Judge, Daniel Kelly, a race that was mostly unnoticed except in Wisconsin. Judge Kelly was appointed by the former governor of Wisconsin, Scott Walker, in 2016, appointed to finish out the last four years of a 10 year term left vacant by retirement. Scott Walker, an abrasive Tea Party Republican elected in 2010, lost the governorship in 2018 to Tony Evers, a mild-mannered Democrat with a background in education. In this April 7th election Walker’s Trump-friendly appointee to the Wisconsin Supreme Court, Judge Kelly, was in serious jeopardy of losing to a less doctrinaire judicial candidate in a fair election. Still more telling of Trump’s and the GOP’s motivation: Judge Kelly, on April 6, the day before the election, joined the conservative majority of the court in a 4-2 decision against Governor Tony Evers’ executive effort to postpone the April 7 Wisconsin primary election to June 9, a postponement clearly in the interest of a safe and fair election. Trump’s interest in the Wisconsin Supreme Court? Wisconsin is likely a swing state in the upcoming November election. If the Wisconsin election is contested this fall (like Florida in 2000), having a partisan friend and a conservative majority on the Wisconsin Supreme Court would be pivotal. 

In the days preceding the April 7 Wisconsin Primary, with this Wisconsin Supreme Court race at the forefront, the Republicans of the Wisconsin legislature and the “Republican National Committee, et al” fought tooth and nail to keep the election on the prescribed date with no accommodations. They obtained rulings from the Wisconsin State Supreme Court, United States District Court for the Western District of Wisconsin (Judge Conley), and the U.S. Supreme Court in a case addressed, tellingly perhaps, “To the Honorable Brett M. Kavanaugh.” The RNC and Wisconsin Republicans cast aside concerns about public health, cast aside the obvious contradiction between a stay-at-home order and gatherings at polling places, and ignored any concerns these facts might silence the voice of a large part of the electorate. All the rulings that came down were made along partisan lines, conservative judges appointed by Republicans siding with the RNC and more liberal judges all dissenting. (This NYTimes article sorts it out some.)

Ruth Bader Ginzburg wrote in her dissent to the U.S. Supreme Court case, “The court’s order, I fear, will result in massive disenfranchisement. Because gathering at the polling place now poses dire health risks, an unprecedented number of Wisconsin voters — at the encouragement of public officials — have turned to voting absentee,” she wrote. “About one million more voters have requested absentee ballots in this election than in 2016. Accommodating the surge of absentee ballot requests has heavily burdened election officials, resulting in a severe backlog of ballots requested but not promptly mailed to voters.”

I am sickened and angry at Wisconsin and national Republicans’ abandonment of the common good in their pursuit of securing Republican partisan dominance. It is no secret that voters in the two main population centers of Wisconsin, Milwaukee and Madison, feel more threatened by the pandemic than are rural voters. Covid-19 cases are more prevalent in the dense populations of these urban areas than in smaller cities. It is also no secret that minority voters and Democratic voters are concentrated in these urban centers. The Republican National Committee saw an opportunity to use the threat of sickness and death to secure partisan advantage. Is there no sleazy avenue Republicans won’t go down in their quest for power? The entire Republican Party has lost its soul. 

Keep to the high ground,
Jerry

P.S. Here’s the Wisconsin electoral context: In 2010, Republicans launched the national REDMAP Project, a cynical, nation-wide, computer-aided effort to secure state and federal legislative majorities in spite of a their representing a nation-wide dwindling minority. Republicans so effectively gerrymandered Wisconsin’s state assembly districts after the 2010 census that, while they lost a majority of voters (garnering only 48.6% statewide in legislative races), they took 60% of the seats in the Wisconsin assembly. (You can see this march of minority dominance at this Ballotpedia entry under the subheading, “Historical party control.”)

In the 2018 midterm election, Wisconsin voters booted out their detestable Republican governor, Scott Walker (later a featured speaker for the Spokane Republicans of the Washington Policy Center). They replaced Walker in with a Democrat, Tony Evers, by a slim majority in the state-wide election. At the same time, thanks to the effectiveness of REDMAP gerrymandering, Republicans kept a 63 to 36 majority in the Assembly (equivalent to the “House” in other states). It is this Assembly majority that strategically planned and saw fit to challenge any change in the details of the April 7 Wisconsin Primary. 

P.P.S. Why is it that the U.S. Supreme Court will hear and pass judgement on this Wisconsin case, but refuses to hear and decide the case that might result in revealing Trump’s taxes? Just asking…

We are witness to a miserable failure of executive leadership. The Chief Executive of our federal government is responsible for an organization that should provide him (or her) with the best and broadest curated assessment of what is happening in the world and what it means. Instead, our Chief Executive, deeply suspicious of the motives of anyone with whom he disagrees, has presided over an executive branch he disdains, governing with a series of “acting” administrators he fires as soon as they utter a peep of dissent. He listens more to the guidance of the unqualified and unvetted talking heads of Fox News (the “everybody says” of many of his statements) than he listens to the qualified voices of the demeaned bureaucracy he is supposed to oversee. In contrast, as the videos referenced below vividly show, the correlation between Trump and his favorite news source, Fox News, is so close it is hard to tell who leads whom.

Remember when Representative Cathy McMorris Rodgers lauded Trump as her “positive disruptor.?” How has our Trump’s penchant for disdain and disruption played out in the ramp up of the Covid-19 pandemic?

The magnitude of pandemic threat was laid out in detail in a now viral video (23 million views) in a TED talk given by Bill Gates in 2015 in the wake of the Ebola epidemic. The Trump administration’s effort to prepare a response for future outbreaks of pandemic disease was non-existent. In May of 2018 the administration jettisoned the top White House official in charge of pandemic response and disbanded the global health security team he oversaw, presumably part of the overriding Republican/Libertarian credo to “shrink” government.

Trump’s budgets consistently threatened to cut funding for our Centers for Disease Control. Congress balked at the shrinkage, but the intention to cut and Trump’s disdain for the organization and the scientists it employs was clear.

Trump and his ragtag, shrunken, and partially blinded administration missed the early warning. The threat was already clear in early January: Read the story of Li Wenliang, the Chinese ophthalmologist in Wuhan, China, who warned his colleagues using WeChat on December 31, 2019, of a SARS-like virus cluster. His warning, intended for a limited medical audience, instead went viral on electronic media (where the U.S. should have seen it and paid attention). Li Wenliang was promptly questioned and reprimanded by the local police of the Wuhan Public Security Bureau for “making false comments on the Internet.” Tragically, Li Wenliang died of Covid-19 on February 7 at age 33 despite modern and heroic attempts to save him. His illness and death were prominent news in China. The Chinese government launched an investigation into the reprimand.

Alarm bells were clanging loudly in China even before the China CDC Weekly (the Chinese also have a CDC) published Vital Surveillances: The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020 on February 21, 2020. Click and read. It’s sobering in its clarity. Rapid person-to-person spread of Covid-19 was abundantly clear. The implications for the world should have been obvious to any functional, world-wide information gathering apparatus. Instead, on February 27th, Trump (in a White House briefing) offered ignorant reassurance, “One day it’s like a miracle, it will disappear.”  A full month later, on March 24, at a Fox News virtual town hall, Trump likened the expected impact of Covid-19 to that of the flu or automobile accidents. 

Our leader failed. He failed to nurture the information gathering culture a President needs. He failed to listen to medical opinion. He failed to understand the threat. He failed to prepare the country from what many knew was coming. He took refuge in denial of reality. He offered platitudes, not preparation.

Worse, sensing electoral danger, he and his propaganda wing, Fox News, now want to re-write history. On March 17 Trump abruptly contradicted himself, bizarrely asserting, “I felt it was a pandemic long before it was called a pandemic…. I’ve always viewed it as very serious.”

He and Fox cannot be allowed to re-write the history of their denial. Not everyone will take the time to assemble a mental timeline of the failure of the Trump/Fox News leadership. Fortunately, a video is worth thousands of words. I recommend: “Saluting the Heroes of the Coronavirus Pandumbic, The Daily Show” on Youtube or Twitter. It would be funny–if we weren’t suffering the deadly consequences of the ignorance and denial these people display.

For a shorter (ad length) chronicle of Trump’s words watch on Twitter; https://twitter.com/prioritiesUSA/status/1242193904553865216?s=20

or Youtube: https://www.youtube.com/watch?v=hl6T2XxNtM0

For a written version: https://www.factcheck.org/2020/04/trump-pence-and-reassessing-coronavirus/

The most detailed account I have read comes from the April 4th Washington Post: https://www.washingtonpost.com/national-security/2020/04/04/coronavirus-government-dysfunction/?arc404=true

No president with this absymal failure of executive and leadership deserves either trust or re-election.

Keep to the high ground,
Jerry

P.S. On the subject of Trump as a leader of our response to the pandemic, I encourage you to click and read Frank Bruni’s devastating opinion piece in the April 6, New York Times: Has Anyone Found Trump’s Soul? Anyone?

P.P.S. What else is happening while all our bandwidth is taken up with Covid-19? Click and read Noah Bookbinder’s piece, also in in the April 6 New York Times or Heather Cox Richardson’s assessment of the same events, click here.

The best treatment for uncertainty is honesty and transparency. I offer the following article in that spirit–and with the fervent hope that all who read it are able to look back weeks or months from now and say, “Phew, my family, my friends, and I dodged that one!” Many of us, including me, tend to make the very poor assumption that our fellow humans share the same understanding and experience as we do. When I read this article, written by a fellow physician, I realized that the realities of healthy lungs, diseased lungs, intubation, pharmacologic paralysis, and the delicate balancing act of managing artificial respiration with a ventilator are experiences opaque to most of my readers. 

“Air hunger” is terrifying to watch and terrifying to experience. Artificial ventilation is no panacea. It is support, not a cure. We still don’t have solid data on how many Covid-19 patients put on a ventilator survive, much less do we know what the long term disability might be of those who survive. I’ve read estimates of death rates for those needing artificial ventilation as high as 80%, an uncertain number because the criteria used to assess the need for artificial ventilation must vary from place to place, tailored to availability of ventilators and the extremity of the patient’s condition. 

I’ve read of the lunatic, ignorant fringe of the right wing currently decrying hospital boards efforts to establish criteria for artificial ventilation as “death panels,” the same framing Republicans used to electoral advantage in 2010 to characterize some provisions of the Affordable Care Act. Damn them. And damn those who would sacrifice other’s lives for some misbegotten understanding of economic progress. They all need immersion in the reality of a Respiratory Intensive Care Unit.

I can verify everything Dr. Kathryn Dreger presents in her article. We all need to hear it, think about it, and proceed accordingly. Now might be the time to discuss with your loved ones how you want them to manage your care if the unthinkable happens. If you live in Washington State and you do not already have a “Physician Orders for Life Sustaining Treatment” (POLST), now might be the time to consider one. (Click here.)
 

What You Should Know Before You Need a Ventilator

It breaks my heart that patients who will get sick enough to need them won’t know what desperate situations they face.

By Kathryn Dreger

Dr. Dreger is a doctor of internal medicine in Northern Virginia and a clinical assistant professor of medicine at Georgetown University.
April 4, 2020Day by day, as the number of Covid-19 deaths soar, we see more clearly that many of us will not survive this storm.

In the most serious cases, breathing becomes so labored that ventilators have to be used to keep patients alive. That there may not be enough of these machines is horrifying and infuriating.

But even if there were, it breaks my heart that Americans who get sick enough to need them won’t know what desperate situations they face, nor will they understand what ventilators can do to help, and what they can never fix.

As hard as the facts may be, knowledge will make us less afraid.

Let me begin simply. When we take a breath, we pull air through our windpipe, the trachea. This pipe then branches in two, then again into smaller and smaller pipes finally ending in tiny tubes less than a millimeter across called bronchioles. At the very end of each are clusters of microscopic sacs called alveoli.The lining of each sac is so thin that air floats through them into the red blood cells. These millions of alveoli are so soft, so gentle, that a healthy lung has almost no substance. Touching it feels like reaching into a bowl of whipped cream.

Covid-19 changes all that.

It causes a gummy yellow fluid, called exudate, to fill the air sacs, stopping the free flow of oxygen. If only a few air sacs are filled, the rest of the lung takes over. When more and more alveoli are filled, the lung texture changes, beginning to feel more like a marshmallow than whipped cream.

This terrible disease is called acute respiratory distress syndrome. Covid-19 can cause an incredibly lethal form of this, in which oxygen levels plunge and breathing becomes impossible without a ventilator.

Specially trained health care workers insert a 10-inch-long tube connected to a ventilator through the mouth and into the windpipe. The ventilator delivers more oxygen into the lungs at pressure high enough to open up the stiffened lungs.

It’s called life support for a reason; it buys us time. Ventilators keep oxygen going to the brain, the heart and the kidneys. All while we hope the infection will ease, and the lungs will begin to improve.

These machines can’t fix the terrible damage the virus is causing, and if the virus erupts, the lungs will get even stiffer, as hard as a stale marshmallow.

“I feel like I’m trying to ventilate bricks instead of lungs,” one intensive care unit doctor who has been treating Covid-19 patients told me.

The heart begins to struggle, begins to fail. Blood pressure readings plummet, a condition called shock. For some, the kidneys fail completely, which means a dialysis machine is also needed to survive.

Doctors are left with impossible choices. Too much oxygen poisons the air sacs, worsening the lung damage, but too little damages the brain and kidneys. Too much air pressure damages the lung, but too little means the oxygen can’t get in. Doctors try to optimize, to tweak.

Nobody can tolerate being ventilated like this without sedation. Covid-19 patients are put into a medically induced coma before being placed on a ventilator. They do not suffer, but they cannot talk to us and they cannot tell us how much of this care they want.

Eventually, all the efforts of health care workers may not be enough, and the body begins to collapse. No matter how loved, how vital or how needed a person is, even the most modern technology isn’t always enough. Death, while typically painless, is no less final.

Even among the Covid-19 patients who are ventilated and then discharged from the intensive care unit, some have died within days from heart damage.

Even before Covid-19, for those lucky enough to leave the hospital alive after suffering acute respiratory distress syndrome, recovery can take months or years. The amount of sedation needed for Covid 19 patients can cause profound complications, damaging muscles and nerves, making it hard for those who survive to walk, move or even think as well as they did before they became ill. Many spend most of their recovery time in a rehabilitation center, and older patients often never go home. They live out their days bed bound, at higher risk of recurrent infections, bed sores and trips back to the hospital.

All this does not mean we shouldn’t use ventilators to try to save people. It just means we have to ask ourselves some serious questions: What do I value about my life? If I will die if I am not put in a medical coma and placed on a ventilator, do I want that life support? If I do choose to be placed on a ventilator, how far do I want to go? Do I want to continue on the machine if my kidneys shut down? Do I want tubes feeding me so I can stay on the ventilator for weeks?

Right now, all over the country, patients and their families are being asked to make these difficult decisions at a moment’s notice, while they are on the verge of dying, breathless and terrified.

If patients get worse after being put on a ventilator, critical care doctors are having to ask their family members what they want done. Covid-19 is too contagious to have these conversations in person, so they are being done over the phone. It is yet another heartbreaking reality of dying during a pandemic. Patients cannot tell us what they want. Family members aren’t able to be with patients and may not know what they would want.

No one can make these choices for us, and no one will know what choices we would make unless we tell them. If you don’t want to be put in a coma and placed on life support, please let your family know. Appoint the person you want to make decisions for you and let your doctor know your wishes. The truth is we are facing a disaster. Let’s not use up precious resources on someone who doesn’t want them. We will still care for you to the end, but we won’t put you on a machine if you don’t want to be on it.

If the person you love is on a ventilator right now, find out exactly how bad his or her lungs are. The doctors will tell you the truth. And the truth, no matter how painful, eases fear. The understanding that comes with it helps us make the best choices for the ones we love.

Keep to the high ground,
Jerry

P.S. For a graphic presentation of what’s going on in the lungs from Covid-19, here’s a good video, courtesy of the New York Times: https://www.nytimes.com/video/health/100000007056651/covid-ards-acute-respiratory-distress-syndrome.html

Social Distancing, hand-washing, and keeping your fingers off your face is the bedrock strategy. Masks, whether homemade or commercial medical grade, are additive. Practiced together this offers the best risk mitigation against becoming infected with Covid-19 and against spreading the disease to others. Keeping proper social distance, washing one’s hands, and wearing a mask in public is the patriotic and respectful thing to do.  

But, but what about those folk who don’t know proper sterile technique, don’t know how to deal with wearing a mask? Here’s a surgeon’s opinion: Ask yourself, is it more dangerous to inhale a droplet directly into your airway or to catch it in the fiber of a mask, then (some time later) touch the uneven surface of the mask with your finger, then (some time even later) absentmindedly rub the corner of your eye? Especially if you hand wash or hand sanitize after handling the mask (when you return from your foray to the grocery and after you touch the mask to take it off) you still reduce the risk of transmission. The virus requires more steps and will likely deliver a lower dose to you than directly inhaling a virus-filled droplet. [If you have any doubt about the potential for airborne spread, read this cautionary tale.]

Don’t have a mask? There are many “how-to” guides. This one, highlighted by one of my readers, seemed particularly ingenious. It requires only rubber bands, a paper clip, a stapler, and a shop towel (the slightly more robust version of a paper towel): https://youtu.be/mai-UqdNRi8, I like this guy’s t-shirt, too.

Daily you hear medical doctors, epidemiologists, and medical scientists answering questions about Covid-19 and the coronavirus that causes it. Questioners often seek a yes or no answer. In jarring contrast, answers from credible scientists are almost always couched in terms of risk–or probability–or analogy, analogy to what is known about other infectious diseases or known about particular coronavirus-caused diseases. These answers reflect honesty about our current wobbly state of specific knowledge about Covid-19, but these answers also reflect a deep understanding of the underlying scientific process, an understanding of biology based on thousands of observations and experiments built up, tested, and cross-checked over recent centuries. I often hear a tension between the human desire for certainty and the scientific reality that any answer, any prediction, is necessarily somewhat uncertain. 

The following article (from the April 1st New York Times) offers important background on viral dosage and transmission. The ideas expressed are the voice of current credible scientific understanding of this disease (and infectious disease in general). 

These Coronavirus Exposures Might Be the Most Dangerous

As with any other poison, viruses are usually deadlier in larger amounts.

By Joshua D. Rabinowitz and Caroline R. Bartman

Dr. Rabinowitz is a professor of chemistry and genomics. Dr. Bartman is a genomic researcher.

Li Wenliang, the doctor in China who raised early awareness of the new coronavirus, died of the virus in February at 34. His death was shocking not only because of his role in publicizing the developing epidemic but also — given that young people do not have a high risk of dying from Covid-19 — because of his age.

Is it possible that Dr. Li died because as a doctor who spent a lot of time around severely ill Covid-19 patients, he was infected with such a high dose? After all, though he was one of the first young health care workers to die after being exposed up close and frequently to the virus, he was unfortunately not the last.

The importance of viral dose is being overlooked in discussions of the coronavirus. As with any other poison, viruses are usually more dangerous in larger amounts. Small initial exposures tend to lead to mild or asymptomatic infections, while larger doses can be lethal.

From a policy perspective, we need to consider that not all exposures to the coronavirus may be the same. Stepping into an office building that once had someone with the coronavirus in it is not as dangerous as sitting next to that infected person for an hourlong train commute.This may seem obvious, but many people are not making this distinction. We need to focus more on preventing high-dose infection.

Both small and large amounts of virus can replicate within our cells and cause severe disease in vulnerable individuals such as the immunocompromised. In healthy people, however, immune systems respond as soon as they sense a virus growing inside. Recovery depends on which wins the race: viral spread or immune activation.

Virus experts know that viral dose affects illness severity. In the lab, mice receiving a low dose of virus clear it and recover, while the same virus at a higher dose kills them. Dose sensitivity has been observed for every common acute viral infection that has been studied in lab animals, including coronaviruses.

Humans also exhibit sensitivity to viral dose. Volunteers have allowed themselves to be exposed to low or high doses of relatively benign viruses causing colds or diarrhea. Those receiving the low doses have rarely developed visible signs of infection, while high doses have typically led to infections and more severe symptoms.

It would be unethical to experimentally manipulate viral dose in humans for a pathogen as serious as the coronavirus, but there is evidence that dose also matters for the human coronavirus. During the 2003 SARS coronavirus outbreak in Hong Kong, for instance, one patient infected many others living in the same complex of apartment buildings, resulting in 19 dead. The spread of infection is thought to have been caused by airborne viral particles that were blown throughout the complex from the initial patient’s apartment unit. As a result of greater viral exposure, neighbors who lived in the same building were not only more frequently infected but also more likely to die. By contrast, more distant neighbors, even when infected, suffered less.

Low-dose infections can even engender immunity, protecting against high-dose exposures in the future. Before the invention of vaccines, doctors often intentionally infected healthy individuals with fluid from smallpox pustules. The resulting low-dose infections were unpleasant but generally survivable, and they prevented worse incidents of disease when those individuals were later exposed to smallpox in uncontrolled amounts.

Despite the evidence for the importance of viral dose, many of the epidemiological models being used to inform policy during this pandemic ignore it. This is a mistake.

People should take particular care against high-dose exposures, which are most likely to occur in close in-person interactions — such as coffee meetings, crowded bars and quiet time in a room with Grandma — and from touching our faces after getting substantial amounts of virus on our hands. In-person interactions are more dangerous in enclosed spaces and at short distances, with dose escalating with exposure time. For transient interactions that violate the rule of maintaining six feet between you and others, such as paying a cashier at the grocery store, keep them brief — aim for “within six feet, only six seconds.”

Because dose matters, medical personnel face an extreme risk, since they deal with the sickest, highest-viral-load patients. We must prioritize protective gear for them.

For everyone else, the importance of social distancing, mask-wearing and good hygiene is only greater, since these practices not only decrease infectious spread but also tend to decrease dose and thus the lethalness of infections that do occur. While preventing viral spread is a societal good, avoiding high-dose infections is a personal imperative, even for young healthy people.

At the same time, we need to avoid a panicked overreaction to low-dose exposures. Clothing and food packaging that have been exposed to someone with the virus seem to present a low risk. Healthy people who are together in the grocery store or workplace experience a tolerable risk — so long as they take precautions like wearing surgical masks and spacing themselves out.A complete lockdown of society is the most effective way to stop spread of the virus, but it is costly both economically and psychologically. When society eventually reopens, risk-reduction measures like maintaining personal space and practicing proper hand-washing will be essential to reducing high-dose infections. High-risk sites for high-dose exposure, like stadiums and convention venues, should remain shuttered. Risky but essential services like public transportation should be allowed to operate — but people must follow safety measures such as wearing masks, maintaining physical spacing and never commuting with a fever.

Now is the time to stay home. But hopefully this time will be brief. When we do begin to leave our homes again, let’s do it wisely, in light of the importance of viral dose.

Joshua D. Rabinowitz is a professor of chemistry and genomics at Princeton, where Caroline R. Bartman is a research fellow.

Keep to the high ground–and wear a mask if you go out,
Jerry

P.S. I want to interject a personal note. What I understand of the science of infectious disease was early on deeply rooted in the stories of the great scientists of past centuries. In the 19th and early 20th centuries science was often transmitted as stories, stories with human details attached, human details that make the science memorable. I fear that as a society we have lost touch with the human roots of science, the stories I found heroic in my youth. When I was about twelve years old (around 1962) I read a book, Microbe Hunters by Paul de Kruif. I still have it. It tells the story of the struggles of the giants of infectious disease, among them Louis Pasteur, Robert Koch, and Walter Reed, the giants upon whose shoulders the modern day experts stand. The book starts with the story of Antonie van Leeuwenhoek (1632-1723), the lens grinder who first revealed the existence of microbes and ends with Paul Ehrlich (1854-1915), a man who, along with his effective treatment for syphilis (arsphenamine [Salvarsan]), are now largely forgotten. The book is such a classic that it is still available at Amazon as an eBook, an Audible book, and as a paperback. It might make good reading or listening for yourself or some curious youngster willing to read or listen to some good stories. (Click the title above for the link). 

It is thanks to the ready access I now have to wikipedia that it was recently learned that I, as my young self in 1962, reading Microbe Hunters , was fascinated by the stories in a book published originally in 1926. 1926 was two years before the discovery of penicillin by Alexander Fleming in 1928, and sixteen years before penicillin was used to treat infections in 1942. Microbe Hunters was written about researchers, like Pasteur, who by reasoning and experimenting developed vaccines for diseases like rabies and smallpox, all long before viruses could be actually seen with electron microscopy and before their biochemistry understood–in the mid to late 1900s. 

For those who have read this far: I’m very curious if any of you are already acquainted with this book. If you remember it, please click “Reply” and briefly tell me your story. Did you read it? Did it have any influence on your life? 

On March 10 sixty members of the Skagit Valley Chorale met for practice at the Mount Vernon Presbyterian Church in Mt. Vernon, Washington. The decision to gather was not taken lightly. The leaders of the Chorale pondered whether it was safe to meet.

Consider the historical context: In Kirkland, Washington, just an hour south of the Chorale’s meeting place on February 29, the nation registered its first death from Covid-19, a man in his fifties who had evidently caught the disease in the community. The man had no connection to travel in China.  Governor Jay Inslee declared a “state of emergency” for Washington State that same day, February 29. (This “state of emergency” directs state government agencies to pay attention. It frees up funds for the purpose. It does NOT direct any particular action on the part of citizens. Inslee’s “Stay Home, Stay Healthy” order came March 23, two weeks after the Chorale practice.) For epidemiologists and infectious disease specialists, alarm bells were ringing. The day before the Chorale met, on March 9, Nancy Messonnier, M.D., Director, National Center for Immunization and Respiratory Diseases at the Centers for Disease Control (CDC) gave a “Media Telebriefing” that reflects deep concern in the federal medical and scientific community. You can read the transcript, published the next day, here. 

On Friday, March 6, four days before the Chorale met in Mt. Vernon, Mr. Trump was still minimizing concern. Questioned as to whether he would continue holding campaign rallies (of thousands of supporters), he replied, “Well, I’ll tell you what, I haven’t had any trouble filling them.” In the same interview at the CDC laboratories he said there “were only eleven deaths” in the U.S. and he “wasn’t concerned.” Entirely against epidemiological understanding of likely exponential spread of Covid-19, Mr. Trump was exuding confidence in a television interview, suggesting he would continue to hold massive rallies.

The federal Chief Executive, the man supposed to lead the nation, Mr. Trump, continued to downplay the seriousness of the threat:

March 7: “No, I’m not concerned at all. No, we’ve done a great job with it.” — Trump, when asked by reporters if he was concerned about the arrival of the coronavirus in the Washington, D.C., area. 

March 9: “So last year 37,000 Americans died from the common Flu. It averages between 27,000 and 70,000 per year. Nothing is shut down, life & the economy go on. At this moment there are 546 confirmed cases of CoronaVirus, with 22 deaths. Think about that!” — Trump in a tweet.

What to do? The leadership of the Skagit Valley Chorale decided on March 6, reasonably it seemed at the time, to meet on March 10, but to exercise reasonable caution amid “stress and strain of concerns about the virus.” Surely, by March 10 they were even more concerned, even though our national leader was still in denial. When the Chorale members met they used hand sanitizer. They spaced their chairs. They each brought their own sheet music. They refrained from hugging and shaking hands.

Three days later, on March 13, three of the choir members developed a fever. In the next few days they and others reported feeling fatigued and achy, some with coughs and shortness of breath, some with nausea and diarrhea. In the end forty-five of the sixty choir members who attended the practice fell ill. Two member of the Chorale who attended the practice on March 10 died. 

This type of incident forms the bedrock of epidemiology. Sadly, there has not yet been a formal study, a minute dissection of the incident. Where was each person standing during the practice? Are their clues that might tell investigators who the asymptomatic (or very sparsely symptomatic) person was who unwittingly brought the virus to the practice? Where did that person acquire the virus? Was there something particular about that person that made them a “super spreader” or are lots of asymptomatic or pre-symptomatic Covid-19 carriers have this potential to spread the virus? This is the realm of the epidemiologist, the medical detective.

Have you ever stood in side-wise sunlight, talking with a person, observing them talk, and noticed fine droplets of spittle project into the air? If you haven’t, be on the lookout. It happens all the time. These fine droplets don’t stop happening because there is no side-wise sunlight to reveal them. 

Does choral singing project more droplets, even aerosols (droplets so fine they remain suspended in the air) than are projected in regular speech? That certainly seems reasonable, but that is not the point. The lesson of this incident is clear: Covid-19 can spread from asymptomatic or pre-symptomatic individuals by airborne transfer. We do not know how often; we do not know exactly how far; we do not know how prolonged an exposure it takes; we do not know how many people acquire the disease this way, but airborne spread definitely happens. 

Bottom line: When you encounter another person neither you nor they can know if they (or you) are spreading virus. Wash you hands frequently, keep your distance, and wear something over your nose and mouth, any commercial mask if you have one, a homemade mask (check out this and this), or a double bandana. At the very least, wearing something over your mouth and nose in those conditions will diminish droplet spread–that’s both  courtesy and protection for all concerned. Not getting this disease is all about odds, and the odds of catching it are diminished by not spreading droplets.

Remember and pass along this story and its links. There is no better teaching or remembering device than a story. Jesus taught in parables for a reason. 

Keep to the high ground,
Jerry

P.S. Regardless of who said it, there is a lot of truth to this statement as regards the impression made by a story: “A Single Death is a Tragedy; a Million Deaths is a Statistic.” Even the most steadfast of deniers of reality and science, Mr. Trump, can be swayed by an incident that hits close to home, a personal story he heard (as well as body bags lined up at a hospital near his home town that he saw on TV) :

Trump’s latest tonal and tactical shift (and almost certainly not the last) was driven by several factors, both personal and political. Trump learned that his close friend, 78-year-old New York real estate mogul Stan Chera, had contracted COVID-19 and fallen into a coma at NewYork-Presbyterian. “Boy, did that hit home. Stan is like one of his best friends,” said prominent New York Trump donor Bill White. (Vanity Fair)

Today is Census Day. Do your part. It really does take only about ten minutes (once you have access to the internet–a problem for too many people who really need to be counted). Covid-19 will not last forever. We must start to spend some of our time thinking past this pandemic and toward our collective future. The Census is the bedrock, the Constitutionally-mandated factual basis on which our federal, state, and local government rests. 

Here’s how the Spokane League of Women Voters puts it:

The census is actually a critical look to the future, data that forms an arc for decision-making for the next 10 years. It is a point-in-time count of everyone living in the United States, a tally that provides all levels of government and businesses with basic and aggregated demographic data. The 2020 census dictates how voters are assembled into districts, how Americans get counted for distribution of federal and state funds, and how—compared to the 2010 census—a city has grown and might attract new businesses to its area.

Don’t put off this bit of civics homework. Go to 2020Census.gov. If you can find the postcard or letter the Census mailed to most of us some time in the last month, retrieve it and use the 12 digit “Census ID” you find there. Can’t find it? Not to worry. The Questionnaire will guide you to properly being counted even if you have no Census ID and even if you have no address. 

Once you’ve done your ten minute civic duty, then check in with at least two other people you know and encourage them to also register with Census2020. 

Popourri:

Wherever you live The Covid-19 Show is coming to a theater near you. Bonner County, Idaho, reported its first case last Sunday, March 29. Bonner County, total population about 41,000, is not exactly a center of population density. Sandpoint, population around 9,000, is the county seat and biggest town. This first reported Bonner County case is community acquired, that is, the virus was already spreading in Bonner County. Idaho Governor Brad Little issued a 21 day stay at home order for the entire state of Idaho on March 25, four days before the first Bonner County case appeared. Little was responding to case clusters already appearing in southern Idaho. (Mr. Trump decided on March 29 to extend his social distancing guidelines to April 30 after he was convinced by TV video of body bags lined up at Elmhurst Hospital near where he grew up.)

There is some hope. Reports out of Seattle (by the New York Times) on Sunday, March 29, tentatively suggested that transmission was slowing, not peaked yet, but slowing. Jay Inslee, governor of Washington, signed his “Stay Home, Stay Healthy” order on Monday, March 23. (Trump attempted to undermine Inslee by instructing VP Pence not to talk to Inslee because Inslee wasn’t sufficiently “appreciative” of Trump’s efforts.)

So how paranoid and compulsive must one be? I found this living room video by a physician working daily in the ICU at Weill-Cornell Medical Center in downtown Manhattan strangely comforting. It helped put Covid-19 into perspective. It lasts an hour, but there is a lot of reality-based, common sense information in the first 30 minutes: 

https://vimeo.com/399733860

I planned to add some of the great and varied humor that people are sharing in every medium. We’re all just trying to stay sane. There is way too much good material. Let me leave you with this link to “We Didn’t Spread The Virus” (Billy Joel Parody) 2020 Covid 19 – YouTube.

Don’t forget: Register with the Census at 2020Census.gov.

Keep to the high ground,
Jerry

P.S. Words are fun. Potpourri has come to mean “a mixture of things.” That’s the way I meant it in today’s title. Looking a little further, though, it also means “a mixture of dried petals and spices placed in a bowl or small sack to perfume clothing or a room,” something I saw a few times in my childhood. But the etymology is really fun: “early 17th century (denoting a stew made of different kinds of meat): from French, literally ‘rotten pot’.” May the “mixture of things” I’ve written about today be far better than a “rotten pot.” 🙂

P.P.S. Only some parts of the U.S. are in actual quarantine, real isolation, the sort of thing imposed in many other historical epidemics. With Trump’s extension of his much weaker “social distancing guidelines,” at least he’s inching closer to the traditional length of a quarantine. The word quarantine comes from the mid 17th century Italian “quarantina,” referring to its forty day duration. Here’s a even nerdier discussion from Science Friday.

Register with the Census! 🙂