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! 🙂

It is time to contemplate that question, to think through what got us here and what sort of world we’ll have, and to set to work crafting the future we want to have. The following quote comes from the end of an article in “The Atlantic” published on March 25. Like The Hammer and the Dance that I highlighted last Friday, How the Pandemic Will End was written by a young, upcoming science writer, Ed Wong. I take solace that members of the next generation are speaking in such clear voices. We should take heed. Here are the ending three paragraphs:

“One could easily conceive of a world in which most of the nation believes that America defeated COVID-19. Despite his many lapses, Trump’s approval rating has surged. Imagine that he succeeds in diverting blame for the crisis to China, casting it as the villain and America as the resilient hero. During the second term of his presidency, the U.S. turns further inward and pulls out of NATO and other international alliances, builds actual and figurative walls, and disinvests in other nations. As Gen C [current youth living the pandemic] grows up, foreign plagues replace communists and terrorists as the new generational threat.

One could also envisage a future in which America learns a different lesson. A communal spirit, ironically born through social distancing, causes people to turn outward, to neighbors both foreign and domestic. The election of November 2020 becomes a repudiation of “America first” politics. The nation pivots, as it did after World War II, from isolationism to international cooperation. Buoyed by steady investments and an influx of the brightest minds, the health-care workforce surges. Gen C kids write school essays about growing up to be epidemiologists. Public health becomes the centerpiece of foreign policy. The U.S. leads a new global partnership focused on solving challenges like pandemics and climate change.

In 2030, SARS-CoV-3 emerges from nowhere, and is brought to heel within a month.”

Those two futures stand in stark contrast. Let us strive to make the second future the one we build–and reject a future of xenophobia, blind nationalism, suspicion, strife, and rejection of science currently embedded in our national politics. We need to create the future of cooperation, speak of it to all who will listen, and support those who share the vision, support them on their way to the November Election.

I encourage you to read Mr. Wong’s entire article. Like many newspapers and periodicals, “The Atlantic” has suspended its paywall for coverage of the coronavirus pandemic. In a political climate where some wish to make an icon of walls, celebrate the symbolism of lowering this one. Here’s the raw link to the article, “How the Pandemic Will End”:

https://www.theatlantic.com/health/archive/2020/03/how-will-coronavirus-end/608719/

Keep to the high ground,
Jerry

“Flatten the Curve” is a great slogan and messaging tool, but it is not enough. We need a clear-eyed vision for how we get from now to a better future. 

The “Hammer” is the Protective Measures the world is struggling to put in place and maintain in spite of the naysayers and doubters. It works, but what is the end game? Do the same number of people have to catch this disease and some of proportion of them die, just dragged out over many months instead of one or two hellacious months of sickness and death ‘getting through it’? After all, the area under the curve of that now famous graph (posted below once again) for both With and Without Protective Measures looks much the same. 

Take heart. An end game for this pandemic is taking shape. It’s “The Dance” part of “The Hammer and the Dance.” The exciting thing it that the argument is coming from very bright, extremely dedicated, mostly young people pooling their efforts with the aid of the internet, pooling them in a network that ignores national boundaries. Settle down for a long, sometimes a bit wonky read and click on this link:

https://medium.com/@tomaspueyo/coronavirus-the-hammer-and-the-dance-be9337092b56

Even if this exercise in logic doesn’t catch fire, even if “Coronavirus: The Hammer and the Dance” doesn’t become the new buzzword, the concepts in this presentation are invaluable. These ideas in it need wide distribution, particularly to those in leadership positions, some of whom are foundering in their own bluster, bravado, and wishful thinking. 

Read. I hear hearty agreement from many medical friends I’ve already sent this link. If you also find this effort by Tomas Pueyo and his long list international, internet-linked collaborators valuable then click on and sign the petition to the White House contained in the document and then share this link with friends. The entire world is focused on this pandemic. Voices of reason and reasoned hope need to drown out the whiners and wishful thinkers. Everyone is listening. 

Keep to the high ground,
Jerry

P.S. A few further musings: Nearly everyone has seen the “Flatten the Curve” graph shown below and nearly everyone regardless of political persuasion understands the basic idea: using social distancing and lockdown tactics we decrease the chance of overwhelming the health care system (as happened in Hubei and is now happening in northern Italy and New York City).

But, as one of my astute readers pointed out on his Facebook page, the area under the curve in the graph “With Protective Measures” is roughly the same as that depicted under the curve “Without Protective Measures.” That depiction suggests that, apart from avoiding the death of a few the health care system might otherwise save (were it not overwhelmed), were it not for that, it suggests we’re facing exactly the same numbers of infected and dead, just strung out over a much longer time period. That’s likely very wrong, as “The Hammer and the Dance” points out.

The purpose of all of what we need to do in this crisis is to buy time. We and our leadership need to use that time to support efforts that will give us understanding and tools, understanding and tools which, if properly implemented, will make the area under the curve “With Protective Measures” ever smaller. We can emerge from this challenge with much clearer understanding of how to deal with the next worldwide crisis–and with much better worldwide collaboration–or we can descend into tribalism, nationalism, and racism, as we cast about for someone on whom to pin the blame. I vote for collaboration. Get on board. Cast off those who cling to nationalism, racism, tribalism, and their misbegotten, contemptible characterization of Corvid-19 as “the Chiinese flu.” Those folks are not leaders and cannot be allowed to lead.

At around midnight Sunday night, Trump tweeted “WE CANNOT LET THE CURE BE WORSE THAN THE PROBLEM ITSELF. AT THE END OF THE 15 DAY PERIOD, WE WILL MAKE A DECISION AS TO WHICH WAY WE WANT TO GO!” Mr. Trump was directly channeling the argument Steve Hilton, a Fox News talking head, had made a little earlier in the evening. (Hilton presents the crux of his argument at 6:28 in the Fox News video you can watch at that link.)

I watched the video to verify the account of it presented here and copied belowfrom the Huffington Post (the quoted material is all in italics):

Hilton played a clip of Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, saying he was fine if people think the response to the virus was an overreaction.

“Well, that’s easy for him to say,” Hilton said. “He’ll still have a job at the end of this, whatever happens.”

Hilton added: 

“Our ruling class and their TV mouthpieces whipping up fear over this virus, they can afford an indefinite shutdown. Working Americans can’t, they’ll be crushed by it. You know that famous phrase, ‘The cure is worse than the disease?’ That is exactly the territory we are hurtling towards.”

Hilton calculated that an economic shutdown in response to the virus would lead to a recession that could kill 1 million Americans. 

“Poverty kills. Despair kills. This shutdown is deadly,” Hilton said. He then urged Trump to reassess the plan within 15 days. After that, it would be time to stop the shutdown while keeping in place bans on large gatherings and measures to protect the elderly.

After Trump’s tweet channelling Steve Hilton, Fox Nation’s “Deep Dive” (that’s a paid subscription website) on Monday added fuel by featuring Dr. Marc Siegel, a talking head on Fox since 2008 (Is he on the payroll primarily because his views align with the network bias?). According to Dr. Siegel, “”About three or four weeks from now, we’re going to back off of these draconian measures because we won’t be able to stay together as a society if we don’t” You can read the FoxNews.com coverage of the Siegel appearance here. Note that Dr. Siegel, an internist, is using his M.D. degree to justify his opinions of sociology and economics, not medicine.

Monday evening on Tucker Carlson Tonight, Texas Lt. Gov. Dan Patrick added fuel by offering to risk his own life as an example of a supposedly selfless senior citizen (he’s 69):

“No one reached out to me and said, as a senior citizen, ‘Are you willing to take a chance on your survival in exchange for keeping the America that all America loves for your children and grandchildren?’ And if that’s the exchange, I’m all in … I just think there’s lots of grandparents out there in this country like me — I have six grandchildren — that what we all care about and what we love more than anything are those children. I want to live smart and see through this. But I don’t want the whole country to be sacrificed and that’s what I see.”

He added that it “..doesn’t make me noble or brave or anything like that… what we all care about and what we love more than anything are those children.” Patrick said that he will “do everything I can to live” and that if he gets sick, he will seek medical help. He went on to echo Trump’s argument that the coronavirus mortality rate in the United States — so far — is not as alarming as it is in other countries. (Just wait, of course, we’re early and Covid-19 takes a week or two to kill most of its victims.)

The trouble is that Mr. Patrick, who rose to the Lt. governorship of Texas from a career as a conservative talk show host after having gone bankrupt in business, is recommending a course of action that endangers not just his own life and those of the supposedly selfless seniors he claims to represent, but also the lives of the healthcare workers from whom he and others vow to seek help if they fall ill. All of these brainless talking heads conveniently ignore the fact that as of March 19th in the U.S. 38% of the 508 patients hospitalized for Corvid-19 were between the ages of 20 and 54. As of March 19, nine of these 20-54 year olds had died–but this is very, very early in what is likely to be a tidal wave of deaths among many age 20 and up. (As of March 19 there were no deaths or hospitalizations in the U.S. of people under age 20 from Corvid-19.)

So what is going on here? It looks like a Wall Street Journal opinion piece got the ball rolling about a week ago. Steve Hilton’s rant on Fox last Sunday, March 22, (detailed above) was channeled by Trump in his tweet later that evening. Dr. Siegel and then Dan Patrick on two other Fox programs on Monday, the next day, noting that Trump was paying attention, pumped up Trump’s faith that the economy should take precedence over people’s lives.

Trump has spent his life stepping on other people in pursuit of money (Trump University). He despises scientists (climate change is a “Chinese hoax”). He is convinced of his native intelligence and overall superiority (stable genius). His worst nightmare is being upstaged (reports on Tuesday suggest Dr. Fauci is losing favor with Trump). Trump desperately wants to be seen as in control–at center stage making the big decisions. Tumult and controversy are at the center of his character.

Fox News is playing to Trump’s confirmation bias. Fox News is calling the shots for our emotionally wobbly and fact-challenged president. If Trump declares, “Go back to work!” will the country follow–or repudiate him?

Or, as a friend suggested (while simultaneously admitting it sounds like a conspiracy theory), is this all an elaborate scheme to goose the stock market in the hope of playing the jump for profit. After all, what the Trump family is doing with the Trump money remains opaque to the electorate.

Meanwhile, people are dying all over the world while these fools propose sacrificing working Americans and thousands of health care workers on the alter of money.

Keep to the high ground,
Jerry

P.S. As I keep reading on the Fox News/Donald Trump circular confirmation bias amplifier I find that others are writing of the same thing. Below are links to two articles I consider outstanding:

Heather Cox Richardson: https://heathercoxrichardson.substack.com/p/march-23-2020?token=eyJ1c2VyX2lkIjo3ODU0MTcsInBvc3RfaWQiOjMyNzg3MSwiXyI6IkZBMFhHIiwiaWF0IjoxNTg1MDczNTU2LCJleHAiOjE1ODUwNzcxNTYsImlzcyI6InB1Yi0yMDUzMyIsInN1YiI6InBvc3QtcmVhY3Rpb24ifQ.kvxJotVOvZVZo81YHNmEAVilFT61EefKipJqzowVbdA

Justin Baragona of The Daily Beast provides a masterful summary of the Fox News amplifiers:

https://www.thedailybeast.com/fox-news-stars-begin-pushing-trump-to-end-coronavirus-restrictions