Archive for the ‘Coronavirus’ Category

It’s Always Been Tough Being A Nurse. Now It’s Worse.

Thursday, April 22nd, 2021

The OSHA Incidence Rate of work injuries (cases per 10,000 workers) for nurses is 12.7; for all other industries, it’s 3.8. Moreover, 40.8% of all nurse injuries involve physically dealing with patient needs, like moving, turning and lifting them, resulting in the highest rate of sprains and strains of all professions.

That nurses experience high rates of injuries is nothing new. Lynch Ryan’s very first client, the year was 1984, was a community hospital where injuries to nurses caused the hospital’s workers’ compensation insurance experience to be nearly three times worse than its peers in Massachusetts. We solved that by creating the concept of modified duty, returning injured employees to work with physician-specified physical restrictions prior to complete recovery.

What is less well known is that America’s health care workers, principally nurses, are victims of violence in the workplace at three times the rate of all other industries, including manufacturing and construction. Among registered nurses, what the Bureau of Labor Statistics (BLS) calls “violent events” make up 12.2% of all occupational injuries; for all other industries it’s 4.2%. Clearly, nursing has been a challenging profession since the time of Florence Nightingale.

The COVID-19 pandemic has made things even worse. A new Washington Post – Kaiser Family Foundation Poll reveals roughly three out of ten health care workers are considering leaving the profession and more than half report being “burned out” due to the overwhelmingly horrific year they’ve just spent trying, and often failing, to save the lives of COVID inflicted patients.

Couple this potential decrease in health care workers with the BLS’s projection (as of 9 April 2021) that health care jobs will be the fastest growing segment of the economy from 2019 to 2029:

Employment in healthcare occupations is projected to grow 15 percent from 2019 to 2029, much faster than the average for all occupations, adding about 2.4 million new jobs. Healthcare occupations are projected to add more jobs than any of the other occupational groups. This projected growth is mainly due to an aging population, leading to greater demand for healthcare services.

So, we were already facing a future serious shortage of health care professionals. Now, the pandemic threatens to thin the ranks even more. Despite this, enrollment in baccalaureate nursing programs increased nearly 6% in 2020, to 250,856, according to preliminary results from an annual survey of 900 nursing schools by the American Association of Colleges of Nursing. In order to hit the BLS projection of 2.4 million new jobs, nursing enrollment will have to grow at this rate every year. That is a tall order.

Meanwhile, occupational injuries, violence events, and, now, illnesses due to the pandemic will continue to plague the health care sector. Try as I might, I have been unable to find any kind of cohesive national strategy to confront and deal with this looming health care catastrophe.

Just another example of our sweeping a coming disaster under the rug for posterity to trip over.

Reflections On WCRI’s Recent Virtual Annual Conference: In A Word, It Was Excellent

Tuesday, March 30th, 2021

COVID-19 impact analysis

Last year, the Workers’ Compensation Research Institute held its Annual conference in Boston at the Westin Hotel on 5 and 6 March. The ballroom was full. COVID-19 was talked about in the conference and on the breaks, but it was too new to be on the Agenda. Everyone was doing elbow bumps instead of hand shaking. Four days after the conference wrapped, Governor Charley Baker declared a Massachusetts State of Emergency. The WCRI conference was likely the last one held in the City before everything shut down.

At that time, per the Johns Hopkins University COVID-19 Dashboard, the nation had seen ~139,000 cases and 2,425 deaths. In Massachusetts, where the conference was held, there had been 4,955 cases and 48 deaths.

The following month, the National Council on Compensation Insurance (NCCI) issued a Research Brief titled, COVID-19 and Workers’ Compensation: Modeling Potential Impacts. 

NCCI’s analysis projected a best case scenario, in which loss costs would increase $2 billion, and a worst case scenario, in which they would increase $81.5 billion, or 250% more than then current total loss costs. Willis Towers Watson also released a scenario-based analysis that suggested pretty much the same thing.

Also in April, the California Workers’ Compensation Insurance Rating Bureau (WCIRB) projected loss costs if conclusive (rebuttable) presumptions were provided to front line workers, something Governor Gavin Newsom actually did through Executive Order one month later, so the “if” became a “done.” The WCIRB report concluded costs would range “from $2.2 billion to $33.6 billion with an approximate mid-range estimate of $11.2 billion, or 61% of the annual estimated cost of the total workers’ compensation system prior to the impact of the pandemic.

A year later, at this week’s virtual annual conference, WCRI Economist Olesya Fomenko, Ph.D., reported results from her analysis of workers’ compensation claims in WCRI study states for Q1 and Q2, 2020. This period, ending 30 June, encompassed the pandemic’s first of what has been up to now three surges.*

Her data and presentation slides are preliminary, but more than likely will stand up to future scrutiny. Her findings confirmed what most students of COVID-19 were intuitively thinking. To wit, it does not appear that, at least through the study period of two quarters, COVID-19 would deal a death blow to the workers’ compensation industry. Claims in her analysis of 27 study states are plentiful, but relatively inexpensive. There is wide variation in the geographic distribution of claims, probably because COVID-19 surged at different times in different states. New York is not among the WCRI study states, but during the period of Fomenko’s analysis, it was the state with more COVID problems than any other. A lot more.

During the study period, Massachusetts, Connecticut and New Jersey had the most reported claims. Massachusetts claims were 42% of all reported claims in the study states and 59% of all lost time claims. Dr. Fomenko suggested that the presence of presumption laws, pay without prejudice (in the case of Massachusetts) and other compensability issues (in New Jersey) might is some way contribute to the high numbers in those states.

Looking at Massachusetts for a moment might be instructive.

At the top of this column we showed Massachusetts with relatively few cases as of early March, two-thirds of the way through Q1. Let’s look at Massachusetts now, at the end of Q1 a year later. The state has been hit hard, but has also rebounded. Here’s a look at the state by county:

As you can see, no county has had less than 3,000 infections, and three have had more than 10,000. But what came of those infections? How did the patients make out medically? Here is a look at cumulative cases from 9 March 2021 through yesterday, 29 March 2021.

There have been 17,130 total deaths since the beginning of the pandemic, but 97% of infected patients have recovered. Deaths are at 3%, which is less than the 5% predicted by the CDC one year ago. And this is the case for most of the country, and is one of the reasons Dr. Fomenko’s data shows claims to be relatively inexpensive.

NCCI Analysis

The WCRI studies define the concept of “early days.” So do those from the National Council on Compensation Insurance (NCCI). The point is, however, that analyses from both organizations appear to be congruent and complementary.

The lasting costs of COVID-19 to the workers’ compensation industry, aside from deaths, are going to come from permanent total and permanent partial disability awards. To that end, in October, 2020, NCCI published a Research Brief updating the Brief cited earlier in this column and titled, COVID-19 And Workers’ Compensation: Permanent Disability. These costs will be significant. NCCI’s analysis determined the average age of hospitalized COVID-19 patients at 49.5 years old. Average life expectancy allows for about 30 more years of benefits. The organization writes:

Given that severe cases are expected to have a higher likelihood of permanent disability, particularly PTD injuries, NCCI
assumed that all PTD claims would occur in this symptom grouping (infections and lung claims). Adjusting our PTD rate to between 0.0% and 1.5% to be applicable to only severe cases, we observe a PTD rate between 0% and 10% (= 1.5% / 15%) using the default Critical Care Rate from the NCCI Hypothetical Scenarios Tool.

Permanent Partial Disability cases are another matter. Here the frequency will be higher as well as the costs:

One interpretation of this assumption could be that moderate cases behave more like infection claims which tend to have a
near-zero PTD rate. If we compare the lung and infection PPD rates, we observe that lung claims have about twice the
likelihood of a PPD injury compared to infection claims. To the extent that moderate cases of COVID-19 behave like
infection claims and severe cases behave like lung claims, then a similar difference in the PPD rate may be expected. Under
this view, the Severe PPD rate would range between 40% and 50% with an implied Moderate PPD rate ranging between
20% and 25%.

With assumptions it clearly states contain wide variability, NCCI suggests the following COVI-19 benefits by injury type:

We’ll continue to follow the NCCI analyses as well as WCRI’s ongoing research.

Interview by John Ruser, PhD, with John Howard, MD, MPH, JD, LLM, MBA

John Howard is the longest serving Director of the National Institute for Occupational Safety and Health, three terms and counting. He is a legend in the field, and WCRI attendees got a good look at why during this wonderful interview by John Ruser. Howard, who has more letters after his name than there are years in elementary and high school combined, put on quite a show.

Some people are one inch wide and ten miles deep; others ten miles wide and one inch deep. Howard seems to know no inch or mile boundaries.  His subject was The Future of Work, and he made a number of highly interesting and prescient points, even going so far as to describe Aristotle’s concerns about automation in the ancient world of 350 BCE.

Asked about fears of jobs disappearing because of Artificial Intelligence and automation, Dr. Howard pointed to a study showing that in 2018 there were 60% more jobs than existed in 1940. Jobs have always gone away, but they’ve been replaced, and then some, by new jobs.

He’s concerned about a safety ergonomic vacuum employers are going to have to manage somehow. He believes employers are facing a “real challenge” adjusting to the new Work From Home paradigm.

My question is: How do employers deal with, let alone manage, workers’ compensation claims bound to occur while working in the home. You’re at your desk or dining room table working, get up for lunch, fall down the stairs and break an arm. Is that compensable? Is your employer going to make you prove it actually happened while you were actually working, and not just taking Junior out to the back forty for a little tag football?

And what responsibility does an employer have with respect to OSHA’s General Duty Clause, the one about providing a safe and healthful workplace?

If anyone can figure this stuff out, my money’s on John Howard.

Conclusion

Under trying circumstances, WCRI did an admirable job of hosting its 2021 Annual Conference. I’m told attendees gave it high marks, as well they should have. At the end of the second day, Dr. Ruser announced next year’s conference as being back in Boston’s Copley Westin Hotel on 15 and 16 March 2022. And I have a suggestion: After this ridiculously stressful year, it would be helpful and probably appreciated to devote a session to the impact of COVID-19 on employee mental health. A lot has happened in the last year to the field of Behavioral Health. It seems to have fitted in quite well to the new paradigm called Telehealth. It would be interesting to learn about that.

 

* Yesterday, CDC Director Dr. Rochelle Walensky said, “We do not have the luxury of inaction. For the health of our country, we must work together now to prevent a fourth surge. I so badly want to be done. I know you all so badly want to be done. We are just almost there, but not quite yet.” Walensky said she is now feeling a sense of “impending doom.”

**The Future of Work: The Economist is presenting a discussion on 8 April, at 4 pm, EST. To reserve a place, go here.

What Is The Real Reason Republicans Oppose The American Rescue Plan?

Friday, March 5th, 2021

At this moment, the Senate is debating the American Rescue Plan, the Biden administration’s $1.9 trillion stimulus proposal currently enjoying deep and wide bipartisan popularity across the country. Consequently, of course, not a single Republican senator will vote for it.

Why is this?

The Federal Reserve, not what you’d call a radically socialist organization, the Treasury Department, and nearly all reputable economists back the plan. A highly credible Morning Consult / Politico National Tracking Poll, with a 2% margin of error, conducted two weeks ago from 19 through 22 February, reported 66% of all registered voters considered stimulating the economy a “Top Priority,” and 76% of registered voters support the $1.9 trillion plan. And the icing on the cake — 60% of died-in-the-wool Republicans support it.*

Additionally, 63% of small business owners support the $1.9 trillion stimulus plan, according to the Q1 2021 CNBC|SurveyMonkey Small Business Survey, including 46% of Republican entrepreneurs.

With that kind of support, what possible reasons could congressional Republicans have for doing “everything we can to fight it,” as Mitch McConnell proclaimed this week?

There are a few reasons, and, is so often the case in political argument, most of them are nothing more than sound bites.

For example, Republicans claim the proposal is “replete” with giveaways having nothing to do with the pandemic. They object to the plan’s $350 billion aimed at helping cities and states, most notably the $10 billion (less than 1% of the entire plan) to shore up pension plans or lower future taxes.

Let’s look a little more closely at Republican opposition to city and state aid. No municipality — red or blue — has designed its fiscal affairs to withstand a simultaneous public-health crisis and economic lockdown. Unlike the federal government, states and cities cannot print or borrow money at near-zero interest rates. Most are constitutionally required to balance their budgets. When a pandemic annihilates their sales and income tax revenues — while dramatically increasing their Medicaid and health-care outlays — states have little choice but to lay off public-sector workers, cut social services, and/or raise taxes. All of those measures would make our current economic woes worse. There is no economic theory to support a stimulus strategy that combines massive stimulus at the federal level and simultaneous austerity at every lower level of government. If you believe that governments can improve economic welfare by filling in shortfalls in private incomes and consumer demand, then forcing state governments to reduce employment and spending is economically indefensible.

In the face of this, there is no coherent theoretical argument behind the GOP’s opposition to fiscal aid for states. But that hasn’t stopped it from trying. Unfortunately, every strata of our nation’s economy, from business, small and large, to the public sector’s 20.2 million federal , state, county and city employees, to nuclear families and single Moms, to you and me — all are in need.

On the other hand, I’d be interested in knowing just how much economic need our elected representatives and senators are experiencing at this moment. Would you?

*To be precise, this is the exact wording of the question in the Tracking Poll. It can be found on page 229 of the 368 page report: “Would you support or oppose a $1.9 trillion coronavirus relief package that provides up to $1,400 in direct payments to Americans making less than $75,000 a year, $350 billion in emergency funding for state and local governments, funding to support K-12 and higher education to re-open, and extends increased unemployment benefits until September 2021?”

Now What?

Tuesday, February 16th, 2021

The Trial of the Century —  So Far

During and after the second impeachment trial of Donald Trump, even Republicans admitted the House Managers had done a masterful job of presenting their case. Having voted the trial constitutional by a margin of 55 – 45, the Senate subsequently acquitted Trump with Republicans contending the trial was an unconstitutional abuse of power. And, as I have written earlier, that became the painted hook on the Senate wall upon which they hung their acquittal hats, all 43 of them.

The entire proceedings seemed scripted and predicable — that is, until Saturday morning, originally scheduled for closing arguments. That was when the leader of the House Managers, Representative Jamie Raskin, of Maryland’s 8th Congressional District, announced that overnight the Managers had learned of a phone conversation between House Minority Leader Keven McCarthy and President Trump at the height of the insurrection on the 6th. Representative Jaime Herrera-Beutler, Republican of Washington, had issued a statement saying McCarthy had described the conversation to her, a conversation in which McCarthy had begged Trump to forcefully call off the mob. Trump had dismissed the request cavalierly, saying, “Well, Kevin, I guess these people are more upset about the election than you are.”

Herrera-Beutler, one of the ten House Republicans who voted for impeachment, had said she was willing to testify under oath about the conversation with McCarthy, and that’s what Manager Raskin said was going to happen. Instead, Hellzapoppin happened.

Trump defense attorney Michael van der Veen, who is a personal injury lawyer, not a civil liberties lawyer, objected strenuously (to be kind about it; as I was watching I thought the Republicans were going to have to peel him off the Senate ceiling), saying if Herrera-Beutler were called to testify, he had at least a hundred witnesses he wanted to call, starting with Nancy Pelosi, and, by the way, he would depose all of them in his office in Philadelphia, because “that’s how these things are done.” At this point, the bell sounded and the fighters went to their separate corners to decide what to do next.

The House Managers, having made their point, and realizing that nothing short of something akin to the parting of the Red Sea, would persuade seventeen Republicans to vote to convict, and even that might not be enough, decided not to call Representative Herrera-Beutler as a witness. Instead, they and the defense team compromised by reading her statement into the record of the proceedings, thereby sparing us of more of Mr. van der Veen’s histrionics.

Shortly thereafter, Donald Trump was acquitted — again.

This was a show trial. With the conclusion foregone, the House Managers knew their real audience was the American public, not the 100 Senators in the chamber. It remains to be seen whether they won their case with the public. An Ipsos poll conducted Friday evening after the Defense had wrapped its case, if you could call it that, but before the Herrera-Beutler bombshell, revealed 55% of Americans believe Trump was “fully” or “largely” responsible for inciting the violence, but only 50% believe he should have been convicted. Strangely, 53% said he should be barred from holding public office again. The poll, which had a confidence level of 4%, shows in stark relief how deeply polarized this nation remains.

There will be more Trump litigation, a lot more. We may never see the end of it. Mitch McConnell, after voting to acquit, specifically mentioned this in a fiery speech (for him) putting Trump on notice that criminal and civil penalties are appropriate for what he did.

And today, it begins. This morning, Representative Bennie G. Thompson (D-Miss.), the chairman of the House Homeland Security Committee, filed a federal lawsuit accusing former president Donald Trump, attorney Rudolph W. Giuliani and two extremist groups whose members have been charged in the 6 January storming of the Capitol with illegally conspiring to intimidate and block Congress’s certification of the 2020 election. Citing an 1871, rarely used law aimed at the KKK, Thompson is suing in his personal capacity and is joined by the NAACP.

So many miles to go

With the conclusion of the world’s fastest impeachment trial, the Biden presidency can take center stage. Job #1: Defeat the pandemic and, in the words of someone who knew a thing or two about national division, “bind up the nation’s wounds.” However, right out of the gate we keep getting reminded just how delicate an undertaking that’s going to be.

Case in point: The scary growth of far right extremism in America and around the world got a boost from the Covid-19 pandemic.

Using historical data-sets from Germany, Kristian Brickle, of the Federal Reserve Bank of New York, concludes influenza mortality during the pandemic of 1918 – 1920 was directly correlated with both lower per-capita spending in the next decade, especially by the young, and the rise of extremist parties in 1932 and 1933, primarily the National Socialist Workers Party (the NAZI party). In her study, Pandemics Change Cities: Municipal Spending and Voter Extremism in Germany, 1918-1933, (May 2020, Revised June 2020), Brickle shows how Germany suffered high mortality in the pandemic, mortality that varied significantly across the country’s municipalities and regions. This variation represented tangible differences between cities and regions that reflected the beliefs and preferences of the inhabitants. In effect, the pandemic served as a means to exacerbate beliefs already held. One of these exacerbated beliefs was distrust for and hatred of minorities, predominantly Jews. Hence the significant increase of the deep-seated antisemitism of the late 1920s and 1930s.

Although Brickle’s work does not blaze a new trail — she builds on the work of many others — her research paints a clearer picture of what can be the unfortunate and unforeseen consequences of a pandemic. The United Nations and others have documented an “explosion” of antisemitism throughout the tenure of the Donald Trump presidency, but with a significant spike during 2020, the first year of the Covid-19 pandemic.

Joe Biden is going to need all the help he can find.

 

 

Thoughts Of The Day

Monday, January 18th, 2021

Was Azar intentionally lying, colossally incompetent, or both?

Given the last four years, I’m guessing Door Number 3.

Because both the Pfizer and Moderna vaccines require two shots, administered 21 and 28 days apart, respectively, Operation Warp Speed’s initial plan, announced in early December, was to hold back half the supply to make sure there was enough for the second shots. At the same time, the Trump Administration was saying it would vaccinate 20 million people by the end of the year.

On Tuesday, 12 January, as it became apparent the first doses of COVID-19 vaccinations were proceeding much slower than predicted (the 20 million prediction had turned into an 11.4 million reality), U.S. Secretary of Health and Human Services (HHS) Alex Azar announced the government was making all of the coronavirus reserve vaccine supply immediately available, urged states to provide shots to anyone 65 and older and warned governors that states with lagging inoculations could see their supply shifted to other places.

You could hear the collective country-wide sigh of relief. Help was on the way.

That is, until three days later when we learned the only place the “reserve supply” existed was in Alex Azar’s imagination, because the Administration admitted to state and federal officials it stopped stockpiling the second doses at the end of last year as it attempted to hit the 20 million goal. The reserve supply no longer existed. The states were left to scramble again, as they have throughout the pandemic. Remember the PPE fiasco? States were forced to compete against each other and the Feds to get any. Remember the Administration’s leadership about masking? Neither do I. I could go on.

This latest FUBAR catastrophe led President-Elect Joe Biden to tell the world the vaccine rollout was “a dismal failure.” Seems fairly accurate to me.

“Never ruin an apology with an excuse” – Benjamin Franklin

Here’s the way it worked. After the election, which he lost, Donald Trump spewed lie after lie about how he actually won “in a landslide.” And he convinced millions of people this was so. A new Quinnipiac poll reports 73% of Republicans believe there was “widespread fraud” in the election, which allowed Joe Biden to win. Trump’s two-month assault on truth led to the 6 January armed insurrection.

It is questionable whether he would have persuaded his millions of followers to believe the lies if he had not had profound assistance from Twitter, Facebook and conservative media. Case in point: the conservative outlet American Thinker which, with no investigation,  bought the Dominion Voting Machines stole-the-election line – again and again.

Yesterday, American Thinker “screwed its courage to the sticking post” and apologized. It was not one of those, “We did a bad thing, but we did it because…” things. No, this was an apology that would have made Ben proud. Here it is in full:

We don’t know what prompted American Thinker to so abjectly fall on its sword. I choose to think optimistically, believing journalistic ethics won the day. Regardless, this is how you do an apology.

Speaking of optimism

Why not end on a lighter note?

Back in pre-pandemic times (you remember those, don’t you?), when you wouldn’t think twice about sitting in a pub with friends discussing the metaphysics of Sartre, I once did just that with two friends, one a conservative republican with whom one could actually debate policy issues with smiles all around; the other, an MIT engineering professor.

We were talking about how people so often view the same thing in different ways, which led us to a discussion about optimism. That led to further discussion about the differences between people who were naturally optimistic and those who were naturally pessimistic.

One of us brought up the old glass half full or empty screed. I, the eternal optimist, said to me the glass was always half full. My conservative friend said he couldn’t help seeing it as half empty.

My friend from MIT said, “There’s too much glass.”

Stay safe – and, if you can, optimistic.

 

 

 

 

 

Now There Are Two, And Other Thoughts

Monday, November 16th, 2020

The Moderna Vaccine

Moderna’s announcement today that its vaccine candidate, mRNA-1273, is more than 94.5% effective in early trial results is wonderful news. Pfizer’s similar announcement from last week about its vaccine, BNT162b2, (also mRNA-based) gives us great hope that by mid-2021 the U.S. may have vaccinated most of the country’s population.

One advantage Moderna has over Pfizer is that its vaccine does not require “ultra cold storage,” as in minus 103 degrees Fahrenheit. As we wrote here, Pfizer says it has developed specially designed, temperature-controlled shipping packages, using dry ice, to keep its vials at roughly minus 103 below Fahrenheit for up to 10 days. But what happens if the doses are not used in ten days? This is one of the many things that is concerning governors and health care experts who are wrestling with the logistics of large-scale vaccinations.

We won’t know if Pfizer’s and Moderna”s vaccines can really do what it seems they might be able to do until the final results of their trials are known, but there is one thing we won’t know even then: How long will they protect us from the Coronavirus? Although both companies will follow all test subjects for a couple of years, if they each file quickly for and receive Emergency Use Authorization, which is all but guaranteed, they will go to market with about four months of data.

Will this lack of certainty about long-term protection cause people to forego vaccination? Personally, I don’t think so. But there is another possibility.

As we have seen for many months, despite the lack of competent leadership from 1600 Pennsylvania avenue, there are significant segments of the population taking the virus more seriously than others: seniors, those who are health-compromised, and myriad others who have paid attention to the science. It is conceivable these groups will take the vaccine, but refuse to return to any semblance of pre-pandemic life until long-term efficacy is known, and that won’t happen until well into 2022. If this happens, it is likely that masks, remote work, telehealth, and a host of other accommodations we’ve made due to the pandemic are here for quite some time longer.

Speaking of vaccines, here comes China

Flying under the media radar was an article in Foreign Affairs (subscription required) from 5 November by Eyck Freymann and Justin Stebbing. China Is Winning The Vaccine Race: How Beijing Positioned Itself as the Savior of the Developing World is an eye-opening look at China’s herculean effort to rebound from its tragically bungled initial response to COVID-19. From the article:

As a result, the disease spread around the world, crippling economies, killing more than 1.2 million people, and badly damaging Beijing’s image. In 2021, China plans to redeem itself by vaccinating a large chunk of the global population. Although it faces stiff competition from the United States and other Western nations in the race to develop the first vaccine, Beijing is poised to dominate the distribution of vaccines to the developing world—and to reap the strategic benefits of doing so.

Four of the 11 worldwide vaccine candidates are Chinese. The most promising of these, developed by Wuhan-based Sinopharm, is already being given to frontline workers in the United Arab Emirates.

Half the world’s population lives in the developing world, and Donald Trump’s administration, with its America First mantra, has no plans to distribute vaccines to that half of humanity, leaving a wide open door through which China is already walking. Also from the article:

The United States has declined to participate in a World Health Organization (WHO) initiative to deliver two billion vaccine doses to at-risk populations in developing countries, and it has not extended financing to or signed preferential vaccine distribution deals with such countries, as China has done.

While the U.S. will supply vaccines to its own citizenry and sell them to other developed countries, the vast underbelly of humanity will go a-begging. The emerging markets of Asia, Africa, the Middle East, and Latin America can barely afford vaccines, China has seized this opportunity by announcing subsidies and striking loan deals with the eighteen countries where its vaccine candidates are now in Phase Three clinical trials. As far back as May, Chinese President Xi Jinping promised that any successful Chinese vaccine would be used for a “global public good.” Thus far, he has kept that promise.

Throughout the pandemic (and, for that matter, the entire Trump presidency), America has ignored no, stiff armed the half of humanity most in need. This is just another Everest the incoming Biden Administration will have to climb as it tries to undo four years of foreign policy misfeasance, which the Oxford English Dictionary defines as “the wrongful exercise of lawful authority.” Kind of fits, doesn’t it?

Barack Obama returns

President Obama jumped back into the political scene as a force for Joe Biden during the recent campaign. Our first Black president did his part to help rally the African American vote, which proved so consequential in Biden’s victory.

Now, President Obama has written the first book in what will be a multi-book memoir. The Promised Land goes on sale tomorrow. So, he’s begun the book interview marathon, that, in his case, will be widely covered by the media. Case in point Yesterday, he turned up twice on CBS, first with Gayle King on CBS Sunday Morning and second with Scott Pelley on Sixty Minutes.

I’m sure the book is interesting and will sell a gazillion copies, but that’s not what I want to mention here. No, I’d like to end this column with a little story Mr. Obama told at the end of his interview with Ms. King.

Having become a private citizen at 12:01 pm, 20 January 2017, the former president began to reacclimate to private life. For security reasons, he was still prohibited from driving himself. So, as he tells it, there he is in the backseat of some vehicle checking his iPad and being driven somewhere by a Secret Service Officer. Then, the car slows and stops. Since this never happens in a presidential motorcade, he wonders why they stopped. Had something happened? Was there some danger? He looks up and sees the red light. At that moment, another car drives up beside him and he sees children playing in the back seat. As he told Ms. King, “Welcome to private life, Barack.”

Sixty-five days from now, Donald Trump will begin to encounter his own red lights for which he must stop. That will be a reality show worth watching.

 

 

Seven Days

Tuesday, October 27th, 2020

A diversion

How about a break from anything having to do with COVID-19 or the election? Would you like that? Then let me tell you a story.

Long ago, in a galaxy far away, a 23-year-old, newly-minted, Infantry 2nd Lieutenant airborne ranger with my name spent two-plus years in a little country in Southeast Asia called Vietnam. I think if Donald Trump had foregone the fake bone spurs and taken his chances over there he might have learned a lot.

But that’s another story, and not the point of this one. Couldn’t help myself.

Three months before rotating home to the U.S., I had been pulled from the field, that is, taken out of the jungle, and given a staff job on Firebase Vegel in northern South Vietnam.

With two months to go, I decided to begin keeping a Short-timer’s Calendar.

My Short-timer’s Calendar consisted of the centerfold of the June, 1971, Playboy magazine. My Battalion Commander, Lt. Colonel  Bulldog Carter (that’s right, Bulldog), and my partner, Buck Kernan (who went on to become a Lieutenant General, like his father before him), marked up the luscious photo into 60 puzzle-like areas numbered from 60 down to one. The trajectory of the progression became increasingly lascivious.

Thereafter we held a nightly, candle-lit ceremony in the bunker occupied by Buck and me.

But before I describe the ceremony, I have to tell you about the Macadamia nuts.

During Vietnam  the army  allowed soldiers a ten-day R&R (Rest and Relaxation) vacation. As a two-year guy I got two of them, which I spent in Honolulu, Hawaii, with my wife, Marilyn. One day, during the second R&R, we went to the PX (Post Exchange) at Scofield Army Barracks to pick up a couple of things. While we were there we bought a large bottle of Macadamia nuts for me to take back to Vietnam. In Vietnam, little things became luxurious delicacies.

Back to the ceremony.

Our bunker had a single bunk bed. There was only one bed, because Buck and I took 12-hour shifts in the Op Center keeping the world safe for democracy. One of us would end his shift, wave to the other and crash into the bed.

Every night, at 2000 hours, 8:00 pm to you, the three of us would gather in the bunker. There was a small table to the side of the bed.  I had pinned the centerfold to the wall above the table. At the appointed hour, I would light two candles and place them on each side of the table under the pin-up. I would open the bottle of Macadamia nuts, which occupied a special spot in the center of the table, and hand each of my comrades one nut, taking one for myself. We would then have a moment of quiet reflection, after which I would, with a red marker purloined from the Op Center, X-out the next descending number on Miss June.

We would then eat the nuts.

We did that all the way down to ONE! On that night, we held a special ceremony, inviting the Battalion XO, the other six staff officers and the Battalion Sgt. Major into the bunker, which became almost as crowded as the stateroom scene in Night at the Opera. We gave everyone a Macadamia nut that night, and, in a service worthy of priestly ordination, I passed the bottle of Macadamia nuts to Buck, who, because he still had six weeks to go, later on would replace my centerfold with his centerfold and continue the tradition. We retired my centerfold to a place of prominence on the side wall of the Op Center, where Bulldog could see it every day all day. Six weeks later, Buck’s would be hung beside it.

The next day, I choppered south, boarded a chartered Pan Am plane with about three-hundred other happy guys and flew home to what we called “the world.”

OK. Break’s over

If it weren’t so stupidly tragic and delusional, one might be forgiven for viewing Donald Trump’s campaign swan song as comical. “We’ve turned the corner.” “It will go away.” “On November 4th, you won’t hear about it anymore.” And the list goes on.

But if you really want to know how we’re doing, there are, actually, reliable places to look. Johns Hopkins Coronavirus Resource Center and the New York Times COVID Tracker, for example.

And now there is this website, which tracks the Rt factor for each state, daily. Rt represents the effective reproduction rate of the virus calculated for each locale. It lets us estimate how many secondary infections are likely to occur from a single infection in a specific area. Values over 1.0 mean we should expect more cases in that area, values under 1.0 mean we should expect fewer. As of today, only one state, Mississippi, of all places, is below 1. You can see what infection rates are like today, two weeks ago, one, two and three months ago. It confirms what all of us, except the aforementioned Mr. Trump, his minions and cult-like followers, know to be true.

If we’ve “turned the corner” it is only to enter Dante’s Ninth Circle of Hell. You remember that one, don’t you? It’s the final, deepest level of hell, reserved for traitors, betrayers and oath-breakers. Up until now, it’s most famous occupant had been Judas Iscariot.

Up until now.

And finally…

Seven days to go.

The number seven comes up a lot in Roman Catholicism. There are seven Cardinal Virtues, called by the church, “Gifts of the Holy Spirit.” They are wisdom, understanding, counsel, fortitude, knowledge, piety, and fear of the Lord.

There are seven Corporal Works of Mercy. They are feed the hungry, shelter the homeless, clothe the naked, visit the sick and imprisoned, bury the dead, and give alms to the poor.

And there are seven Spiritual Works of Mercy. They are instruct, advise, console, comfort, forgive, and bear wrongs patiently.

Judge, now Justice, Amy Coney Barrett is a devout Roman Catholic. I’m sure she is also a very smart person and probably a pretty good lawyer, too.

But for a month now, I’ve been bothered by something about her, and with seven days to go, I’m bothered even more.

For the life of me I cannot get over that, at her super-spreader Rose Garden introduction and follow-on reception in the White House, she did not wear a mask to protect herself and others. I understand everyone else who attended had swallowed the Kool-Aid, but she should have known better. And last night, in the White House Blue Room and outside on its balcony, she was still unmasked.

There are only three possibilities for this behavior.

  1. She doesn’t believe masks protect us and others from the virus, which I don’t believe for a minute;
  2. She is ignorant about masks and doesn’t understand their importance, which I don’t believe for a second;
  3. She was influenced by Trump’s behavior, as well as that of everyone else’s, and just went along to get along.

I’m voting for door #3, and that is a scary thought for our future.

Seven days.

 

 

It’s Been Quite A Week — Here Are Some Things You Might Have Missed

Saturday, October 24th, 2020

From the Department of There’s No Accounting For Stupidity

Since 1980, the population of Idaho has grown from about one million to nearly 1.8 million, considerably outstripping the rate of growth of its neighbors Montana and Wyoming. Over the last 14 days, all three states have seen large spikes in Covid-19 cases, according to the New York Times’s Covid Map and Case Count. And they’re not alone. All the Midwest and Pacific region states are seeing similar surges. Their governors are faced with balancing increased restrictions with the personal freedom inherent in pioneering individualism.

Nowhere did this daunting task become more evident than Thursday in Idaho, a state that has seen a 55% rise in cases in the last two weeks and where, minutes after hearing local hospitals were approaching full capacity necessitating moving patients to Seattle, of all places, the regional health board voted to repeal the local mask mandate.

The regional board, composed of seven appointed members with no requirement to have any medical experience, voted 4-3 to end the mandate. Health District epidemiologist Jeff Lee had just finished describing how the state’s hospitals were becoming “overwhelmed” by the surge in cases. For example, even after doubling up patients in rooms and buying more hospital beds, the hospital in Coeur d’Alene had reached 99% capacity. But, not to worry, it’s just an eight hour, 493 mile ambulance ride from Boise to Seattle.

“We’re facing staff shortages, and we have a lot of physician fatigue. This has been going on for seven months — we’re tired,” Lee said.

He introduced several doctors who testified about the struggle COVID-19 patients face, the burden on hospitals and how masks reduce the spread of the virus. But that didn’t matter to the Board’s majority who just did not see the sense in masks, no matter what the experts said.

To put a period on the “Health” Board’s meeting, member Allen Banks got to the heart of the matter by denying the existence of Covid-19. Lecturing the medical professionals who testified, he said, “Something’s making these people sick, and I’m pretty sure that it’s not coronavirus, so the question that you should be asking is, ‘What’s making them sick?”

That penetrating question came from a gentleman with a Ph.D. in chemistry from the University of Colorado, who for 30 years has worked in medical research in biotechnology and pharmaceutical development.

Dr. Banks would make a wonderful addition to the White House Coronavirus Task Force.

How cold is cold enough?

Have you stopped to consider the logistics of delivering upwards of 200 million doses of a future Covid-19 vaccine? That’s a lot of syringes. If you laid them end to end they would stretch from the North Pole to the South Pole, about 13,000 miles.

And the vaccine would have to be kept cold, very cold. Just how cold you ask? Try minus 103 Fahrenheit. That’s nearly four times colder than your home freezer, colder even than Antarctica in the dead of winter.

This is a complex challenge. For months, manufacturers, federal and state governments, and large health care systems have been quietly planning how to navigate this ultra “cold chain” that stretches from vaccine manufacturers to hospitals, nursing homes, doctors’ offices, and many far-flung clinics. Now that Pfizer has announced it plans to apply for emergency-use authorization designation in late November for its vaccine currently in Phase 3 trials, solving the cold problem becomes more urgent.

The nation’s governors wrote the Trump Administration last Sunday expressing concerns about the supply of ultracold freezers and dry ice — already experiencing shortages. Pfizer says it has developed specially designed, temperature-controlled shipping packages, using dry ice, to keep its vials at roughly minus 103 below Fahrenheit for up to 10 days. But what happens if the doses are not used in ten days? This is what is confounding the governors.

This issue is even more difficult than it appears, because the vaccines of both Pfizer and Moderna, another leading vaccine developer in Phase 3 trials, require two shots within 21 and 28 days, respectively. The situation is eased somewhat, because Moderna’s vaccine, at around minus 4 Fahrenheit, does not require the same ultra-cold storage temperature as Pfizer’s.

Might be a good time to buy stock in a maker of dry ice.

High Deductibles: Another nail in the rural hospital coffin

Since 2010, more than 130 rural hospitals have closed, 15 thus far in 2020. One mostly overlooked reason is the health insurance deductible. Depending on the plan (employer-sponsored, ACA Marketplace, etc.) a family deductible can range from $0 (but the out-of-pockets are huge) to well over $8,000.

Families in rural communities often face deductibles in the $2,000 to $4,000 range. And when family members require hospitalization, it often happens they cannot pay the deductible. Rural hospitals are forced to eat this less than tasty bill, send it to a collections company, or set up a payment plan with the patient. They prefer the payment plan route, but this significantly delays getting the money, and the bill is often reduced because of the patient’s economic circumstances. So, the hospital goes further in the red and its patients go further in debt. The pandemic has only exacerbated this problem.

Just another example of our nation’s dysfunctional health care “system.”

How to get rid of an irritating federal employee

Despite a great swath of the public thinking otherwise, federal employees can be fired, although it is true that this happens rarely. Of the 2.1 million federal employees about 10,000 are terminated annually, according to the Merit Systems Protection Board (MSPB).

Firing a federal worker is similar to what would occur in the private sector, with one twist. In both settings, best practice recommends, and the federal system requires, the three step verbal warning, written warning, termination process. The twist comes after that. Federal employees can appeal to the MSPB, and the appeals can take a long time to adjudicate.

This past week, the Trump administration threw an interesting log on the fire when the President issued an Executive Order stripping long-held civil service protections from employees whose work involves policymaking. This will affect tens of thousands of workers, and will reduce them to being, for all practical purposes, “at will” employees, meaning they can be fired for cause or not for cause at a moment’s notice.

Under this order, federal scientists, attorneys, regulators, public health experts and many others in senior roles would lose rights to due process and in some cases, union representation, at agencies across the government.

These are not politically appointed employees who require confirmation to their positions, whom the president can terminate or have terminated by whim. Rather, they are professionals who serve as a cadre of subject-matter experts for every administration. I will let you consider the possible ramifications of this Executive Order, which to me seem profound. The Order, while not affecting a majority of the government, could upend the foundation of the career workforce by imposing political loyalty tests.

It is possible, with less than two weeks before election day, this may be more symbolic than real, because the Order requires agencies to indicate employees who would be affected by 19 January 2021, a day before the next inauguration. If Joe Biden wins the election he would be unlikely to follow through on the president’s order. But if Donald Trump is re-elected, this tectonic Order will monumentally reshape the federal service.

Think about that. Please.

 

 

 

 

COVID-19 Analysis from Jennifer Christian, M.D., M.P.H.

Monday, September 21st, 2020

I have written before of my great admiration for Dr. Jennifer Christian and for her Work Fitness and Disability Roundtable (WFDRoundtable@groups.io). The Roundtable is a mainstay for clinicians and other health care professionals.

I thought this morning’s Roundtable post by Jennifer to be particularly thoughtful and thought-provoking, so I asked her if she would allow us to republish the post in its entirety here at the Insider. She very kindly gave permission.

I think Jennifer is one of those brilliant three or four folks I’m lucky enough to know who think around corners. Her mind makes intuitive leaps where others (like mine) plod along.

Here is Jennifer’s post:

How many people have some pre-existing immunity to COVID-19

There is growing uncertainty about what this fall and winter is going to look like with regard to the COVID-19 pandemic.  Are we going to have a second, and possibly even bigger wave of worldwide infections — or is the biggest part of this pandemic over and done with once each geographic area has had its first wave?

A new review from the British Medical Journal says researchers may have been paying too much attention to antibodies and too little attention to a second part of the human immune system that protects against and reacts to infections:  T cells.   More on this in a moment…..

But first, a reminder.  We are in the middle of the first large-scale pandemic with a new and highly contagious respiratory pathogen since the field of immunology was born!   Immunology is still quite young compared to other specialty areas in biological science and medicine.  It was only in the mid-20th century that advances in cell biology started making it possible to study the detailed processes that make up the immune response in detail.  That has led to much deeper understanding of the mechanisms by which vaccines work, to the development of the first cancer chemotherapy agents that selectively killed rapidly-proliferating immune cells, and to the development of immune-modulating drugs, which enable the transplantation of organs by muting the body’s natural rejection of foreign tissues.

The appearance of HIV/AIDS in the 1980’s again precipitated huge leaps in funding for research to increase our understanding of the immune system, which in turn highlighted the function of T cells and other previously unrecognized aspects of it.   However, in comparison to other bodily systems and organs, our knowledge of the human immune system is still primitive — it’s obvious there is much left to learn — and some of what we don’t know may seem very basic!

If you’re an immunologist, virologist, epidemiologist — or a public health officer trying to figure out how to protect and guide your local population — this is the overwhelming challenge of a lifetime.  Personally, I hope that the media and the general public will remember that this pandemic has attacked our society at the very edge of what is known.  All of those professionals are working at a feverish pace to observe carefully, assemble enough data to be confident they have enough to detect a real pattern if it’s actually there, make sense of what they are seeing, and then figure out the implications for action.  Let’s agree to be forgiving of the fact that “the facts” have not all been revealed to us yet, and “the scientists” simply don’t yet know everything we wish they did.

Back to the T cell story.   Researchers have shown that people with the most severe cases of COVID-19 (the ones in ICU and who are most likely to die) often have low T cell levels.  But some other puzzling data has appeared. For example:

  • some countries — and especially some areas within those countries that had bad initial outbreaks — have not seen widespread new infections despite having relaxed protective restrictions; and,
  • blood tests in a noticeable fraction of people with no record of exposure to SARS-CoV-2 virus show some of the T cells reacting weakly to it anyway — indicating a potentially partial immune response.

This has led scientists to start wondering whether we really know enough about the human immune system’s ability to develop partial T cell “cross-reactivity” to families of closely-related viruses and whether that might predictably and reliably reduce the severity of illness or even reduce the likelihood of getting ill at all when a new-but-related virus appears.   And, that, of course, raises some possibilities that need to be investigated:

  1. Does cross-reactivity explain why some geographic areas that had first pandemic peaks are not seeing second ones — because the people who got sick had no immunity and were more susceptible, and most of the remaining ones have some limited immunity which is protecting them?
  2. Does cross-reactivity explain some of the disparity between people who get deathly sick from COVID-19 and people who are exposed to the virus but never get infected, or, if they do, remain asymptomatic or have only mild illness?  Note that there are two  possibilities:  Cross-reactivity could be making the illness worse or it might be making it less severe — we don’t know yet.
  3. How could cross-reactivity be protective if it develops after prior exposure to coronaviruses, because children are the least likely to get a severe case of the disease and adults are the most susceptible to severe COVID-19 illness and death?  (Children have not had a lifetime of colds, and thus less opportunity to be exposed to coronavirus and develop partial-immunity to SARS-CoV-2)

In short, my best advice as of 21 September 2020 is:

  1. Stay tuned for further developments in the factual realm – both changes in case counts and new research results;
  2. Hope for the best but prepare for the worst as autumn approaches and we all retreat indoors.

Sisyphus Must Have Felt Like This

Wednesday, September 16th, 2020

The COVID-19 boulder, full of facts, lies, information, misinformation, disinformation, and just plain delusional thinking keeps rolling back down the mountain. Try as we might, it’s certainly difficult to make sense of COVID-19. But we keep trying, anyway. As in:

Unions during COVID-19

I have written previously about the perplexing case of union participation in America. In 1960, about a third of hourly workers belonged to unions. In January of this year, the BLS reported that number had dropped to 10.3%. Yet, in the same press release, the BLS reports:

Nonunion workers had median weekly earnings that were 81 percent of earnings for workers who were union members ($892 versus $1,095).

Right now we won’t get into why this puzzling paradox exists, except to say we now have another log to throw on the pyre.

A new study authored by researchers at George Washington University, the University of Pennsylvania Perelman School of Medicine and the Boston University School of Medicine, published in Health Affairs, found that having a unionized workforce at a nursing home greatly reduces the likelihood that residents or staff will die from COVID-19. From the study’s Abstract:

Health care worker unions were associated with a 1.29 percentage point mortality reduction, which represents a 30% relative decrease in the COVID-19 mortality rate compared to facilities without health care worker unions.

The study analyzed data from more than 300 nursing homes in New York from March 1 through May 31. The authors conclude the unionized health care workers in the nursing homes were able to negotiate for more PPE, higher pay, and better working conditions.

During the pandemic, New York has suffered nearly 7,000 nursing home deaths, more than any other state except New Jersey.

My take on this? If you have loved ones who may be headed for a nursing home, it might be a good idea to ask if the staff is unionized.

Avoiding medical care during COVID-19

Since early in COVID-19, we’ve known that many people, fearful of the disease, have put off getting routine, or, in some cases, emergency medical care. What we have not known is what demographic groups are doing that and to what degree. Now, the CDC has put a full stop period to that issue.

In its 11 September weekly Morbidity and Mortality Report, the CDC published a comprehensive analysis concluding 40.9% of U.S. adults delayed or avoided medical care as of June 30. This includes urgent or emergency care (12%) and routine care (32%). Regarding what population segments are doing this, the study had this to say:

The estimated prevalence of urgent or emergency care avoidance was significantly higher among the following groups: unpaid caregivers for adults versus non-caregivers (adjusted prevalence ratio [aPR] = 2.9); persons with two or more selected underlying medical conditions† versus those without those conditions (aPR = 1.9); persons with health insurance versus those without health insurance (aPR = 1.8); non-Hispanic Black (Black) adults (aPR = 1.6) and Hispanic or Latino (Hispanic) adults (aPR = 1.5) versus non-Hispanic White (White) adults; young adults aged 18–24 years versus adults aged 25–44 years (aPR = 1.5); and persons with disabilities§ versus those without disabilities (aPR = 1.3).*

So, Mary, taking care of her aged mother at home, foregoes either emergency or routine care at nearly three times the rate of Sarah, her next door neighbor who is not burdened with an aged relative, because she doesn’t want to bring COVID-19 home to Mom. Even more troubling is that people with two or more co-morbidities forego care at nearly two times the rate of people without such underlying conditions.

The CDC’s paper advises that, “… urgent efforts are warranted to ensure delivery of services that, if deferred, could result in patient harm.”

Enough said.

*By way of example for the statistically challenged, an adjusted prevalence ratio of 2 means that the prevalence of cases among a study group is 2 times higher than among the control subjects. It’s calculated through a series of regression analyses. There. Now you know.

U. S. life expectancy

COVID-19 has sucked all the air out of any national attempt at healthcare reform, while revealing in sharp detail the foundational flaws in the current system. Eventually, however, America is going to have to confront this issue in a meaningful manner. Healthcare cost in America is still twice the average of all 37 member countries of the Organization for Economic Cooperation and Development (OECD), and Americans still have poorer health and lower life expectancy than the average of the member countries (78.7 versus 79.5)

In its latest Health At A Glance publication, the OECD updated its life expectancy data, as shown here:

There are many cracks in our healthcare house that Jack built. Ignoring them is not a strategically viable plan for improvement, improvement that all citizens deserve.

To quote the venerable A. E. Housman, “Terrence, this is stupid stuff.” Another example of our woebegone healthcare system.

Trump’s Nevada rally

Last night, during an ABC-TV Town Hall Meeting President Trump once again pilloried cities and states run by Democrats and blamed their leaders for any problems with the response to COVID-19.

A little contextual background is required here. On 14 April, Trump asserted “absolute authority” to control the nation’s response to the pandemic, saying, “When somebody is president of the United States, your authority is total.” He made it clear he would be in charge and the states would have to fall in line.

Two days later, he reversed himself on a call with all the governors, telling them, “I’ve gotten to know almost all of you, most of you I’ve known and some very well. You are all very capable people, I think in all cases, very capable people. And you’re going to be calling your shots.”

Since then, he has repeatedly repeated the “You’re on your own” line. The result, of course, has been that we have seen 51 different plans and approaches  with varying degrees of success.

Nevada, one of the “you’re on your own” states, is still in the midst of a tough fight against the disease with a Daily Positivity Rate of 7.1% and a Cumulative Positivity Rate of 10.2% as of 10 September.

On 24 June, Nevada Governor Steve Sisolak imposed certain restrictions, among them the requirements that all Nevada residents wear masks when in public and that no more than 50 people, socially distanced, congregate in one place.

Enter Donald Trump and his the-sky-is-the-limit indoor rally of last Sunday evening at Xtreme Manufacturing in Henderson, Nevada. Fire officials estimated the size of the crowd was 5,600 people, nearly all of whom were maskless (except for the people right behind Trump who were constantly on full TV view).

Just as we saw in Tulsa after his previous rally, we’ll probably see a spike in cases in Nevada in two to three weeks.

Beyond the nonchalant and willful endangerment to peoples’ lives, what bothers me most of all about this event is Donald Trump’s cavalier and metaphorical raising high of his two middle fingers to Nevada’s scientifically-based efforts to keep its citizens alive. After repeatedly telling the nation’s governors they should do what they think they need to do to combat COVID-19, this “law and order” president, without compunction of any kind, imperiously violates the law while telling his large crowd Nevada’s Governor Sisolak is “a hack” and “weak.”

Allow me to close with Joseph Welsh’s question to Senator Joe McCarthy on 9 June 1954: “Have you no decency, sir?”