Archive for the ‘Medical Issues’ Category

Mississippi: America’s Third World Country

Wednesday, May 11th, 2022

Although I have been there only once, I can’t help thinking about Mississippi.

Mississippi has recently been in the news, of course, because its 2018 Gestational Age Act will be upheld in the same Supreme Court decision overruling Roe v. Wade, which we discovered from Justice Samuel Alito’s leaked first draft opinion for the majority.

This is not Mississippi’s first foray into restricting abortion. In 2007, the state passed its version of an abortion Trigger Law, which “bans all abortions unless necessary to save the life of the pregnant woman or if the pregnancy was caused by rape and charges have been filed with law enforcement,” and which takes effect immediately following the state attorney general certifying the Supreme Court has overturned Roe v. Wade. The Trigger law had 19 male legislative sponsors and zero female sponsors. Regardless, Mississippi has been ready for this for 15 years.

But has it been ready for what comes next?

Matthew Walther, editor of The Lamp, a Roman Catholic literary journal, and a person who will never be accused of favoring abortion, sees predictable and unpleasant consequences after Roe is no longer the law of the land. In his 10 May 2022 guest essay for the New York Times, “Overturning Roe will disrupt a lot more than abortion. I can live with that,” Mr. Walthern acknowledges what very few anti-abortionists want to admit.

Research over the years has suggested that an America without abortion would mean more single mothers and more births to teenage mothers, increased strain on Medicaid and other welfare programs, higher crime rates, a less dynamic and flexible work force, an uptick in carbon emissions, lower student test scores and goodness knows what else.

But Mr. Walther, despite envisioning a gloomy horizon, “can live with that.” I cannot restrain myself from pointing out that Mr. Walther is of the male persuasion and, consequently, faces little likelihood of ever having to “live with” personal pregnancy.

Nonetheless, he makes a good argument, which brings us back to Mississippi.

A few points worth considering:

  • Poverty: According to the Department of Agriculture, 20.29% of Mississippi’s adults and 27.6% of its children live below the poverty line. This is the highest poverty rate in America where the national average is 11.4%.
  • Income: The median family income in Mississippi is $45,081. This is the lowest in the nation. According to the National Census Bureau, the national average in 2019 was $65,712.
  • Education: Only Texas, at 84%, ranks lower than Mississippi, at 85%, for the percentage of high school graduates. The national average is 89.6%. Only West Virginia, at 21%, ranks lower than Mississippi’s 22% for the percentage of college graduates. The national average is 31.28%.
  • Life Expectancy: At 74.4 years, Mississippi has the lowest life expectancy rate in the nation. Of note, the life expectancy rate for Mississippi’s men is 71.2 years.
  • Fetal Mortality: Mississippi’s fetal mortality rate, the number of deaths at 24 or more weeks of gestation per 1,000 live births, is 6.6. This is the highest in the nation. The national average is 3.68. If that isn’t enough, fetal deaths have lately doubled among unvaccinated pregnant women who suffer COVID-19 infections, State Health Officer Dr. Thomas Dobbs said during a Mississippi State Department of Health press conference in September, 2021.
  • Infant Mortality: The Infant Mortality Rate is the number of infant deaths per 1,000 live births. At 8.27, Mississippi’s is the highest in the nation, far exceeding Louisiana’s rate of 7.53, which is the second highest.
  • Maternal Mortality: According to the Centers for Disease Control and Prevention (CDC), Mississippi’s maternal mortality rate is 20.8, again, the highest in the country, where the national average is 17.4, which is the highest among all members of the Organization for Economic Co-operation and Development (OECD). A maternal death is defined by the World Health Organization as, “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”
  • Maternity Leave: Mississippi has no guaranteed Maternity or Sick Leave in its state laws.
  • Smoking: According to the CDC, 20.4% of Mississippians smoke. This is the fourth highest in the nation.
  • Autopsies: Something you probably have never have considered until now: Autopsy backlogs. According to the National Association of Medical Examiners (NAME), 90% of all autopsies should be completed within 60 days of death. The NAME has never accredited Mississippi, which has the highest backlog in the nation. The Mississippi State Medical Examiner’s Office was waiting for about 1,300 reports from as far back as 2011, records sent to the Associated Press in early April show. Around 800 of those involve homicides – meaning criminal cases are incomplete.
  • Abortion: According to the Mississippi Department of Public Health, the state has about 3,500 abortions annually. This represents 4.3 abortions per 1,000 women of reproductive age.
  • Finally: Mississippi ranks highest in the nation for Percent of Births to Unmarried Mothers, Cesarean Delivery Rate, Preterm Birth Rate, and Low Birthweight Rate.

Reading the above, one might be forgiven for thinking  there is a significant population in Mississippi who are actual victims of the state’s inability, or outright refusal, to carry out its first responsibility: to provide for the security and safety of its citizens.

Thinking about this, I have to ask: Given how well it’s doing now, how in the world is Mississippi going to cope with 3,500 new births per year? On CNN this past Sunday, Jake Tapper interviewed the state’s Republican Governor, Tate Reeves. That interview offered a glimpse of what is likely coming, a catastrophe becoming worse than it already is, which is considerable.

Tapper: Mississippi, as you know, has the highest rate of infant mortality in the United States. You have the highest rate of child poverty in the United States. Your state has no guaranteed maternity leave that’s paid. The legislature in Mississippi just rejected extending post-partum Medicaid coverage. Your foster care system is also the subject of a long-running federal lawsuit over its failure to protect children from abuse. You say you want to do more to support mothers and children, but you’ve been in state government since 2004. Based on the track record of the state of Mississippi, why should anyone believe you?

Reeves: I believe in my heart that I was elected, not to try to hide our problems, but to try to fix our problems. We are focusing every day on fixing the challenges that are before us.

Good luck, Governor. You and all those “unborn” children who are about to be “saved” are going to need a lot of it. And so are the Mississippi women who are about to become the state’s newest victims.

 

 

 

 

Unmasked In America

Wednesday, April 20th, 2022

Having now fully recovered from a week-long dance with COVID 19, I can report that here in the heart of the Berkshire mountains, once again all seems right with our little corner of the world. The grey and red squirrels have resumed tormenting Lancelot, the mighty wonder dog, as they contemptuously steal the bird seed he daily guards, impervious to his barking, too fast for his chasing. But he continues to try. We should all be so determined.

Meanwhile, in a surprise ruling yesterday, US District Court Judge Kathryn Kimball Mizelle struck down the Centers for Disease Control and Prevention’s national mask mandate for public transportation. Airlines and their passengers appeared jubilant.

Much has been made of the fact that Judge Mizelle is both a Trump appointee and was judged by the American Bar Association “not qualified,” as noted in its 8 September 2020 letter to the Senate Judiciary Committee when Judge Mizelle was being considered for her current position.

Judge Mizelle had been nominated to serve as a district court judge for the United States District Court for the Middle District of Florida. As part of its analysis of a candidate’s qualifications for such a position, the ABA goes by criteria laid out in its Backgrounder.

The Backgrounder provides that “a nominee to the federal bench ordinarily should have at least 12 years’ experience in the practice of law.” The Backgrounder further provides that “in evaluating the professional qualifications of a nominee, the Standing Committee recognizes that substantial courtroom and trial experience as a lawyer or trial judge is important.”

The ABA noted Judge Mizelle was admitted to the Bar only eight years before her nomination and had never “tried a case, civil or criminal, as lead or co-counsel.”

Judge Mizelle had clerked for four judges, including Justice Clarence Thomas, and spent all of ten months at what the organization called a “reputable law firm.” Although the ABA wrote that the Judge had a “keen intellect,” in what appeared to be a sardonic coup de grace dripping with cynicism it noted, “We also are aware that as a law school student the nominee participated as co-counsel with her supervising law professor in two one-day state court trials as part of her curriculum.”

I’m wondering if the ABA, in its long history of evaluating people for district court judgeships, has ever before felt the need to dip into a candidate’s law school course history in order to say something, anything, nice about the candidate’s experience.

Moving beyond how she got to where she is, we need to ask how Judge Mizelle’s order will play out? As mentioned above, airlines seem to be overjoyed, but airplanes are well-ventilated conveyances. Her order affects all public transportation, and subways at rush hour, for instance, have about as much ventilation as a well-traveled sarcophagus.

And what about other industries? Although Judge Mizelle’s ruling applies only to public transportation, it is forcing others to re-examine their policies. For example, consider the health care industry.

Most health systems and physician groups have indicated they will maintain their masking requirements, regardless of changes in other industries. Some providers are easing the rules in certain markets as COVID-19 infection rates decline, but those decisions were made independent of Mizelle’s ruling.

Trinity Health’s chief clinical officer, Dr. Daniel Roth, said the Judge’s ruling jeopardizes the immunocompromised and those who can’t be vaccinated. “Trinity Health has followed guidelines from the CDC to ensure the safety of our colleagues, clinicians and patients. Yesterday’s court decision removing the requirement for face coverings on public transportation was irresponsibly abrupt and increases risk,” he said in a statement.

This evening, the Biden administration’s Justice Department, in keeping with a recommendation from the CDC, announced it would appeal Mizelle’s ruling. Although this might be the right health decision, it is likely the wrong political decision. It will perpetuate the uncertainty and confusion Americans face every day as they travel, and that will only strike another blow at Biden’s approval ratings. It may be time, finally time, to let Americans decide for themselves, with all the heartbreak that might bring to some.

No one’s asking me, but if they were, I would dearly love to advise President, also Politician, Joe Biden to do nothing, absolutely nothing. Let this go and, with a smile on your face, watch it fly off into the vastness of the darkest of nights never to be mentioned again. With all the problems of the last 15 months, if he never again had to get into the “to mask or not to mask” debate, our President would be one very happy guy.

Yes, I would dearly love to offer that advice.

But what about the many immunocompromised people who have to travel but are scared to death to do it. What about them?

And what about the children? What about the children too young to be vaccinated, in some cases too young for a mask? What about unmasked adults on public transportation near those children who might infect them because they chose their personal “freedom” over the potential harm to a child?

What about that?

COVID-19 Update

Friday, September 18th, 2020

To close out your week we offer a few items that may have flown nap-of-the-earth under your radar.

The AstraZenica/Oxford vaccine bump in the road

On 8 September AstraZenica (AZ) halted its Phase 3 study, because one of its study participants came down with Transverse Myelitis, a neurological condition affecting the spine and caused by infection, immune system disorders or other disorders that can damage or destroy myelin, the fatty tissue that protects nerve cell fibers.

The UK has allowed AZ to restart its study there (AZ is a UK-based company), but as of this writing, the U.S. has not. In fact, in an interview with Kaiser Health News, the National Institute for Neurological Disorders and Stroke’s Avindra Nath said “the highest levels of NIH are very concerned.” According to Nath, the NIH has yet to access tissue or blood samples from the patient, who was part of the U.K. portion of AZ’s Phase 3 study. NIH believes AZ is being far too coy with its data. Nath called for the company “to be more forthcoming,” adding that “we would like to see how we can help, but the lack of information makes it difficult to do so.”

Given this halt in the U.S. study, it is not inconceivable that, if the AZ vaccine, known as AZD1222, proves efficacious and safe in the UK, regulators there could approve it for general use well before the U.S. does. This would not make our Commandeer in Chief happy.

The Mask versus Vaccine dust up

Speaking of the Commander in Chief, he recently took CDC Director Dr. Robert Redfield for a quick walk to the woodshed for suggesting during testimony to a Senate subcommittee, “Masks are more guaranteed to protect me against COVID-19 than a vaccine.”

President Trump, who is not a doctor, but repeatedly plays one on TV, took exception to this. He publicly chastised Redfield for his comments and said a vaccine could be available in weeks and go “immediately” to the general public. Diminishing the usefulness of masks, despite a wealth of scientific evidence to the contrary, he said his CDC chief was “confused.”

Well, no, he wasn’t. Redfield told subcommittee members that if everyone in the U.S. would wear masks in public the pandemic could be under control within 12 weeks. His issue with a vaccine lies in its degree of immunogenicity, which he suggested would be in the area of 70%, meaning if 100 vaccinated people are exposed to the virus, 30 of them will have insufficient protection to ward it off. Those 30 will probably be comprised of groups who are most susceptible to the vaccine now, like the elderly.

People, masks will be with us for a long time.

Health insurance losses

Before the pandemic, 49% of Americans got health insurance through employer sponsored insurance (ESI). COVID-19 has reduced that percentage, because 6.2 million of our neighbors have lost their jobs and, consequently, their health insurance. When you factor in spouses and children, the number of people who have been shoved out the door into the COVID cold becomes 12 million.

Researchers at the Economic Policy Institute (EPI) have recently documented the losses in a new study. Researchers Josh Bivens and Ben Zipperer write:

  • Extreme churn after February 2020 has led to very large losses in ESI coverage. In March and April, for example, new hiring led to 2.4 million workers gaining ESI coverage each month, but historically large layoffs led to 5.6 million workers losing coverage each month. This rate of lost coverage—over 3 million workers—dwarfs a similar calculation for the number of workers losing coverage each month during the biggest job-losing period of the Great Recession (September 2008–March 2009). Our analysis using the monthly, high-quality measure of the total number of jobs in the economy from the Current Employment Statistics (CES) program of the Bureau of Labor Statistics (BLS) is consistent with 9 million workers having lost access to ESI in March and April 2020 but 2.9 million workers having gained coverage between April and July 2020.

Bivens and Zipperer say about 85% of those who lost ESI coverage were able to gain at least some coverage either through a spouse’s plan, the Affordable Care Act or state Medicaid programs, but that still leaves about a million laid off workers and their familes with nothing. Bivens, Zipperer and others argue the job losses have only worsened the public health crisis created by COVID-19.

Of course, recognizing that millions of people losing employer sponsored health insurance is a public health crisis is not the same as fixing the system to prevent it from happening again. However, as I have written before, having exposed gross inadequacies in the nation’s health care system, COVID-19 also provides opportunities for improvement. What is needed now is the determined motivation and will to make that happen. That is a Herculean task about which I wish I were more optimistic.

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?”

 

The Sad Saga Of The Masks

Wednesday, April 22nd, 2020

face masks

Michael Einhorn is CEO of Dealmed, a medical supply importer and distributor for the New York, New Jersey, Connecticut Tri-State area, the hottest COVID 19 spot in the U.S (so far).

Although Dealmed buys gowns, gloves and other medical supplies from manufacturers around the world, it gets all its masks from China. Prior to the COVID 19 pandemic, Einhorn would buy medical masks for about $.50 apiece. He would then, at a cost of around $15,000, or $.05 per mask, put 300,000, or so, of them on a container ship, which would reach the U.S. a couple of weeks later, whereupon, under contract, he would sell them for between $.70 and $.80 per mask, garnering a tidy, volume driven profit.

At the beginning of January, Einhorn’s world turned upside down thanks to an unfortunate series of events.

  1. On 8 January, the CDC announced “a pneumonia of unknown cause” was spreading in Wuhan, China. This greatly alarmed Einhorn. “It was then I knew that something shocking was happening”;
  2. On 25 January, the Chinese new Year, the Year of the Rat, began. Lasting 23 days, this is the major vacation period for Chinese workers. Think Paris is August;
  3. Wuhan is the “world capital” of medical mask manufacturing. All of Dealmed’s masks come from three companies within one hour’s drive of Wuhan;
  4. On 23 January, China issued the Wuhan (Hubei province) lockdown, which lasted 76 days until 8 April; and,
  5. The Chinese government allowed mask-manufacturing to begin again in early March, but all masks stayed in China to fight its own COVID 19.

Meanwhile, back on the home front, the COVID 19 tsunami was washing over America.

  • In early January, U. S. intelligence agencies began warning the Trump Administration that China wasn’t being honest about the scale of the crisis.
  • On 10 January, former Trump Homeland Security Advisor Tom Bossert urged action on COVID-19, saying,“We face a global health threat…a new kind of coronavirus.”
  • On 21 January,  The CDC’s Nancy Messonnier said in a congressional briefing that more cases were expected in the United States.”This is an evolving situation and again, we do expect additional cases in the United States”
  • On 28 January, former FDA Administrator Scott Gottlieb and Luciana Borio penned an op-ed in the Wall Street Journal offering a 4-point plan to prepare for COVID-19.
  • And on 29 January, both the New York Times and The Atlantic published articles detailing the woeful shortage of masks in the U.S., and reporting, in the words of the Times, “the hoarding has begun.”

Two decades ago more than 90% of America’s masks for the healthcare community were made in the USA. But then, China entered the game. China with significantly lower manufacturing costs. The result: Now U.S. firms make only 5% of the masks we need. China has cornered the market.

So, in early January, when the fecal matter impacted the whirring instrument, Michael Einhorn was catapulted overnight into a new wild west style universe where everyone in the health care community all over the world was competing with each other for a finite number of masks.

Eventually, his Chinese manufacturers were willing to once again make his masks, but at greatly elevated prices. A mask that used to cost him $.50 was now $2.00, or more. Because of the urgent need, he could no longer use container ships; they took too long. Enter Air Freight. At first, “We were paying $40,000 to $60,000 for cargoes that were one-fourth what we’d put on container ships,” he says. “Then, the cargo planes were in such short supply that the cost went to $80,000 to $90,000.” Consequently, his total costs are now in the $3.50 to $6.00 range for masks, which he sells to his health care clients for about $5.00, which is more than six times higher than pre-COVID 19.

If you didn’t know any better, you’d think Einhorn is price gouging, but he’s not. The Chinese manufacturers and the air freight companies on the other hand….

People, this did not have to happen. Our federal government, yes, the Trump administration, should have seized control of this supply chain fiasco from the beginning and put in place a comprehensive and coordinated program to secure and distribute the essential medical equipment the nation was going to need during COVID 19.

If the Trump administration had done that governors would not have to compete with each other, hospitals would not have to compete with each other, and no one would have to compete with the federal government for a single mask.

And maybe, just maybe, a lot of health care heroes who have given their lives saving others would still be with us.

 

Governor Kristi Noem’s Magical Thinking

Tuesday, April 14th, 2020

Once more unto the Covid 19 breech, dear friends, once more.

Ever been to South Dakota? Beautiful place. Miles and miles of rolling prairies. Postcard worthy. Home to Mount Rushmore, the Crazy Horse Memorial, and the Black Hills.  Remember the three-season HBO series Deadwood? The real city of Deadwood is in South Dakota, although how a place with 1,300 people gets to be a city is beyond me. But that’s rural America for you.

South Dakotans are hardy souls, rugged individualists. They have to be; there are less than 885,000 of them all spread out over 77,000 square miles. That’s about 11 people per square mile.

With about 182,000 people, Sioux Falls is the most populous city in South Dakota. Virginia-based Smithfield Foods, the city’s fourth largest employer, is the third largest pork processor in the country, producing 18 million food servings a day. Two days ago, Smithfield announced it was closing down and ceasing operations indefinitely after more than 300 of its 3,700 workers tested positive for COVID 19. More than 550 independent family farmers supply the plant. This is a huge blow to Sioux Falls and South Dakota, as well as a kick in the gut to the nation’s food supply and supply chain.

This morning, Sioux Falls Mayor Paul TenHaken gave a passionate press briefing about the current situation and the horror he sees coming if drastic mitigation efforts don’t happen. The Mayor reported that in the last three days, the number of COVID 19 cases have been 149, 182 and 218, respectively. He would like to issue a stay at home order. Trouble is, the South Dakota legislature has stripped him of much of his authority to do so. He has to “request approval” from the legislature, which requires a seven-day notice period. Today, he made his request, and the earliest his order can take effect is 21 April. In the Mayor’s words, “This is crap. A shelter-in-place order is needed now. It is needed today,”

The Mayor is taking his action, the only action he can take, because the state’s governor refuses to issue such an order.

Which brings us to Governor Kristi Noem and her magical thinking.

Noem did, by Executive Order, compel everyone over the age of 65 to stay at home, except for essential travel. That’s only 14% of the state’s population. For everyone else, well, they can do what they want. She acknowledges her action could result in around 70% of South Dakotans contracting COVID 19, but she said it is not up to government to tell people how to behave. “The people themselves are primarily responsible for their safety,” she said. “They are the ones that are entrusted with expansive freedoms.”

As we have just seen in Sweden, this type of governing puts one firmly on the path to doom.

It appears Noem may be the only person in South Dakota who actually believes this idiotic laissez faire attitude is correct. Mayors like Sioux Falls’s TenHaken and Rapid City’s Steve Allender have joined with 160 county and city leaders who have petitioned her to declare a statewide public health emergency. In addition, more than 30,000 front-line health care workers have sent their own petition to Noem demanding she order people to stay at home.

Thus far, Noem seems to be an “n” of one. Drastic mitigation, Noem said disparagingly, reflected a “herd mentality.” It was up to individuals — not government — to decide whether “to exercise their right to work, to worship and to play. Or to even stay at home.”

So, what happens when, not if, the rancid COVID 19 flower blooms in South Dakota in the next week of two?

Among 44,000 cases in China, about 15% required hospitalization and 5% ended up in critical care. In Italy, the statistics so far are even more dismal: More than 50% of infected individuals have required hospitalization and about 10% have needed treatment in the ICU.

Nearly half the population of South Dakota lives in cities. That’s about 431,000 people. New York’s experience showed us COVID 19 spreads much more readily through densely packed populations. Consequently, it is logical to presume the cities of South Dakota are where it will strike more fiercely. If, because of Noem’s inaction, COVID 19 infects only 10% of that population, more than 43,000 cases will happen. If only 20% of those cases require hospitalization, the state will need 8,600 hospital beds.

As of 2019, South Dakota had 2,735 hospital beds; Sioux Falls,1,159. According to the 2019 State Physician Data Workforce Report, South Dakota has 240 doctors per 100,000 people, or about 1,920 in the entire state. The number of ICU beds is unknown.

South Dakota could be in for a monumentally rough ride.

 

 

More COVID 19 Quick Takes

Tuesday, April 7th, 2020

Offered without comment. None needed.

“The notion of the federal stockpile was it’s supposed to be our stockpile, It’s not supposed to be state stockpiles that they then use.” – Jared Kushner, the president’s son-in-law and adviser, at a White House briefing last Thursday, 2 April.

The federal stockpile of you know what.

I know, I know. You’re saying, “What? Another piece on the federal government’s inept performance to get masks and ventilators to the states?”

Yup. Some seemingly dead horses need new beatings when new facts emerge, and, as John Adams said 250 years ago when defending British soldiers on trial for their roles in the Boston Massacre, “Facts are stubborn things.”

But first, a word about the Associated Press (bet you didn’t see that one coming).

The AP, founded 173 years ago, is a cooperativeunincorporated association. Its members are U.S. newspapers and broadcasters. Its 3,200 employees operate out of 263 bureaus in 106 countries. It’s won 53 Pulitzer Prizes since the prize was created in 1917, and its AP Stylebook is the gold standard for reporters. Although everyone makes mistakes, and the AP is no exception, it exemplifies what news reporting ought to be.

Yesterday, the AP reported on its investigation into federal purchasing contracts for COVID 19 Personal Protective Equipment (PPE) and Ventilators. The investigation showed that:

As the first alarms sounded in early January that an outbreak of a novel coronavirus in China might ignite a global pandemic, the Trump administration squandered nearly two months that could have been used to bolster the federal stockpile of critically needed medical supplies and equipment.

A review of federal purchasing contracts by The Associated Press shows federal agencies largely waited until mid-March to begin placing bulk orders of N95 respirator masks, mechanical ventilators and other equipment needed by front-line healthcare workers.

By that time, hospitals in several states were treating thousands of infected patients without adequate equipment and were pleading for shipments from the Strategic National Stockpile.

The President has said repeatedly that the states should be purchasing the PPE they need to confront the virus and that the stockpile is a last resort (see the Jared Kushner quote, above). On 19 March Trump said of the federal government, “We’re not a shipping clerk.” Trouble is, we now have a situation where:

  • The stockpile is nearly empty, because Trump, under constant criticism from the governors, was forced to distribute much of it;
  • The federal government is now buying all the PPE and ventilators it can find all over the world;
  • The states continue to try to buy, scrounge, or borrow PPE and ventilators wherever they can; and,
  • Everybody’s competing with each other for the stuff, driving up prices, creating a seller’s market (think price gouging as an art form).

What’s going on in the Situation Room?

CNN is reporting a “heated disagreement” over the weekend in the Situation Room about the efficacy of the anti-malaria drug hydroxychloroquine. Multiple sources told the network Donald Trump’s top trade adviser Peter Navarro, recommending widespread use of the drug,”feuded with other officials over the drug’s unproven effectiveness to treat coronavirus.” In particular, Navarro took great exception to Dr. Anthony Fauci, Director of NIH’s National Institute for Allergy and Infectious Diseases, a post he’s held since 1984, telling him there was no data to indicate hydroxychloroquine is in any way effective, let alone safe, for treating COVID 19. CNN reports Navarro came to the meeting armed with documents he said proved his point, but which Dr. Fauci called anecdotes, and anecdotes are not data. Apparently, Dr Fauci saying to Navarro, who is not a member of the White House Task Force, “What are you talking about?” was particularly upsetting to the Trade Advisor.

Asked about the exchange today on CNN’s “New Day” Monday morning, Navarro claimed he is qualified to disagree with Dr. Fauci about COVID 19, despite not working in the health care field, because he has a PH.D. and is a Social Scientist. According to Merriam-Webster, Social Science is “a branch of science that deals with the institutions and functioning of human society and with the interpersonal relationships of individuals as members of society.” Surely that qualifies Dr. Navarro to recommend unproven medical treatments for the hundreds of thousands of current and projected victims of COVID 19 and to hijack the Task Force’s valuable time in the Situation Room. Split hairs are thicker than Navarro’s logic.

On the other hand.

This morning, Maggie Haberman, of the New York Times reported that Navarro warned the administration late in January that the “coronavirus crisis could cost the United States trillions of dollars and put millions of Americans at risk of illness or death.” Navarro wrote in a memo that a “lack of protection elevates the risk of the coronavirus evolving into a full-blown pandemic, imperiling the lives of millions of Americans.”

Too bad Navarro couldn’t prevail in that discussion back in January. We give him points for trying.

And what about those masks?

China is the world’s leading producer of surgical masks, turning out 50 to 60 million of them per day. When COVID 19 happened, China increased production to – get ready for this – 200 million per day. But because the pandemic originated in China, most of those masks stayed there. When the pandemic eased in China, masks once again began flowing, albeit more slowly and at greater cost, to the rest of the world, which, by that time, was already in the throes of the pandemic. Masks became the new gold.

Yesterday, NPR’s Mary Louise Kelly interviewed Mike Bowen, Co-Owner and Executive Vice President of Prestige Ameritech, located in North Richmond Hills, Texas. Mr. Bowen’s firm is the largest domestic maker of healthcare masks in this country. Governments, the healthcare industry, and companies from all over the world are asking him and the other American mask makers to supply them with masks, given the Chinese have turned down the spigot. During the interview, Bowen was discouraged and discouraging about his firm’s success prospects in picking up the Chinese slack to produce more masks. According to Health and Human Services Secretary Alex Azar, as of 10 March, the U.S only had about 1% of the 3.5 billion masks it needs to combat this pandemic. Bowen said every day he gets more than 400 emails asking for masks. But he can’t provide what he doesn’t have. He said, “It’s not like flipping a switch.” Machines have to be built, employees hired and trained. And when this is over, what does he do with the new machines and the new workers when demand has dropped off?

Bowen told Kelly he has been here before, during H1N1, when he built new machines, hired and trained workers and, after the scare was over, nearly went bankrupt. He had to lay off 150 people and moth-ball his machines. He’s afraid that’s what will happen again, as are all the other mask manufacturers.

And why is that? Bowen says because his masks are made in America, they are more expensive than masks made in Mexico and China. Consequently, until COVID 19, his firm had, in his words, “zero masks” going to federal agencies. Prestige has repeatedly bid on federal contracts for masks with HHS and DOD, but has never succeeded, because of cost.

Even going all out, 24/7, Bowen claims there is no way on God’s Green Earth he, and all the other mask-making companies, will ever be able to get all the masks COVID 19 requires to American health care workers. Sobering, indeed.

On that happy note, I leave you until next time.

 

 

 

CoVid 19 Quick Takes

Friday, April 3rd, 2020

 

Quote of the day: “To put it bluntly, the U.S. economy went from full speed to full stop — and millions of workers were not wearing seat belts.” – Josh Lipsky, director of global business and economics policy at the Atlantic Council, a nonpartisan think tank.

 

Keeping up with all things CoVid 19 is like swimming through Semolina. It takes a lot of fortitude and stamina. But here goes, anyway.

The states versus the nation

Examining the national response to CoVid 19….no, wait, we don’t have a national response. We have close to 60 responses, one for each of the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands and the other US territories. If you don’t think they’re all on their own, just ask Andrew Cuomo. He said yesterday that none of the governors were currently screaming for states rights. They all want help, they all want national leadership, and they want it yesterday, maybe last week. Look at Ron DeSantis, Governor of Florida. For weeks, under withering criticism and through the debacle of Spring Break on the beaches, he refused to issue a Stay At Home order. Said the state didn’t need it. His excuse? The White House hadn’t told him to do it. But yesterday it did, so he did. Well, actually, the White House “recommended” it. DeSantis made a point of saying he “cleared it with the President.”

Contrast DeSantis’s actions with those of Mario Cuomo, Jay Inslee, Gavin Newsom, JB Pritzker, Gretchen Whitmer, Janet Mills, Charley Baker, and Mike DeWine. They’ve all been on their own, but they’ve been decisively responsible, and their constituents will one day thank them.

Every governor is reacting, and reacting is the right word, differently. It’s like watching an Athenian Trireme in the Mediterranean with all 170 oarsmen rowing at different speeds.

Don’t believe me? Let’s look at Stay At Home orders. Here’s a New York Times map showing state Stay At Home orders from 30 March, four days ago:

And here’s the same map as of yesterday, four days later:

The nation’s Governors are all having to act like European Prime Ministers, many of whom have issued travel restrictions and sealed borders. A week ago, Rhode Island’s Governor Gina Raimondo began letting New Yorkers into her state only if they would self-quarantine for 14 days, and she had the National Guard at the border to enforce the order.

All Governors would like their constituents to view them as Horatius At The Bridge, but Covid 19 is likely not the particular bridge they would have in mind. They need national leadership, not national cheerleading. Absent that, they’ve been forced to step into the void, some, like DeSantis, very reluctantly.

Trouble coming for the southeast

Vann R, Newkirk, II, has a terrific piece in this week’s The Atlantic looking at the public health difficulties facing young people, made even more severe by CoVid 19, in America’s southeastern states. Newkirk says:

So far, about one in 10 deaths in the United States from COVID-19 has occurred in the four-state arc of Louisiana, Mississippi, Alabama, and Georgia, according to data assembled by the COVID Tracking Project, a volunteer collaboration incubated at The Atlantic….The coronavirus is advancing quickly across the American South. And in the American South, significant numbers of younger people are battling health conditions that make coronavirus outbreaks more perilous.

Some context is needed. A new study by the World Health Organization (WHO), endorsed and published by the National Academies of Science, Engineering and Medicine ranks America at or near the worst in just about every mortality rate category you can think of when compared with the other 16 wealthiest countries. U.S. Health in International Perspectives: Shorter Lives, Poorer Health paints a grim picture that should concern us all.

Now, look at the health of people in the deep south, particularly young people, who, according to a new study by the Kaiser Family Foundation, have more comorbidities than young people anywhere else in the country. Those comorbidities put them at much greater risk of becoming seriously ill if they contract CoVid 19.

According to Newkirk:

If you define Oklahoma as part of the South, southern states fill out the entirety of the top 10 states in percentage of population diagnosed with hypertension by a doctor. Southerners are more likely to suffer from chronic diseases than other Americans—even as Americans are more likely to suffer from chronic diseases than citizens of other countries with comparable wealth.

Imagine you have a big barrel full of apples. Inside that barrel is a smaller barrel with apples your farm stand might label “seconds.” Inside that “seconds” barrel is a third and smaller barrel with apples your farm stand wouldn’t ever sell. The third barrel is health in the deep south.

The USNS Comfort

Remember this photo?

That’s the USNS Comfort, the 1,000 bed ship Donald Trump, to great fanfare, sent to New York to help with the serious hospital bed shortage, getting worse every day.

I’m guessing not too many people knew that the Comfort’s orders prohibit treating CoVid 19 patients. As President Trump said when he sent her on her way, “By treating non-infected people remotely on the ship, it will help to halt very strongly the transmission of the virus.” Note the words, “non-infected.”

So far, the Comfort has taken in three of New York’s patients. It’s kind of a Catch 22 thing. The ship can only take patients not infected with CoVid 19, but without sufficient testing, the ship’s clinicians won’t know if anyone actually has the disease, or not. Result: three patients. “If I’m blunt about it, it’s a joke,” said Michael Dowling, the head of Northwell Health, New York’s largest hospital system.

And finally – Getting back to the deep south

The American Association of Medical Colleges is out with its 2019 State Physician Data Workforce Report,

This annual report examines the supply of physicians in the United States. It documents the number of physicians per 100,000 inhabitants of every state. I’m proud, (I think) to report my home state, the Commonwealth of Massachusetts, takes the Gold Medal with 449.5 doctors per 100,000 people. On the other end of the scale, coming in at Number 50, is Mississippi with 191.3. I would love to know what goes on in Mississippi. It seems to be at or near the bottom of anything you can name.

Here are how all the southern states rank:

State                                MDs/100K                       Rank

Mississippi                       191.3                                50

Oklahoma                        206.7                                48

Arkansas                          207.6                                47

Alabama                           217.1                                43

Texas                                224.8                                41

Georgia                            228.7                                39

South Carolina                 229.5                                38

Kentucky                          230.9                                36

Tennessee                        253.1                                29

North Carolina                255.0                                28

Louisiana                          260.3                                27

Florida                              265.2                                23

Given that New York, which is begging for retired clinicians and clinicians from other states to come and help with its CoVid 19 fight, and given that New York, with 375.1 doctors per 100,000 people, ranks Number 3 on the list, just behind Massachusetts and Maryland, how do you think a state like poor Mississippi is going to fair when the full weight of this virus lands on it with a loud thud?

I hope all of you hermits have a safe weekend!

 

 

Andrew Cuomo Is Right: Send Him The Ventilators!

Friday, March 27th, 2020

If the state of New York were a country, it would have the highest rate of CoVid 19 cases per million inhabitants in the world. By far. As of 8:00 AM this morning, 27 March, New York clocked in with 38,987 cases, up more than 8,000 cases, or 27%, from two days ago. With 19.54 million people, New York’s rate of CoVid 19 cases is 1,995 per million inhabitants. The country with the highest rate is Switzerland with 1,387 cases per million inhabitants. But Switzerland only has 8.6 million people.

 

 

The populations of Spain, Italy and France are two to three times that of New York’s; Germany’s four times. So, New York would rank as a relatively small, but still respectably-sized, European country.

Looking at the dire predictions of most experts, Governor Andrew Cuomo believes New York is going to need 30,000 ventilators, and it’s going to need them about two weeks from now.

Donald Trump does not agree. He doesn’t see the need. At his daily… well, what would you call it? It’s certainly not a traditional press briefing. But, whatever you’d call it, yesterday he downplayed the need, and Dr. Deborah Birx, the White House Corona Virus Response Coordinator, whatever that means, sort of backed him up. Sort of. But we’ll get to that in just  a moment.

Last night, talking with Sean Hannity, who may be the sub rosa White House Coordinator, Trump said, “I have a feeling that a lot of the numbers that are being said in some areas are just bigger than they’re going to be. I don’t believe you need 40,000 or 30,000 ventilators. You go into major hospitals sometimes, and they’ll have two ventilators. And now, all of a sudden, they’re saying, ‘Can we order 30,000 ventilators?'”

“I have a feeling.” ” I don’t believe.” Think about that for a minute and ponder the implications.

But back to Dr. Birx, who is skilled at nuance. What did she say about Cuomo’s request for ventilators? She said she was told New York had enough ventilators “to meet current needs.” She said that, while New York City may have a shortage of ventilators at the moment, there are other parts of the state “that have lots of ventilators and other parts of New York state that don’t have any infections right now.”

Unpack what Dr. Birx said and you find she is careful to talk about what is needed right now. Cuomo is talking about what will be needed in two weeks when the proverbial fecal matter has hit the whirring instrument head on.

Right now New York has scrounged up about 15,000 ventilators, half the ventilators Cuomo and his experts say they’ll need in two weeks.

The White House Corona Virus Response Team has a choice here. It can either look at New York with a panoramic view, or continue to pretend they’re glimpsing an arrow as it whizzes past a crack in the door.

If you were making the ventilator decisions, which view would you want?

 

CoVid 19 And The Flu: Some Historical Perspective That Might Surprise You

Thursday, March 26th, 2020

Early in the morning of 4 March 1918, at Fort Riley, Kansas, Private Albert Gitchell reported for sick call at the Fort’s Hospital complaining of sore throat, fever and  a headache. By that noon, more than 100 other Fort Riley soldiers were at the hospital with similar symptoms. This was soon followed by similar outbreaks at other Army posts and prisons around America. Epidemiologists believe this to be the beginning of what came to be known as the Spanish Flu.

That March, 84,000 “Doughboys” shipped out for Europe, to be followed by another 118,000 in April. They brought the highly contagious flu with them. Soon, all of Europe and parts of Asia were infected. In June, Great Britain reported 31,000 cases (As I write this – 26 March – New York is reporting more than 30,000 cases of Covid 19). France and Germany suffered, too. Germany’s Crown Prince Rupprecht wrote on August 3. “Poor provisions, heavy losses, and the deepening influenza have deeply depressed the spirits of men in the III Infantry Division.” Soon, Russia, North Africa, India, China, Japan, the Philippines and even New Zealand would fall victim, as well.

The war ended on 11 November and the soldiers went home, bringing more of the disease with them. A second wave then hit America, much more devastating than the first. It infected 28% of the country’s population including my 5-year old Dad, who survived, thank you very much. It finally petered out at the end of 1919. As today, younger people seemed to combat the disease better than the aged.

From March through November, Americans did not know much about the Flu and its effect on the population. The Central Powers took great pains to censor bad news, trying to keep morale high. The first reports of the Flu came in May from Spain, a neutral country with uncensored media. Hence, it became the Spanish Flu. But when the war ended the ropes came off and the world knew it was in the grips of what would become the worst pandemic in history, rivaled only by the Bubonic Plague, caused by Yersinia Pestis, the black rat, in the mid-14th century. That plague killed more than two million people in England alone, 40% to 50% of the population, and the population would not recover to its former level until the early 1800s.

When Americans finally learned what the Spanish Flu was doing to them what happened?

Well, first of all, there was no vaccine and no curative treatment. Sound familiar? Second, because of not wanting to spread bad news, the government delayed mobilizing fully to combat a different kind of enemy. Sound familiar? When it did, what did it do? As now, with CoVid 19, the burden fell mostly on Governors, Mayors and local health officials. Because the Flu was so widespread, affecting the entire country at once, most states and cities were on their own. Many made tragic mistakes, as many are doing now. Actions in Philadelphia and St. Louis, MO, provide two 1919 examples.

As cases mounted, Philadelphia went forward with a Liberty Loan parade attended by tens of thousands, shoulder to shoulder. The disease exploded exponentially. In just 10 days, over 1,000 Philadelphians were dead, with another 200,000 sick. Only then did the city close saloons and theaters. By March, 1919, over 15,000 Philadelphians had died.

In St. Louis, the mayor ordered schools and movie theatres closed and banned public gatherings. The St. Louis mortality rate was one-eighth that of Philadelphia’s.

On the whole, Americans fought the Spanish Flu the same way we’re fighting CoVid 19 – social distancing, wearing masks and gloves, washing hands and staying at home. They had no cure; neither do we. Eventually, in the 1940s, the first flu vaccine was created. Now, sixty years later, only 40% of Americans take the trouble to get vaccinated yearly for the flu, 30,000 to 40,000 die annually and 200,000 are hospitalized.

Make no mistake. CoVid 19 is not like the flu – of today. But it is very much like the Spanish Flu of 1918 and 1919.

We will have a vaccine to combat CoVid 19. Right now we’re in the middle of a traffic jam of attempts, but it will happen. I only hope for two things. First, that the Corona Virus doesn’t mutate annually, like the flu. Second, that all Americans wake up and get vaccinated for both this virus as soon as they can and, finally, for the flu.