Archive for the ‘Medical Issues’ Category

Updates On Recent Stories I Covered

Friday, March 3rd, 2023

Israel’s judicial crisis continues as far right bills advance in Knesset

In mid-February I wrote about Israel’s descent into judicial chaos.

Israel had gone through three elections in late 2022 to elect a new government. To regain power, the historically conservative Likud Party, headed by Benjamin Netanyahu, joined in a coalition with five right-wing and religiously conservative parties, some of which are hugely influenced, perhaps dominated, by Israel’s ultra-Orthodox community, known as the Haredim. The coalition won the third election, and Netanyahu became Prime Minister for the sixth time. Six days after the election the government filed bills in the Israeli parliament, the Knesset, to severely limit the power of the country’s Supreme Court in that:

  1. A simple majority in the Knesset, 61 votes out of 120, would have the power to annul Supreme Court rulings. This would enable the government of the day to pass legislation without fear of it being struck down. It is called the “override” provision, in that the Knesset could override a Supreme Court ruling;
  2. The Supreme Court’s ability to revoke administrative decisions by the government on the grounds of “reasonability” (what would a reasonable person say about this?), would end, significantly decreasing judicial oversight; and,
  3. For the Supreme Court to strike down a Knesset-passed law would require 80% of the court’s 15 judges voting for such a ruling. But even if that were to happen, a simple Knesset majority could “override” the ruling.

At the time I wrote about this there was a singular complication: Benjamin Netanyahu is on trial, actually three trials, for corruption. If he is convicted of anything and appeals, the coalition government could override any Supreme Court ruling. Some might say this places Netanyahu at the mercy of his coalition partners.

Update

In order for these measure to become law requires passing three readings in Knesset committees. Last week, in a long and tense plenary session, the combined bill passed its first reading in the Knesset. Yesterday, the Knesset’s Constitution Committee advanced the bill for its second reading.

The judicial crisis was only made worse last Sunday when, in revenge for the killing of two Jewish Israeli brothers as they drove through the West Bank town of Hawara, near the city of Nablus, a mob of Jewish settlers attacked the town, torching 36 homes and 15 cars. The Palestinian Red Crescent reported one death and 98 Palestinians wounded in the attack. Three ambulances were also destroyed.

The attack was met with a public outpouring of support from settler leaders and Knesset members. Moreover, the Israeli coalition Finance Minister, Bezalel Smotrich, a firebrand of the first order, told the settlers, “Hawara must be destroyed.” It nearly was.

The U.S. condemned the violence in unusually strong terms. “Just as we condemn Palestinian incitement to violence, we condemn these provocative remarks that also amount to incitement to violence,” State Department spokesperson Ned Price said.

It does not seem too much of a stretch to conclude the new coalition government, with its uber-nationalistic sway, has emboldened the highly nationalistic settlers who continue to gobble up land and force Palestinians into ever more woeful conditions.

Israel’s other western allies, for example the UK and France, have also condemned Sunday’s violence and, along with U.S. Secretary of State Antony Blinken, have told Mr. Netanyahu—to his face—that the judicial reforms he is championing are a serious threat to the future of their relationship. So far, the Prime Minister and his coalition partners are calling their bluff.

At this point, it does not appear this situation will end well—for anyone.

Mississippi extends Medicaid postpartum coverage duration

In February, I wrote about maternal mortality in America. Bottom line: It’s the highest in the developed world. At that time, I wrote:

Federal law requires Medicaid to cover postpartum care for only 60 days following birth, which is one of the prime reasons for our lagging maternal mortality global performance. In the other OECD countries, mothers not only receive postpartum care for a year, they also average 51 weeks of paid maternity leave. (The U.S. is the only OECD country with no requirement for paid maternity leave.)

The  American Rescue Plan Act of 2021 (ARPA) created an option for states to extend postpartum coverage for Medicaid beneficiaries from 60 days to a full year. Under the Act, the option was scheduled to expire in 2027. Under the Consolidated Appropriations Act of 2023, the 12-month extended Medicaid postpartum coverage option was made permanent. Now once states take up the option to extend the postpartum period from 60 days to 12 months, federal matching funds will continue to flow. Thus far, 35 states have already taken advantage of the option and the federal cash that goes with it.

Nine other states have legislation pending to follow the 35. Mississippi is one of them.

Update

I can’t tell you how happy I am to report that yesterday the Mississippi legislature passed the postpartum permanent extension, and Governor Tate Reeves signed it into law. Reeves had been opposed to the measure, but had a change of heart when he realized that a lot more babies were about to be born in Mississippi due to the repeal of Roe v. Wade and the state’s strict (to say the least) anti-abortion laws, which meant some mothers could die without the postpartum extension, and the politically astute Reeves did not want to be the one taking incoming fire for helping that to happen. To which I say: Whatever works.

Mississippi’s joining the postpartum extension club only happened because Division of Medicaid Executive Director Drew Snyder, whose department reports to the Governor and who for months has refused to take a stance on postpartum coverage extension (how medically courageous of him, eh?), wrote a letter on 27 February to House Speaker Philip Gunn voicing his newfound support for the legislation’s passage (notably, after his boss, Governor Reeves had his change of heart). Gunn had been vehemently opposed to the measure, believing it put the state in the awful position of expanding Medicaid under the Affordable Care Act, something he has vowed would never happen. In his letter, Snyder assured Gunn that permanently extending Medicaid postpartum coverage would not equate to expanding Medicaid a la the Affordable Care Act, and he urged the Speaker to come on board for all the reasons that had swayed Governor Reeves. You know, all those babies about to be born in Mississippi. He also reminded Gunn the state has a $3.1 billion surplus, the annual cost of the extension is pegged at $7.1 million, and the feds will chip in more than $35 million. Reading Snyder’s letter is like reading George Orwell.

Whatever the reasons, Mississippi has done the right thing.

Ely Lilly to drop the cost of basic insulin to $35 per vial

I have written a number of times about what I consider the obscene price of insulin for Type 1 diabetics. See here and here for the history of the discovery and how we got to this point. Bottom line, as I wrote in 2018, the three discovers of insulin, led by Frederick Banting, who won the Nobel Prize for it:

sold the patent to the University of Toronto for the princely sum of $3.00. When asked why he didn’t cash in on his discovery, Banting said, “Insulin is my gift to mankind.” With Banting’s blessing, the University licensed insulin’s manufacturing to drug companies, royalty free. If drug companies didn’t have to pay royalties, Banting thought they would keep the price of insulin low.

And they did. For decades.

But patents expire, and capitalism being what it is, people get greedy, and greed is why we have no generic, low-cost insulin today and why, over the past 20 years, insulin prices have risen anywhere from 800% to 1,157%, depending on the variety and brand. It’s why, lacking health insurance, some Type 1 diabetics have recently been driven to ration their precious insulin. Some of them have died.

Update

Yesterday, the Ely Lilly company, the first company to license Banting’s discovery, announced price reductions of 70% for its most commonly prescribed insulins and an expansion of its Insulin Value Program that caps patient out-of-pocket costs at $35 or less per month. In its press release, the company said it is:

  • Cutting the list price of its non-branded insulin, Insulin Lispro Injection…to $25 a vial. Effective May 1, 2023, it will be the lowest list-priced mealtime insulin available, and less than the price of a Humalog® vial in 1999.
  • Cutting the list price of Humalog® …, Lilly’s most commonly prescribed insulin, and Humulin® (insulin human) injection … by 70%, effective in Q4 2023.
  • Launching RezvoglarTM …injection, a basal insulin that is biosimilar to, and interchangeable with, Lantus® (insulin glargine) injection, for $92 per five pack of KwikPens®, a 78% discount to Lantus, effective April 1, 2023.

Lilly also said:

  • Effective immediately, Lilly will automatically cap out-of-pocket costs at $35 at participating retail pharmacies for people with commercial insurance using Lilly insulin.
  • People who don’t have insurance can continue to go to InsulinAffordability.com and immediately download the Lilly Insulin Value Program savings card to receive Lilly insulins for $35 per month.

This, of course, is marvelous news for the 1.3 million Type 1 diabetics in the country not on Medicare, which already has a $35 cap thanks to the Inflation Reduction Act of 2022.

It is not an exaggeration to say insulin made Eli Lilly and Company and Novo Nordisk two of the top pharmaceutical companies in the world. It also hasn’t hurt the bottom line of Sanofi, the company that rounds out the insulin producing triumvirate and is the world’s fifth largest pharma by sales. I think it is a good bet these last two will quickly follow Lilly’s lead.

The greed of these three companies over the last two or three decades has hurt a lot of people, both physically and economically. Let’s hope this move by Lilly is the first step in making amends.

 

 

Maternal Mortality In America: The American Rescue Plan Act of 2021 Is Here To Help

Thursday, February 9th, 2023

The maternal mortality rate in the US is the highest in the developed world.

The World Health Organization and the OECD define maternal mortality as “the annual number of female deaths from any cause related to, or aggravated by, pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy.” The rate of maternal mortality is the number of these deaths per 100,000 live births.

The U.S. defines it differently. In the U.S., the maternal mortality ratio (MMR) covers a full year following birth, not the 42 days of the WHO and OECD. This is why the CDC reports the latest MMR figures  in the U.S. as 17.3, while the OECD has it at 5.8 (for 2020). To confuse things even more, a highly regarded study in The Lancet in 2016 noted, ” The overall decrease from 1990 to 2015 in global maternal deaths was roughly 29% and the decrease in MMR was 30%.” However, the same study pointed out the U.S. rate for 2015 had risen to 26.4.

But regardless of how you count it, our rate still outpaces all the other developed nations. Moreover, according to the CDC, the U.S. rate has been rising since 1987, while our OECD global competitors have seen theirs decline since 1990.

In America, the maternal mortality rate is much higher among Black, Hispanic, and Native American communities. An October 2022 study by  the GAO (Government Accountability Office) put it this way:

• The maternal death rate for Black or African-American (not Hispanic or Latina) women was 44.0 per 100,000 live births in 2019, then increased to 55.3 in 2020, and 68.9 in 2021. In contrast, White (not Hispanic or Latina) women had death rates of 17.9, 19.1, and 26.1, respectively.
• The maternal death rate for Hispanic or Latina women was lower (12.6) compared with White (not Hispanic or Latina) women (17.9) in 2019, but increased significantly during the pandemic in 2020 (18.2) and 2021 (27.5).

Disparities in other adverse outcomes, such as preterm and low birthweight births, persisted for Black or African-American (not Hispanic or Latina) women, according to GAO analysis of CDC data.

The GAO study lays this squarely at the wide open door of racism:

Additionally, racism negatively affects the health of millions of people, according to CDC. We previously reported, and research has shown, that racial and ethnic disparities in maternal health outcomes persist, even after controlling for other factors like socioeconomic status, education, and access to care.¹ Some studies described specifically how racial discrimination can contribute to worsened maternal health outcomes. For example, chronic stress associated with racism can cause physiological changes and adverse health conditions. Moreover, bias or discrimination within the health care system can create communication challenges between providers and their patients, which may increase the risk of adverse outcomes. For example, pregnant women may be reluctant to ask questions about their condition if they faced discrimination from their provider.² In addition, the COVID-19 pandemic has highlighted racial and ethnic health disparities.³

From the GAO study

MMR is highest in Louisiana, at 58.1, and lowest in California, at 4.0, which is the average for the OECD.

Federal law requires Medicaid to cover postpartum care for only 60 days following birth, which is one of the prime reasons for our lagging global performance. In the OECD, mothers not only receive postpartum care for a year, they also average 51 weeks of paid maternity leave. (The U.S. is the only OECD country with no requirement for paid maternity leave.)

Enter the  American Rescue Plan Act of 2021 (ARPA), the Act Republicans derided and didn’t vote for, but love to take credit for back in their home districts. The Act offers significant resources for states to extend postpartum care for Medicaid beneficiaries.

Here’s how it’s working. ARPA created an option for states to extend postpartum coverage for Medicaid beneficiaries from 60 days to a full year. Under the Act, the option was scheduled to expire in 2027. Under the Consolidated Appropriations Act of 2023, the 12-month extended Medicaid postpartum coverage option was made permanent. Now once states take up the option to extend the postpartum period from 60 days to 12 months, federal matching funds will continue to flow. Thus far, 35 states have already taken advantage of the option and the federal cash that goes with it.

And today, the Washington Post’s McKenzie Beard, author of The Health 202 newsletter, reported Republican legislatures in nine red states have pending legislation to extend postpartum health coverage for their Medicaid beneficiaries, thereby joining the other 35 states in taking up the option created by the ARPA.

For these nine states, and their red state peers, this is all in response to the repeal of Roe v. Wade, a highly unpopular decision all around the country, which could create a significant uptick in pregnancies. There is a quite justified fear among Republican Governors and legislators that as they severely tighten restrictions on abortion our already horrible maternal mortality rate will worsen even more and they will be the ones held responsible. By extending postpartum care for 12 months they may avoid that unhappy and unfortunate political outcome while actually doing something good for the poorest of their citizens.

This is the one positive thing I have seen come out of the Roe v. Wade decision.

_________________________________________

¹See two studies of severe maternal morbidity in New York City: E. Howell et al., “Race and Ethnicity, Medical Insurance, and Within-Hospital Severe Maternal Morbidity Disparities,” Obstetrics & Gynecology, vol. 135, no. 2 (Feb. 2020): 285-293; and
M. Angley et al., “Severe Maternal Morbidity in New York City, 2008–2012,” New York Bureau of Maternal, Infant and Reproductive Health (New York, N.Y.: 2016).

²See R. Hardeman et al., “Developing Tools to Report Racism in Maternal Health for the CDC Maternal Mortality Review Information Application (MMRIA): Findings From the MMRIA Racism & Discrimination Working Group,” Maternal and Child Health Journal, vol. 26 (2022): 661–669.

³See Centers for Disease Control and Prevention, “COVID-19 Weekly Cases and Deaths per 100,000 Population by Age, Race/Ethnicity, and Sex,” accessed 9 February 2023.

A Few Items To Ponder, Two Of Them Important

Wednesday, November 30th, 2022

Type 1 Diabetics get good news

As I have written before, Type 1 diabetes (T1D) is a horrific disease. It is a leading cause of stroke, heart disease, blindness, kidney disease and non-traumatic amputations. It also costs a lot to manage. The media has been full of stories of unfortunate people who have had to choose between taking insulin or food. The Inflation Reduction Act, passed in August, caps the cost of a vial of insulin at $35 for Medicare beneficiaries, but does nothing for diabetics not on Medicare. About 70% of the nation’s 1.9 million Type 1 diabetics are on Medicare.

Research has proven Type 1 diabetics contract the disease in three stages over time. According to a 2015 study on the presymptomatic stages of Type 1 diabetes:

Insights from prospective, longitudinal studies of individuals at risk for developing type 1 diabetes have demonstrated that the disease is a continuum that progresses sequentially at variable but predictable rates through distinct identifiable stages prior to the onset of symptoms. Stage 1 is defined as the presence of β-cell autoimmunity as evidenced by the presence of two or more islet autoantibodies with normoglycemia and is presymptomatic, stage 2 as the presence of β-cell autoimmunity with dysglycemia and is presymptomatic, and stage 3 as onset of symptomatic disease.

Type 1 diabetics go through two stages of disease development before full-blown diabetes appears in Stage 3. Imagine a platform diver. Stage 1 is climbing to the platform and standing at the edge. Stage 2 is lifting off and moving through the air. Stage 3 is hitting the water and getting very wet. Diabetics don’t know they have the disease until they hit the water. But what if they did, and what if the time in the air between the platform to the water could be extended, say by 25 months?

On 17 November, the FDA approved a biologic therapy that delays the onset of Stage 3 by about that much.

The monoclonal antibody teplizumab, which will be marketed under the brand name Tzield, from ProventionBio and Sanofi is given daily through intravenous infusion over two weeks. And it works. Patients who take it extend Stage 2 by a little more than two years.

But there’s a catch, two, in fact. First, PreventionBio announced last week it is pricing Tzield at $193,900, which is considerably higher than insurers anticipated. Second, how does a person know they’re in Stage 2 and, therefore, should be taking the drug? The answer is screening for autoantibodes that are markers for diabetes. This will also incur a cost. More about that below.

The question to be answered is will insurers cover the considerable cost for screening and drug infusion?

In 2014, the FDA approved Harvoni as treatment for Hepatitis C, which is the leading cause of liver failure. Hep C is a life-threatening disease. Harvoni cured it. Completely. Its maker, Gilead, priced the pill at $95,000 for a twelve-week course of treatment. At the time, I was a Director at a Boston HMO. We wrestled with the cost issue. In the end, because Harvoni cured what was a horrific and terrifically costly disease, we gladly decided to provide it for our members.

Tzieild is different. It does not cure diabetes. Rather, it delays its onset. The American Diabetes Association and the Juvenile Diabetes Research Foundation (JDRF) are ecstatic about the arrival of Tzield. They point out this is the first time a successful treatment for diabetes has appeared on the scene, although it’s not really a treatment. However, they’re concerned about the screening issue.

Aaron Kowalski, CEO of JDRF, says the main challenge in prescribing Tzield will be finding people who need it. The drug is approved for people who don’t have any symptoms of the disease and may not know they’re on the road to getting it.

“Screening becomes a really big issue, because what we know is, about 85% of type 1 diagnoses today are in families that don’t have a known family history,” Kowalski said. “Our goal is to do general population screening” with blood tests to look for markers of the disease.

It will be interesting to learn how insurers and health plans react to Tzield. According to the JDRF, 64,000 people a year are diagnosed with Type 1 diabetes. If every one of them received the drug the total cost would be about $12.5 billion. But if you were one of the 64,000, my guess is you’d happily stand in line for it. So would I.

Donald Trump and the Mar-A-Lago fiasco

By now, every sentient person in America knows ex-president Donald Trump dined last week with Nick Fuentes, the poster child for anti-Semitic white nationalism, and Kanye West, who now calls himself Ye and has also spouted anti-Semitic whinge. Afterwards, when social media lit up like the Rockefeller Center Christmas tree, Trump claimed he didn’t know Fuentes was going to be there; West just brought him along.

Putting aside the fact that Trump’s Secret Service detail would never in a month of Sundays allow just anyone to drop in to break bread with the big cheese without getting clearance from the big cheese himself, I’m more concerned with the response of the Republican Party’s leadership to this. Republicans who are likely to run for President, notably Mike Pence and Chris Christie, criticized their former leader, although it took them two or three days to do it. It took more than a week for anyone in Republican leadership to put their wet finger in the air and decide to say he shouldn’t have done it.

The stench wafting from the halls of Congress is remarkable, indeed.

A personal note

Starting tomorrow I shall be away from this, and any other, keyboard for a little bit.

Since I was eight years old, I have been an avid, competitive, pretty good, tennis player. I’ve calculated that in the intervening years I have hit somewhere around just under a million overhead smashes. That’s a lot of serves and put-aways. And they have taken their toll. So, at 7:00 AM tomorrow morning, a very good doctor (I hope) will be concentrating deeply (I hope) on the job of giving me a new shoulder. I’m told it will be a little painful for a while, but on the other side lies bliss, and more overheads.

I look forward to being back at the keyboard.

Friday Thoughts About Precrime: Alive And Well In The Florida Of Ron DeSantis

Friday, August 5th, 2022

Precrime: A predictive policing system dedicated to apprehending and detaining people before they have the opportunity to commit a given crime. The term was coined by Philip K. Dick and became the basis for the plot of The Minority Report, a short story of his, published in Fantastic Universe Science Fiction magazine in 1956.*

On Thursday of this week, Florida Governor Ron DeSantis, surrounded by Tampa Bay Area sheriffs (fifteen of them, all male), suspended Andrew Warren, the twice-elected Hillsborough County State Attorney, saying he violated his oath of office and has been soft on crime.

DeSantis then appointed Susan Lopez to serve as acting state attorney during Warren’s suspension. Lopez was appointed by the governor to serve as a Hillsborough County judge in 2021. She previously served as the Assistant State Attorney in the 13th Judicial Circuit.

DeSantis suspended Warren because in June, following the Supreme Court’s overturning of the Roe v. Wade decision of 1972, Warren joined 91 other attorneys general and district attorneys around the country in signing a statement  declaring they would “decline” to prosecute “reproductive health decisions.”

Florida’s Senate will now take up Warren’s suspension. If it upholds the governor’s move, Lopez will remain State Attorney until an election can be held to choose Warren’s permanent replacement, permanent, that is, until the next election, or until another suspension if DeSantis becomes annoyed again.

I would like to mention a few points to consider about all this:

First, Florida’s Constitution gives its Governor the right to remove any elected official “for reasons of misfeasance, malfeasance, neglect of duty, drunkenness, incompetence, permanent inability to perform official duties, or commission of a felony.”

Governor Rick Scott, DeSantis’s predecessor and a politician about whom we have written before, exercised this power twice. In 2018, he suspended Broward County elections supervisor Brenda Snipes on the heels of a tumultuous recount, citing a litany of well-publicized problems, including the misplacement and inadvertent mixing of ballots. A year before, he had reassigned more than two dozen potential death penalty cases away from Orlando state attorney Aramis Ayala after she declared she wouldn’t pursue capital punishment.

As the Editorial Board of the Tampa Bay Times wrote yesterday, “That remedy was more appropriate than a blanket removal from office.” But still, DeSantis does have the power to do what he did.

Second, everything Ron DeSantis does from morning till night must be colored in the light of his presidential ambitions. He, like so many other politicians who believe they deserve to be President, is forever circling above the bloated body of Donald Trump, waiting and hoping for the former President to stumble and fall, so he may swoop down and grab the political gold ring. Sadly, there is no Cincinnatus here, Cincinnatus, the Roman farmer of 458 BCE revered for his virtue, who left his farm to become General and in 16 days rescued Rome from imminent defeat and promptly retired to his farm.

Third, what exactly did Warren do? Answer: Nothing, except signing a group statement saying “we decline to use our offices’ resources to criminalize reproductive health decisions.” Yes, the wording could have been better, much better, actually. It should have made clear the prosecutors would make decisions on an individual basis. Regardless, Warren has yet to refuse to prosecute anybody for violating Florida’s anti-abortion law. DeSantis’s suspension is a pre-emptive strike by the Ron DeSantis Precrime Unit, a bone thrown to his political base for his upcoming 2022 gubernatorial reelection and presidential run in 2024. If you doubt that, ask yourself why DeSantis spent so much time at his Thursday press conference talking about San Francisco, George Soros and “woke” criminal justice reform? Ask yourself why the sheriffs he called upon to speak spent so much time talking about the “evils’ found in other parts of the country, the very blue parts?

Finally, if Governor DeSantis can “suspend” Andrew Warren because he thinks Warren will do something he has yet to do, then he can suspend any legitimately-elected Florida official with whom he disagrees. That is scary.

Who’s next?

 

*

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.