Still More Covid 19 Quick Takes

April 27th, 2020 by Tom Lynch

The age problem

“You know you’re getting old when you stoop to tie your shoelaces and wonder what else you could do while you’re down there.” ― George Burns

Question: When will elderly people, say over the age of 70, dare to venture out of their present tightly-wrapped cocoons and back into general society?

Answer: I will go out on a very fat limb and suggest not anytime soon.

Today marks the 118th day since 31 December 2019, the day the World Health Organization (WHO) reported the first case of a “pneumonia of unknown cause” in Wuhan, China. It’s the 47th day since 11 March 2020, the day the WHO officially declared the newly named COVID 19 a pandemic. And it’s the 53rd day since 5 March 2020, the day the Workers’ Compensation Research Institute (WCRI) convened its annual conference in Boston.

John Ruser, WCRI’s President and CEO opened the conference by advising everyone to avoid shaking hands; elbow bumps were the order of the day, but social distancing was non-existent, about two feet was typical.

I mention the WCRI’s just-before-the-deluge conference because of one chart shown during it. This chart:

WCRI’s injury database shows about 40% of injured workers over the age of 60 have two or more comorbidities, which increase inexorably with age. Sort of like the way those of us who still have it have been watching the steady growth of the stuff on top of our heads over the last five or six weeks. My hair hasn’t been this long since 1980.

I thought of that chart this morning as I was beginning my new daily routine: studying various COVID 19 dashboards (more about that below). I was struck by two charts from the Commonwealth of Massachusetts that put the problem the elderly now face into stark relief. Here they are:

Massachusetts is not unique; COVID 19 does not respect state boundaries. One realizes this as one attempts to quantify the disease’s impact in the nation’s 15,600 nursing homes housing 1.4 million elderly and disabled people. A difficult task, as USA Today discovered when its journalists tried to investigated the issue (article dated 13 April):

At least 2,300 long-term care facilities in 37 states have reported positive cases of COVID-19, according to data USA TODAY obtained from state agencies. More than 3,000 residents have died.

The numbers eclipse those previously disclosed by the Centers for Disease Control and Prevention (CDC), which in late March estimated that 400 facilities had reported cases of the virus. But the new totals still represent an incomplete accounting due to the ongoing lack of widespread testing for the virus and inconsistent record-keeping from state to state. On the federal level, neither the CDC nor the Centers for Medicare and Medicaid Services is tracking the number of U.S. nursing homes with COVID-19 cases, or the number of total cases and fatalities in those facilities.

In Massachusetts, 56% of COVID 19 deaths have occurred in long-term care facilities. One would think this cries out for federal data tracking conducted in a consistent manner across the nation. One would think.

About those dashboards

Where are you getting your information on the daily spread of COVID 19? Where do you think most Americans are getting theirs? Could the answer be Twitter? Or Facebook? How about the daily White House Coronavirus Task Force briefings (Randy Rainbow beautifully summed up last Thursday’s, which was highly controversial and chock full of more than ordinary mediocrity)?

If you’re thinking of the CDC’s dashboard, you’ll find the data in a few places, not all in one, easy to navigate spot. For example, go here; or here; or here. You get the point. A lot of information, but you really have to dig.

There are national dashboards, which are organized well and highly informative. Two that I recommend are the Coronavirus Resource Center at Johns Hopkins University and the New York Times’s Coronavirus in the U.S.: Latest Map and Case Count. Updated frequently, at least daily, each is excellent. The Johns Hopkins dashboard is global in scope; the Time’s focuses on the U.S.

The Massachusetts dashboard is the best state-maintained dashboard I’ve found. Disclosure: I live in Massachusetts. However, the dashboard is truly exceptional. Take a look. Scroll through it. I think you’ll agree this should be a model for all others.

Where one gets information about COVID 19 matters, because of all the disinformation and outright lies being thrown up against the wall every day. Some of it will always stick, and this is too serious for that. The more we know about this disease, the more we ought to realize how much we really don’t know. Ignorance is not bliss. Benjamin Franklin said, “It is in the religion of ignorance that tyranny begins.”

 

The Sad Saga Of The Masks

April 22nd, 2020 by Tom Lynch

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.

 

At The Heart Of COVID 19: Fear

April 16th, 2020 by Tom Lynch

 

“One fear creates a dereliction, which brings a greater fear, and there comes a point where the fear is too great and the human spirit just gives up…” – Wolf Hall, by Hilary Mantel.

“We have to remember the enemy is the virus. Not one another.” – Michigan Gov. Gretchen Whitmer.

The protests are ramping up. Over the last two days groups demanding governors reopen state economies have gathered to protest stay at home orders.

Protesters in Michigan, Kentucky, Ohio, Utah, North Carolina and Virginia have made their presence felt and voices heard. Timed to coincide with governors’ daily press briefings on COCVID 19, to varying degrees of success they tried to drown out the gubernatorial updates.

By far, the largest protest was yesterday in Lansing, Michigan where, for five miles, thousands of vehicles blocked traffic going into or out of the city. They also blocked all traffic heading to Sparrow Hospital, which meant hospital workers were denied access to the most important jobs in the nation: Treating COVID 19 victims. And, to make a bad situation worse, many, perhaps most, of the protesters were unmasked, standing around as if they’d never heard the term, “social distance.”

Here’s a pretty alarming photo from Ohio:

And this from Michigan:

Yes, those really are automatic weapons in the hands of angry protesters. People, this is a bad combination.

What in the name of Galen is going on here?

How about fear and insecurity?

When I was a commander in Vietnam, training, and lots of it, kept my unit alive. We trained for everything imaginable, and when bad things happened, we were scared, but prepared. Running toward danger is not an intuitive response. Training takes over in those situations. Here, in the midst of COVID 19, no one has any training, and that includes most of the health care workers on the front lines fighting this entirely new disease. Everyone is making it up as they go along, and our health care workers…excuse me, our health care heroes… are learning new things every day aimed at keeping people alive.

Americans have no training or experience to guide them through the stay at home period, however long it turns out to be. And so, they fearfully worry. About themselves, their kids, their parents and grandparents, and their jobs. Many of those jobs could be gone forever, and this scares them to their core. That, along with the open-ended nature of the stay at home orders, leads to fearing the worst.

People are looking for something to believe in, some hope, someone to blame, so, when right wing rabble rousers stoke their fears…

Defusing this growing powder keg starts at the top. The nation’s governors, with some notable exceptions, have stepped up and are doing all they can to keep their citizens alive. They have to, because Donald Trump and his administration have performed so poorly during the crisis. It is unfortunate, indeed, that the president cannot help himself from fanning the flames of his base. Yesterday’s protests were replete with Trump and MAGA hats, as well as, ironically, protesters calling the stay at home orders “tyranny.”

The protests without social distancing or masks are going to result in more infections and deaths. That is a terrible thing. And so unnecessary.

Governor Kristi Noem’s Magical Thinking

April 14th, 2020 by Tom Lynch

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

April 7th, 2020 by Tom Lynch

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

April 3rd, 2020 by Tom Lynch

 

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!

March 27th, 2020 by Tom Lynch

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

March 26th, 2020 by Tom Lynch

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.

CoVid 19 Upate

March 17th, 2020 by Tom Lynch

Nuggets arriving over the transom.

Blood Supply

The American Red Cross is facing a serious blood shortage RIGHT NOW.

“We need people to start turning out in force to give blood,” Dr. Peter Marks, director of the FDA’s biologics evaluation and research, said in a statement. “We need people to prevent the blood supply from getting depleted. We need it not to get to the point that surgeries are having to get cancelled,” Marks said. “That’s something we absolutely do not want to have happen. To ensure an adequate blood supply we need people to come out and donate blood.”

Although hospitals around the country are cancelling elective surgeries, they cannot cancel emergency surgeries. A 2018 study concluded the Emergency-To-Elective Surgery Ratio to be 9.4 in the U.S., 5.5 in the E.U., but a whopping 62.6 in sub-Saharen Africa (not a lot of elective surgery going on there). Emergency surgeries still have to happen. So, what’s the beleaguered Red Cross to do? In this time of CoVid 19, it has quite the dillema. Federal and state governments tell us to stay home as much as possible, but the Red Cross, which faces an emergency every eight minutes, depends on people going to one of their centers to donate blood, which, given the virus scare, is something many are finding hard to do.

Information – Where To Get It

Everywhere you look (including this blog), people are passing on CoVid 19 updates. It can all be a bit of a mish-mash. So, at the risk of compounding the problem, I’d like to suggest looking at the website of the European Centre for Disease Prevention and Control (ECDC). It is superbly organized and helpful. Its staff publishes Situation Updates every day, both for Europe and the world. The main reason to spend some time with the ECDC is to get a better idea of what is likely heading our way. Europe is about two weeks ahead of us for CoVid 19 communal spreading, and the ECDC’s charts are well-done, enlightening and scary. Compare the Situation Updates in Europe to the CDC’s here and here in the U.S.

And In The World Of Workers’ Compensation

The state of Washington was the first U.S. CoVid 19 hot spot. We noted yesterday the plight of a 70-year-old Washington ER doctor who was in critical condition after contracting the disease. That certainly qualifies for workers’ compensation benefits. But what about clinicians, doctors and nurses who, although asymptomatic, are forced to quarantine themselves for two weeks following exposure? It’s one thing if their employers continue to pay them while quarantined, but what if they don’t? And what about the health care charges incurred during quarantine? Who pays?

In a move that could start a trend, Governor Jay Inslee yesterday said any Washington health care workers forced to quarantine themselves following exposure would qualify for workers’ compensation benefits. Will this propel health care institutions to discontinue paying clinicians under quarantine? Regardless, workers’ compensation covering all the health care charges is a big deal.

Like a red rope in the snow, we will follow this story to see whether other states follow Inslee’s lead.

And now to once more assume the position of the CoVid 19 shut-in and watch the Dow Jones bounce around like a bee bee in a boxcar.

Stay safe.

 

 

CoVid 19 Update

March 16th, 2020 by Tom Lynch

Physicians on the front lines of CoVid 19 defence are getting sick. The American College of Emergency Physicians reports two ER doctors are in critical condition after contracting the disease, one in his 40s in Washington State, the other a 70-year-old doctor in New Jersey.

Which brings us to something nobody seems to be talking about, nobody, that is, except the inestimable Jennifer Christian, about whom I wrote last week. In today’s Work Fitness and Disability Roundtable, Jennifer asks about the consequences to elderly doctors and nurses when the federal government and all the states tell the elderly to stay home. What are the implications?

From today’s Roundtable:

The 2018 Census of Licensed Physicians in the US ( https://www.fsmb.org/siteassets/advocacy/publications/2018census.pdf ) by the Federal of State Medical Boards found 985,026 physicians now licensed to practice medicine the US (which doesn’t necessarily mean they are in active practice), with 30.3% of them 60+ years old in 2018, compared to 25.2% in 2010.   If we use the 2019 State Physician Workforce Data Report ( https://store.aamc.org/2019-state-physician-workforce-data-report.html ) from the Amer Assoc of Medical Colleges which identifies physicians in ACTIVE PRACTICE based on the 2018 AMA Physician Masterfile, there are currently 908,760 physicians in active practice, and of those 32.1% are at least 60 years of age.   Sending them all home means benching 291,711 doctors.

Alright, let’s all agree we’re not going to tell nearly 300,000 physicians to stay home during the worst healthcare crisis of the last century. So, how do we protect them?

The first line of defence for ER physicians and nurses is personal protective equipment (PPE). That means appropriate face masks, gowns, gloves, soap and the like. Trouble is, the U.S. doesn’t have nearly enough PPE to go around if our coming experience resembles that of Italy or Wuhan. Think about that for a minute.

The only way to reduce the coming harm to elderly clinicians is to reduce the cases – flatten the curve. This presents each one of us with a choice. Either we do everything possible to avoid the disease – social distancing, staying home, washing hands, etc. – or, we engage in communal irresponsibility by treating all the warnings as mere suggestions, sort of the way we treat highway speed limits.

That type of behavior was very much in evidence over the weekend, from St. Patrick’s Day get togethers all over the country to Bourbon Street parties in New Orleans. Then, of course, there was the horrendoma at O’Hare and twelve other airports yesterday, as thousands of people tried to get back to  the USA from overseas and had to stand for hours elbow to elbow waiting to get screened for a virus many of them were probably spreading  during the communal scrum. Will somebody please tell me why our federal government continues to do things that have all the competence and well-thoughtoutedness of a Keystone Cops car chase?

All clinicians, expecially the heroic elderly ones now on the front lines, deserve our full-throttled disease avoidance engagement. Otherwise, we’re going to wake up a couple of weeks from now only to discover, as the bodies pile up, that what we did was way too little, way too late.

Have a nice day.