Tagged bioethics

100,000

Dear students,

Before I share a few post-Memorial Day thoughts about the virus and this tragic and needless milestone, I would like to mention two people who have died recently but not from the corona or any virus: George Floyd, a black man who was killed by police in Minneapolis, Minnesota, by strangulation, while handcuffed on the ground begging for his life, and Ahmaud Arbery, a black man shot and killed by vigilantes while jogging, in a modern-day lynching in Brunswick, Georgia. These tragic and needless deaths were part of the same long-standing pattern of structural racism which, as you know, accounts for the huge over-representation of African-Americans in the deaths from COVID-19.

I am frankly confused about where we are in the pandemic right now, both in our country and the world. More Americans have died of COVID-19 than in all the wars since the Korean War, and it is quite possible that before this is over we may be able to include the Korean War in that count. I see what appears to be a wholesale abandonment of the science of public health and medicine by many Americans. I can’t tell you how many, but I am pretty sure it’s enough to keep the U.S. epidemic boiling (not simmering) for months. Maybe we get a rest in September before the second wave. Or will it be the third wave?

I’ve always told you the most important thing you have to know is the limits of what you know. So I’m telling you now. I don’t know. I don’t know. I don’t know.

I don’t know about future cases, hospitalizations, or deaths because the models are shot to hell by the unpredicted and unpredictable behavior of a substantial minority of Americans. I don’t know about progress in vaccines or treatment because every announcement is not a scientific publication but a press release that hugely moves stock prices, especially of the companies involved. Remdesevir and convalescent plasma are in wide use and seem to have some effectiveness, but convincing studies have not been published. I do know something about the anti-malarial drug Whaddayagottalose-oquine. Worldwide randomized controlled trials have been stopped because more people die with it than without it. I took it for years, first to prevent malaria in Africa, then for a minor autoimmune condition. On March 25th in a private email I said that more research was needed but that I would take it if I got COVID-19. Now I wouldn’t. Lesson? Anecdotes, even from smart people, are no substitute for real studies.

This past weekend we commemorated those who gave their lives for our freedom; they died hoping we would use freedom wisely. Yesterday we flew our flags at half-mast to mourn 100,000 dead Americans. Today I want to celebrate the new warriors at the front of the coronavirus wars.

Good News

  1. Dr. Richard Levitan, 59, a leading expert on teaching intubation, left safe Northern New Hampshire to volunteer for ten days at New York’s dangerous Bellevue hospital. After his first exhausting shift he went to his brother’s apartment, where he was staying, and was kicked out by the building’s other residents. He found some kind of lodging, completed his ten days, and wrote an article teaching others throughout the world how to deal with COVID-19 pneumonia.
  2. If you click on one link in this message, make it Dr. Sharon Duclos, a Family Medicine specialist in Cedar Valley, Iowa, and watch the video, recorded on May 6th, the day before the local Tyson meatpacking plant, the source of the cases that overwhelmed Dr. Duclos and her colleagues, reopened under government orders. She appeared calm today (May 28) at a press conference with other local medical leaders; she is at around minute 14:30 in this new video. She implored people to keep taking precautions, “as we go through the little lulls and valleys, and the peaks that will occur with this, for months to come.” More on this below.
  3. Sylvia Leroy, 35, was a labor and delivery nurse at Brookdale Hospital in Brooklyn, where patients she cared for were positive for the virus. She got it. She was 28 weeks pregnant with her second child. Her own hospital did not take proper care of her. She was transferred to Mount Sinai where she got better care but went into cardiac arrest for some four to eight minutes; the doctor who called Sylvia’s sister was crying herself. They delivered her baby, Esther, by C-section. The baby needed oxygen but was “pink and healthy.” As of May 20, Sylvia was very slowly recovering from brain damage; Baby Esther was doing well. See their GoFundMe page here. Her sister once asked her why she didn’t go into private practice. “And she said to me, ‘This is an underserved community. Who is going to help them if I don’t help them?’”
  4. Dr. Ryan Padgett, 45, who played football for Northwestern in the Rose Bowl, was one of the first U.S. doctors to get the virus. It was still February, and nobody knew anything, but he was taking care of a string of patients from one nursing home in Kirkland, Washington. He was in great shape, hardly ever missed a day of work, but in March he was near death. He recovered, but still had more recovery ahead of him, when he said, “As an emergency physician, you walk into every single room and take care of whatever is there. Going back, I don’t think that will change. I hope not.”
  5. Dr. Theresa Greene, an emergency physician in Miami, temporarily lost custody of her 4-year-old daughter because she takes care of COVID-19 patients. She said, “I think it’s not fair. It’s cruel to ask me to choose between my child and the oath I took as a physician. I won’t abandon my team at work or the patients who will increasingly look to me to save their lives in the coming weeks, but it’s torture.” She and her husband have amicably shared custody since their divorce two years ago. Why is this under “Good News”? Nobody’s sick. Nobody died. However unfair it may be, mother and daughter will live to put this separation behind them.

Bad News

  1. Madhvi Aya, 61, was a doctor in India but a senior physician assistant in the U.S. She worked at a hospital in one of the poorest sections of Brooklyn; it was overflowing with coronavirus patients, and she was there until she got sick herself. At the end, in a different hospital, she was alone after texting with her husband, mother, and daughter, whom she had been very afraid of infecting. She often said, “We have to take care of our patients first.”
  2. A nurse who must keep her identity secret for her own protection was on a bus in Chicago, coming home in her scrubs from a difficult shift, coughed into the crook of her elbow, with a mask, and was punched in the face by a man who accused her of trying to give him the virus. He gave her a black eye. Attacks on coronavirus heroes in all frontline professions have been happening all over the world. “It’s not going to stop me from coming to work every single day and taking care of the people I take care of,” she said.
  3. Immigrant Celia Marcos, 61, worked as a nurse at Hollywood Presbyterian Medical Center for 16 years until her death in April from COVID-19, which she almost certainly contracted from a patient. Her family and colleagues state that she was not provided with proper PPE, which the hospital denied. Her son Donald said, “when the call of duty came, she will do the best that she could.” He also said she “coded seven times” before she died. In their last conversation he said, “when you get out of that hospital, you will retire immediately.” She barely was able to say yes. Both were crying.
  4. Jason Hargrove, 50, a bus driver in Detroit, loved his job and did it faithfully, carrying essential workers and others to their own jobs. A passenger openly coughed near him without covering her mouth, and he recorded a Facebook video about the incident. He was worried about the other passengers and himself. He said, “I feel violated.” He died of the virus 11 days later. He left home by 5am and disinfected his bus every day. He would tell his wife, “Baby, when you get off work, make sure you grab me some more Lysol… I gotta make sure that my people are protected.”
  5. Dr. Lorna Breen, 49, head of the emergency medicine department at NY Columbia-Presbyterian Hospital, contracted the virus while heroically trying to save others. She recovered, but the hospital told her to stay home. She moved from NY to her parents home in Charlottesville. There, with no history of mental illness, she took her own life. Her father said, “Make sure she’s praised as a hero.”

Under the Russian Tsars, young men were drafted into the army for 25 years. As a child I knew an old man who had chopped off the first joint of his own trigger finger to avoid that fate. And why do I mention this? Because many, maybe even most of you, have told me you want to become nurses, physician assistants, or physicians. You are signing up for roughly twice the length of service that the Tsars demanded of young people. There will be another pandemic like this in your career. You will be called on. Even medical students have been called on in this crisis. You will not say no when you are asked to put your own life, and that of your loved ones, in danger, because that is your oath. Even when you think or know that you are risking your life for stupid people who put their own lives in danger, you will serve. Know what you are signing up for.

It was very interesting for me to watch today’s press conference on local television in Black Hawk County, Iowa. This is the cutting edge of the U.S. pandemic going forward. The local Tyson meatpacking plant reopened because the governor and the president said so, and because it was in their financial interest. Three leading local physicians and county health officials spoke. They stated that they did not know what was going on at the Tyson plant and would not be getting that information. They said they could not do contact tracing of confirmed cases. A county health official laughed at the idea of testing health care workers in nursing homes, because they don’t have the resources to do it.

Don’t think about New York any more. Think about Black Hawk County. Times ten. Or maybe times 100.

Stay safe,

Dr. K

Opening to What?

            “I think right now, because there’s been good news really, that the opening up is starting to happen faster than we expected, appears to be doing so safely, then there is a chance that we won’t really need a Phase Four [Congressional support package].” White House economist Kevin Hassett, Fox News, Saturday

            “Is this guy serious?” Mayor Bill DeBlasio, later that day

            “It’s devastatingly worrisome to me personally because if they go home and infect their grandmother or their grandfather who has a co-morbid condition and they have a serious or a very — or an unfortunate outcome, they will feel guilty for the rest of our lives,” Dr. Deborah Birx, Sunday.

            “This is definitely government overreach.” Lockdown protester on social distancing

Dear Students,

Given our studies of evolution in disease (Darwinian medicine), you won’t be surprised to learn that the pandemic coronavirus is mutating and adapting, although fortunately more slowly than seasonal flu. Nor will you be surprised to see natural selection operating at different levels. We are not sure that a bat was the origin, but if bats have it you know they’ll be evolving too. And so will we. Here is how the city planning commissioner of Antioch, California put it in a Facebook post:

The shelter in place needs to end, we as a species need to move forward with our place on Earth…This virus is like a human version of a forest fire, a forest fire will burn through and burn off all the dead trees, old trees…The strong trees survive and the forest replenishes itself and flourishes once again… If we look at our population as the forest you will see many similarities. We have our old, we have our weak and we have our drains on our resources. This virus is targeting those sectors of our population. If we were to live our lives, let nature run its course, yes we will all feel hardship, we will all feel loss. I am sure everyone of us would lose a person who we hold dear. But as species, for our Nation and as a Planet we would we would strengthen when this is all settled. We would have significant loss of life, we would lose many elderly, that would reduce burdens in our defunct Social Security System, health care cost…make jobs available for others and it would also free up housing… We would lose a large portion of the people with immune and other health complications… But that would once again reduce our impact on medical, jobs and housing. Then we have our other sectors such as our homeless and other people who just defile themselves by either choice or mental issues. This would run rampant through them and yes I am sorry but this would fix what is a significant burden on our Society… Of course we would lose many of the “Healthy” maybe even myself but that is the way of the World!

I am sure you see the logic in this as clearly as you see its inhumanity. This is so-called Social Darwinism at its worst, and the end result is a Nazi-like culling of the “unfit” from our populations. Nazis carried out mass murders as “euthanasia,” and one of the ways they did it was to crowd Jews into ghettos where typhus and other deadly microbes were brewing and then (see above) “let Nature take its course.” A friend of mine, Tosia Szechter Schneider (now 92) lost her mother and other family members to typhus in one of those Nazi-encouraged experiments in letting Nature take its course. You may remember what Darwin said about this in The Descent of Man:

The aid which we feel impelled to give to the helpless is mainly an incidental result of the instinct of sympathy, which was originally acquired as part of the social instincts, but subsequently rendered…more tender and more widely diffused. Nor could we check our sympathy, if so urged by hard reason, without deterioration in the noblest part of our nature… If we were intentionally to neglect the weak and helpless, it could only be for a contingent benefit, with a certain and great present evil.

In other words, Darwin rejected the moral lapses that some people argued should derive from his own theory. He understood that being human gives us choices that other animals don’t have, and he wanted us to use those choices to protect the weak, not “let Nature take its course.”

            But you might decide Darwin is wrong and the Antioch commissioner is right. I hear some young people have suggested COVID-19 parties where you can infect each other, get a (probably) mild illness, and get it over with! I suggest the following song after you’ve had a few beers. (It’s sung to the tune of the title song in the ‘60s musical Bye Bye Birdie.):

Bye bye Grannie,

We’re gonna miss you so!

Sorry, Grannie,

But ya gotta go!

If you’re curious about this tune click the link now, because after Nature takes its course, no one left alive will remember it, and you’ll never hear of it again.

[Important disclaimer! I don’t really advise you to have a COVID-19 party!]

Good News

  1. “Good to be with you,” said Gov. Cuomo Sunday to one of the four governors joining him virtually and pragmatically in a new consortium. New York, the tip of a severed starfish point, has regenerated much more of the point by bonding with Connecticut, New Jersey, Pennsylvania, and Delaware to coordinate rules and to bulk-buy protective and testing equipment at better prices.
  2. Remdesivir, an antiviral that was developed for Ebola, has reportedly shown its ability to reduce ICU stays from 15 to 11 days in very sick patients. This, if it holds up, is great news. The drug will not be withheld in new trials (now unethical), but will be added to other study drugs in continued research. Bill Gates’s foundation and others are working aggressively (“The Therapeutics Accelerator”) on a treatment that would use monoclonal antibody technology to derive drugs from convalescent plasma, among other treatments.
  3. Testing of two main types (for current virus and for antibodies raised by past virus) is ramping up, although not nearly fast enough. Home self-tests (like the ones we have for pregnancy) should soon be more widely available. Contact tracing, far behind testing, is slowly improving. Random-sample testing in a few places is beginning to clarify how the virus has spread and who (by age, location, ethnicity, and gender) is affected most.
  4. New cases in South Korea that appeared to be reinfections of people who already had it (i.e. they lost their protection in weeks to months) now appear to have been head fakes (false positives), caused by what one expert calls “viral litter”—non-dangerous fragments of viral RNA lingering from the infection.
  5. As many as a hundred labs worldwide are working as hard and fast as they can on vaccine candidates. 95 percent of these could fail in clinical trials (the hard part) and we would still have a few to use. Factories are being built and adapted long in advance of this to produce up to billions of doses that will eventually be needed. Up to 14 vaccines have already entered Phase 1 clinical trials, much sooner than most experts expected.
  6. The modelers at the University of Washington (IHME, led by Chris Murray) have detected a heat effect that is much less than it is with some other viruses but greater than previously thought for this one. Therefore a hot summer will work to a modest extent against the social factors making things worse.

Bad news

  1. Rules are being relaxed by states in an uncoordinated way, without a flicker of national leadership, except in the direction of greater risk. Few if any of the states reopening have met the national standard, put forth recently, of having declining cases for two weeks; most still have rising cases. The Federal government has ordered meatpacking plants, essentially petri dishes for the virus (like cruise ships and prisons), to reopen and stay open, and these are and will be places from which many American communities will become disaster areas.
  2. As Bill Gates remarked on CNN Friday, the so-far modest impact of remdesivir is not going to make us say, “Let’s go to the movies.” Experts note that a smaller study (but a good one, and large enough to show a substantial effect if there were any) in The Lancet found no effect of the same drug. The larger study praised by Dr. Fauci has not been published or peer-reviewed, and all we have so far is a press release and his word.
  3. Testing and contract tracing, the life blood of safe reopening (and therefore of economic recovery) is primitive in our country. We have around 200,000 tests a day nationally, done for the sick and a few others (like health care workers) in most places, but otherwise haphazardly. Expert opinion on how many tests we need range from 5 million a week to 20 million a day. Given that we are most infectious in the first few days of symptoms, or even before, tests that take days to get results are of limited value in controlling the pandemic. “What’s the point?” Bill Gates asked the other evening. “Do you just send apology notes to the people you infected in those 3 or 4 days?” The Gates foundation is supporting the scale-up of rapid testing.
  4. Perhaps the biggest unanswered question is what is the extent of our immunity after having had the virus and how long it will last. Could it be like chickenpox, one and done for life? Or more like flu, protection for a season? The same questions apply to vaccines; this year’s flu vaccine was 50 percent effective.
  5. Speaking of vaccines, the 12-18 month time-frame often mentioned for getting to distribution of a safe and effective vaccine would be by far the shortest in history. Animal models have limits; Dr. Sanjay Gupta reminded us the other day of an old doctors’ saying: Rats lie, monkeys exaggerate. Perhaps the brute force of a hundred labs parallel-processing various methods will accelerate the time to large human trials, but those trials take time. Many will fail and some may fail dangerously.
  6. Internal Trump administration memos revealed today project 3,000 cases per day in June, about double what we have today and higher than the highest peak so far (~2500 in mid-April). These new projections may to be what led President Trump to say yesterday that total deaths could go to 100,000. Given how optimistic he has been in the past, this could be interpreted as meaning that he is deliberately choosing economic activity over preventing mortality, and we should be prepared for more.

Almost half the country is officially open to some extent as of today. “Government overreach”—for your protection—is (temporarily) ending in many states. Watch the states, as well as other nations (with much better testing) that are opening and see what happens. It’s interesting that Dr. Birx (quote up top) misspoke slightly in expressing her worries about the people who don’t do social distancing in protests: “they will feel guilty for the rest of our lives”—the line between “their” and “our” indeed blurs.

Nationally, we’ve been stuck on a fairly stubborn plateau of cases and deaths as states with increases replace those with declines. Projected cases, hospitalizations, and deaths that two weeks ago gave me hope of a more normal summer before a possible fall wave were based on the assumption of serious social distancing through May. That hasn’t held, and all models are projecting more deaths. The latest today (May 4) from IHME projects 134,000 deaths by August, almost double the number projected 6 days ago. I wish I could tell you that college will be live in the fall. As Gov. Cuomo said today, “Know what you don’t know.”

I don’t know for sure, and I’m sorry to have to say it, but it seems to me we have chosen mobility over sheltering and death over life.

The weather’s great, go out (seriously), enjoy a walk or a run alone or with someone you trust. Wear a mask (as Cuomo says, it’s a sign of love and respect for others, because it protects them from you), stay at least six feet (two meters) away from anyone not part of your household, go home as soon as you can, and wash your hands obsessively. While you’re out, observe the crowds who aren’t doing the above, and if you’re religious say a prayer for them, because in a couple of weeks they are going to need it.

As for you, please to take to heart what Tim Cook, head of Apple, said to the new Ohio State grads in his online commencement address: “I hope you wear these uncommon circumstances as a badge of honor.” This is my hope for you in your own futures. Do the right thing now, and live to brag for the rest of your lives about how you made it through COVID-19. As you have heard me say many times, you are lucky to have great gifts, and the world has a right to expect leadership from you.

Dr. K

Note: Please don’t just rely on me. I recommend the following good sources: The Bill & Melinda Gates Foundation COVID-19 Update, aka The Optimist; This Week in Virology (TwiV) podcast; IHME (U. of Washington) model website; COVID-19 UpToDate for medical professionals; and for all readers: Why the Coronavirus is So Confusing. Dr. Ashish Jha of the Harvard School of Public Health said on Thursday, “I grew up as a public health person loving and admiring the CDC, arguing and believing that it is the best public health agency in the world… But in this entire pandemic, it’s been one fiasco after another. And it’s either possible that all of the scientists all of a sudden forgot their science, or there’s something at the leadership level that’s really hindering them.” 

 

 

 

 

 

 

 

 

 

 

 

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