From health

Vaccine Hesitancy -2.0

My previous essay was entitled Vaccine Hesitancy. I follow that essay with a similar title, Vaccine Hesitancy 2.0, because I think this is a very important issue that needs urgent attention. The fourth surge can be entirely laid at the feet of the unvaccinated, as it is only the unvaccinated that require hospitalization and are the ones that are dying. Folks, there is no one else to blame. I am puzzled by this new phenomenon, which in my half-century experience in medicine and surgery has never come up, except in a group of people called anti-vaccers, who refuse to vaccinate their children for a variety of reasons, religion, fear of autism, and just general kookiness. But to see almost half the population fear vaccination is a new phenomenon. I have heard some pretty screwball reasons for not getting vaccinated. For instance I don’t want to become sterile, or they inject microchips into you so they can control you, or Bill Gates and Anthony Fauci created the virus so they could profit from the sale of vaccines. These are among many more crazy conspiracy theories that are just off the wall.  Two main demographics are afraid to get vaccinated, white Republican males and people of color.  There are not many characteristics linking these two diverse groups. But both have a deep-rooted distrust of big government. I think it is that issue that fuels most of the fear of vaccination.

Past vaccinations have mostly come from medical research and have been promoted by the medical profession. This is the first time that the government has been the agency that has promoted vaccination.  I have given a lot of vaccinations over the last half-century and have not seen any serious consequences.  I realize that bad things can happen, but they are extremely rare, like one in a million.  The purpose of vaccination is to eliminate the much more serious consequence of the diseases that they are designed to fight.  Those diseases have a mortality of a lot higher than one in a million. 

When I was drafted into the military during the Vietnam conflict, I was the physician in charge of the vaccination program at my Base.  I did not give the shots. My nurses did that, even though most of them outranked me. I was just a Captain then, and many of them had been in the military much longer and were Majors or higher, but I was professionally higher in rank.  As soon as the FDA fully approves the Covid vaccines, the military will incorporate those vaccines in their mandated panel, as the danger of having the majority of the fighting force open to this plague is an untenable risk to national security.

Available vaccines

  1. Cholera
  2. COVID-19 (corona virus)
  3. Dengue
  4. Diphtheria
  5. Hepatitis
  6. Haemophilus influenzae type b (Hib)
  7. Human papillomavirus (HPV)
  8. Influenza
  9. Japanese encephalitis
  10. Malaria
  11. Measles
  12. Meningococcal meningitis
  13. Mumps
  14. Pertussis
  15. Pneumococcal disease
  16. Poliomyelitis
  17. Rabies
  18. Rotavirus
  19. Rubella
  20. Tetanus
  21. Tick-borne encephalitis
  22. Tuberculosis
  23. Typhoid
  24. Varicella
  25. Yellow Fever
  26. Covid-19 still voluntary at this point

 But in two years and thousands of doses, I did not have one serious event, including getting mine. The worst was a couple of recruits who fainted.  See above for the shortlist of vaccinations that could be given depending on the deployment of the soldier. Working in emergency rooms for more time than I care to admit, I shot a lot of DPT, and DT (Diphtheria +Pertussis+ Tetanus and Diphtheria+Tetanus) vaccine into people’s arms, along with a lot of MMR (Measles, Mumps, and Rubella) and Trivalent Polio Vaccine during my days as a General Practitioner, again not one significant reaction. But a lot of kids did not get Measles, Mumps, Rubella, or Polio, all of which have serious consequences, including death, and Rubella can cause horrible heart defects, brain abnormalities, diabetes, and deafness if a pregnant mother should get it.  Until Jonas Salk came up with his Polio vaccine, a lot of people got “Infantile Paralysis,” which destroyed their lives! I remember the braces that some of my schoolmates had to wear so they could walk. The “Iron Lungs” on the Polio wards at LA Couty Hospital during my Internship were a sad testament to those that did not get vaccinated.

IRON LUNG

The Covid vaccines are very safe and statically more so than all the ones I used, which have a risk ratio of 1 to 1,000,000 of serious reactions. The Johnson and Johnson, the supposedly most dangerous of the Covid vaccines, has a death risk of 1 to 3,500,000, making it three and one-half times safer than what I dished out. People please get a grip! Think and look at the evidence! It is not rocket science! The anti-vacc rhetoric is changing. More and more radio and TV personalities are promoting getting vaccinated in their message. Even Phil Valentine, a well known conservative Radio personality who is seriously ill with Covid, is pleading with his audience to go get vaccinated! Add to that Mitch McConnell (Senate Minority Leader), Steve Scalise (Minority Whip), Sean Hannity, Steve Doocy (both Fox TV hosts), every physician member of Congress on both sides of the aisle, 17 in all, except for Rand Paul who has had Covid, Kamala Harris, Karim Abdul-Jabbar, Barack and Michelle Obama, Tyler Perry, Rupert Murdoch (conservative billionaire and owner of Fox),  and many more.

55 professional organizations produced a joint statement to demand all workers in health and long term care should be mandated to be vaccinated including: The American Academy of Family Practice (AAFP), the American Academy of Ophthalmology (AAO), Academy of Physician Assistants (AAPA), American Academy of Pediatrics (AAP), American College of Pharmacy, American College of Physicians, American College of Surgeons, American Medical Association (AMA), American Nursing Association (ANA), American Pharmacists Association, American Psychiatric Association (APA), American Society of Hematology (ASH), Infectious Diseases Society of America (IDSA), American Hospital Association (AHA), and more! All UC schools have just announced they will mandate vaccination and most colleges and universities across the country have done the same or are on the verge of mandating vaccinations. These are some of the smarter people we have on this planet. I leave it to you to decide what that makes you? If you do not believe our doctors, nurses, pharmacists, and academics, nothing I say will change your mind. I feel sorry for you, and “MAY GOD HELP YOU!”

 Even Donald Trump and Melania got their vaccination, for God’s Sake!

Vaccine Hesitancy

Dance of Death

Pandemics have been around forever.  One of the earliest discovered was from 3000 BC, ironically in a village in China that was wiped out, killing everyone.  In 430 BC the Plague of Athens killed 100,000. The Antonine Plague 165 to 180 AD in the Roman Empire, killed as many as 10,000,000. The Plague of Justinian, 527-565 AD made several appearances said to have reduced the population of the world by 10%. The Black Death also made multiple appearances, starting in Asia and marching across Europe through Russia, France, and England. An estimated 60% of the world’s population succumbed to the Plague. The Spanish Flu, 1918-1920 infected 500,000,000, with 20% dying, the worst pandemic so far. There have been many more, at least 20 major pandemics, defined as a mortality of several millions up to 60% of an entire continent, and a few hundred of lesser pandemics and local epidemics. I don’t know if Covid 19 with 4,070,341 deaths (Johns Hopkins estimates to date) has yet made into the major league.

I am amazed by the resistance to vaccination. It is unbelievable that so many are willing to shoot themselves in the foot out of ignorance.  It is not a political issue. It is not a constitutional issue. It is a health life and death issue.  Vaccines have been around for several hundred years ever since Edward Jenner discovered that giving people an infection with a weaker virus prevents the deadly form of smallpox from killing you.  Absolutely everything we do just by living, does have risks. Lightning kills 1 person in 15,000. You are more likely to get killed by a Sunday drive in the country.  Car accidents have a lifetime risk of 1 death in 100 people. We all eat. The odds of dying from choking on food is 1 in 2535. Drowning, electrocution, and natural disasters all are risks we face every day, not to mention the myriad of all the allergic, traumatic, and other viral, bacterial, degenerative, and autoimmune diseases that lurk around every corner. 40% of humans get cancer sometime during their life, and anywhere from 20 to 50% will die of it depending on the type of cancer and at what stage it is discovered. The death rate of the vaccine is 1 in 3,500,000.  The risk of death if you get Covid 19 is 2% (1 in 50) for the unvaccinated and 0 for the Covid vaccinated. Does that give you a hint?

I do understand our right not to have anything injected into us. That would be a constitutional right, but by you exercising your constitutional right infringes with my constitutional right not to get the virus from you. That means you must stay away from me, and  I need to know who you are.  You will need to wear an armband, or better yet, a tattoo on your forehead, as well as a mask.

Everyone that goes to school must be vaccinated. Every military enlisted person must have multiple vaccinations, as I did when I was drafted during Vietnam. If you drive a car, you must be insured, and you must obey all the rules of the road. You are not allowed to walk around with a gun at your side. And you certainly cannot go around shooting people, and by extension, you cannot spray your Covid 19 on me.

Shifting the goal post in dealing with this pandemic has been confusing and admittedly unfair. Wear a mask, don’t wear a mask, wear two masks, keep a distance of 3 feet from other people, now keep a 6 foot distance, or maybe 15 feet. Unfortunately, science is not infallible and not always right.  It is an evolving field as new knowledge and new developments are introduced. When I learned my trade fifty years ago, I was taught the sum total of medical knowledge of the time. Fifty years later, most of that does not apply anymore.  If I did 90% of what I do as I learned it, I would be sued or, worse, go to jail. There are obligations and even mandates we must obey if we live in a communal society.  If we do not conform to the required standard, society has a right to take corrective action.  Depending on what risks we pose to our fellow man, society can reprimand us, imprison us, all the way to executing us, which by the way the constitution allows and is not unconstitutional, by far more of an infringement than having you wear a mask, I think.  I am surprised that lawsuits have not materialized if you can prove that someone or some institution contributed to your getting infected.

It is not comprehensible to me as to why the most vaccine-hesitant are Republican males and people of color.  It is because of Donald Trump’s efforts that the vaccines have become available as quickly as they have. And everyone in Trump’s family, including Donald Trump, has been vaccinated. A little more understandable is the distrust of the black population ever since Tuskegee.  Public announcements from Trump and prominent people of color, like our VP, to encourage vaccination would do a lot more than anything Anthony Fauci could say. It would save lives!

If you are not yet vaccinated, you have not educated yourself adequately, and are endangering others by your stubbornness. You are the one who infringes on my constitutional right to live in a safe environment and not to get infected. Everything we do has a risk-benefit ratio. I spent my entire professional life working within that risk-benefit equation. The risk-to-benefit ratio of getting vaccinated vastly tilts to BENEFIT for you and society. Take my word for it!

RUDOLF VIRCHOW

Most of you will not be familiar with the name.  He influenced the course of health care, medicine, science, anthropology, biology, and politics.  He was a personality of immense intellect and achievements who deserves our knowing who he was.

Rudolf Virchow © Photos.com/Jupiterimages

He was born on October 13, 1821, as Rudolf Ludwig Carl Virchow in Schivelbein, Prussia, now Poland. His parents were farmers.  Rudolf was a brilliant student.  In gymnasium (equivalent to high school) he became fluent in German, Latin, Greek, Hebrew, English, Arabic, French, Italian, and Dutch. He was headed for a position in the clergy, but his uncertainty about God and his self-assessment that he had a weak voice made that an untenable career. He chose medicine instead. He studied at the University of Berlin. After graduation, he did an internship at Charité Hospital, the most prestigious hospital in Berlin.  He introduced the use of the microscope to study diseases and developed a method for discovering the cause of death, the autopsy. Forensic medicine was another one of his creations, and he was often called as an expert witness in criminal cases.

In 1847 the Prussian government sent him to study a typhus epidemic in Silesia.  It was there that he came upon the principles of public health for Germany and, eventually, the rest of the world.  His theory was that medicine is the study of disease, and the enlightened government is nothing more than medicine expanded to the population.   Because of his political activism, he lost his position at Charité. He left Berlin to be the chair of pathology at the University of  Würzburg in Bavaria, the first such position in Germany. Eventually, he was invited to return to Berlin to become Charité’s director of pathology for the next 20 years.  

He realized that all cells come from other cells (Omnis cellula e cellula).  From this sprang his theory of cancer origin and how it spread.  He discovered blood cancers that he was the first to call Leukemia, coining that word and many more, such as spina bifida, embolism, thrombosis, and others.  The “Node of Virchow” is now recognized as a swelling in the left side of the neck that is the harbinger of the lethal spread of a gastrointestinal malignancy.  “Virchow’s Triad” details the causes of blood clots in vessels due to one of three causes, stasis of blood, injury of the vessel’s inner lining, and blood that is hypercoagulable.

He discovered that many animal diseases could be transmitted to humans, from which he coined the term “zoonosis.” Coronavirus is a zoonosis that is said to have originated from bats. Virchow was ahead of his time. He found the cause of Trichinosis, the tiny parasitic larval form of worms, trichinella spiralis, that resided in the muscles of pigs and by eating insufficiently cooked pork, could infect humans. Introducing meat inspections in Berlin eventually wiped out that disease in Germany.  The sewer system and water supply of Berlin were designed by him. Virchow managed to get himself elected to the German Reichstag (the Parliament) from 1880 to 1893, and often championed better sanitation, support for the poor, improvement of health care, and other issues that concerned the public good.  The Chancellor, Otto von Bismarck, who acted as the head of state, often did not see eye to eye with Virchow, especially on excessive military spending.  He irritated Bismarck to such an extent that Bismarck challenged Virchow to a duel.  The rules of such a potentially lethal encounter required that the one who was challenged gets to choose the weapons.  Virchow cleverly chose Kielbasa, Polish sausage, filled with trichinella spiralis worms. Bismark refused to do battle with him based on it being undignified as well as too dangerous!

History, anthropology, and paleontology were his passionate avocations.  He accompanied Heinrich Schliemann to the site in Turkey, where he believed the city of Troy was formerly located, to help in the excavations there.  Furthermore, Virchow was convinced that no Aryan race existed, by studying over 6,000,000 school children, concluding that the people of Europe belonged to a mixture of races that could not be sufficiently identified to be separated, much less considering any group as being superior.  He is often mentioned as an opponent of Charles Darwin’s theory of evolution, but that is not entirely accurate.  Virchow was just not convinced that it should be considered fully proven, but a hypothesis. 

He was offered an aristocratic title but declined this as a privilege he deemed too snooty.  He did, however, subsequently accept the title Geheimrat (Privy Councillor), a distinguished title of the highest advising official or high ranking academic professor who made outstanding contributions to science.  Having published over 2,000 papers and books, he certainly qualified for the title.

Early in 1902, Virchow jumped from a streetcar and broke his thighbone.  He never recovered from that accident and died later that year at age 80. For his liberal ideas, champion of freedom, and proponent of elected representational government by the German people, and his pronouncement that there was no such thing as a superior Arian race, his non-scientific books were burned by the Nazis, even though he had died decades before.

WE ARE AT WAR! (This Time with a Virus!)

It pains me to see the bitter divisiveness our country is undergoing, specifically understanding the current ad hominem attacks on President Trump. Ad hominem attacks, rather than attacking the substance of a position, attack the person’s character, his motives, or other personal attributes of the individual, and make the argument that because of these traits, his position is also wrong. It was Aristotle who first pointed out that such arguments are illogical and unsound. These attackers focus on Trump’s stupidity, his narcissism, his self-aggrandizement, his lack of humor, his small hands (and we all know what that is supposed to mean) etc. etc. Is this helpful?  Does this add anything to the discussion? Will this change anything? Almost none of these tirades focus on meaningful critique as to what he should do differently. This makes me think the critics either don’t know what he should do differently or they are afraid to voice any opinion because they very well may be wrong. 

Former Vice-President Biden was very critical of Trump about shutting down travel from China.  He called him hysterical, xenophobic, and fearmongering.  The spinmeisters claim those labels did not specifically relate to him closing travel from China, even though those critical remarks came right after the travel restrictions.  If that is so to what did it refer? Ah! I know. He named the virus “the Chinese virus,” which called forth another straw man, the race card.  Trump is a racist! But is that realistic? The fact that the epidemic started in Wuhan, China, ostensibly from Chinese bat soup, makes it relatively easy to call it a Chinese virus, just as the 1918 pandemic was called the Spanish Flu with much lesser justification. The first case of the 1918 Flu was actually in Kansas. 

Biden’s fearmongering critique demonstrates how being critical too soon can backfire.   The newest Biden critique complains the opposite, that Trump acted too slowly.  Trump tends to be positive about opening up the country, about medications that may help, about the stock market coming back, about fewer deaths than the models predicted.  He often puts the better spin on the message given by his consultant doctors; nevertheless, he does what they say to do. I might add that doctors are trained to hang black crepe.  It is in their nature. I know, I am one. Trump does not want to be the fearmonger that Biden claims him to be.  He wants to be reassuring but has not acted on that positivity, and sticks closely to what Dr. Anthony Fauci recommends. I am sure the President would like to be a cheerleader, and we certainly need one!  

In a few months, we will have the chance to elect a new president.  That will be the time to exercise your opinion, your rights as a citizen, and your wisdom.  The word Democracy comes from two Greek words, Demos (the people) and Cratos (the power). We shall see what our Democracy will do, and then I shall support what the people decide, as our Founding Fathers envisioned, and I hope the rest of the country will also do as I do. In the meantime, I believe for the current COVID war, our Democracy has already spoken twice. For almost 250 years we have had certain rules for electing the President, and those rules have not changed. It is appropriate to go with the lawfully elected President, given our time of uncertainty and combat against an unseen enemy.

Ad hominem attacks lack style and put the attacker into a lesser class.  If you can’t argue intelligently with facts and figures, don’t succumb to name-calling.  It does not make you look classy. Donald Trump is no Ronald Reagan, but he is our President, whether you like it or not. We are in a war, even though this enemy is a virus, and war demands we act on a war mentality that traditionally requires unity and civility.   I plead that we keep our cool and act with style, intelligence, and wisdom, and listen to Aristotle!   

THERE IS NOTHING NEW UNDER THE SUN

It has been a month now that the government edict to stay at home has been proclaimed.  Many have lost jobs, and there is a natural resistance that is evolving among the restless among us.  The question of individual rights and freedoms is raised.  Is it not my right to control where I go and what I do? This philosophy has evolved into a political movement of Libertarianism that emphasizes freedom of choice, voluntary association, and holding the individual’s judgment as the holy grail of how we should live. There are right-leaning and left-leaning Libertarians. But both pit governmental authority against individual opinion. Why should I wear a mask when I am not sick, why should I vaccinate my children when vaccination has some risk and has in some cases shown not to be completely protective?  Why should I stay at home when I need to get back to work?  There are only two certainties, death and taxes. People die all the time, how is that different from this virus?  The country’s and my personal economic condition is deteriorating while I sit at home bored out of my mind.  It is my decision to risk my life if I deem it necessary?  We live in a democracy.  How can the government tell me what to do?

Those are the arguments I hear from friends, the radio, talk show hosts, and sometimes I even have these thoughts myself.  There is, however, an overriding principle.  Humans live in social groups.   Only hermits can act out their fantasies. Our actions impact others. We have social responsibilities that go beyond our personal being.  When our freedom impacts society adversely, society has a right to regulate what we do.  Willie Sutten, when he was caught, was asked why he robs banks?  His answer, “Because that is where the money is.” I have always wanted to be rich, but I can’t go to banks, like Willie, and take what I want.  My right to be rich is infringed upon by other’s rights not to have their wealth stolen. My right to refuse vaccinations interferes with the population’s rights not to have a carrier of disease spread the plague and shorten their life span.

Mary Mallon was born in County Tyrone in Northern Ireland. She came to New York and was a  cook working in restaurants, and also for a number of families that hired her to cook for them.  Everywhere she went, people got sick with fever and diarrhea; some even died.  The disease that caused this illness was determined to be from a bacteria, Salmonella Typhi.  She was not ill and appeared perfectly healthy.  At least 50 deaths from Typhoid fever were attributed to her.   

She was held in quarantine from 1907 to 1910.  But when released, she went back to her old job of cooking.  This time she moved on, when people got sick, to the next cooking job.  Authorities failed to catch her until 1915.  She spent the rest of her life in jail and died in 1938 of pneumonia. History assigned the name “Typhoid Mary” to her.

It was Rudolph Virchow, a German pathologist of the 19th century, who gave us the word “zoonosis,” a disease that originates in animals and then is transmitted to humans.  In its more aggressive form, it can then spread from human to human. There are many zoonoses, Swine Flu, Avian Flu, Ebola, Malaria, Anthrax, Trichinosis, Rabies, Plague, COVID-19, etc. Our close association with animals started with the domestication of animals, going back to the late Pleistocene, beginning 129,000 to 11,700 years ago during the last ice age.  The Middle Ages brought humans and animals together even closer, when farmers brought their animals into their houses for warmth and to guard them.  Because we lived in close proximity to animals, their bacterial, viral, and protozoan diseases could now jump to us quite easily.

When our freedom interferes with the freedom of others, a compromise must be negotiated.  We can only exercise our freedom if it does not take away the freedom of others.  That principle is what allows the imposition of shelter in place dictates, immunization mandates, social distancing rules, and the wearing of face masks. South Dakota resisted implementing social isolation for much too long in the name of freedom of choice, with many unnecessary deaths. This recent pandemic has been a new experience for us, but it is not unprecedented.  1918 gave us the Spanish Flu, named because of a misunderstanding.  Spain was neutral in World War I.  The first case of that Flu was actually March 11, 1918, in Kansas.  Because there was censorship, as not to reduce the morale of the troops, it was not reported.  Spain, on the other hand, was not bound by that censorship and reported all the gory details, including that their king, Alfonso XIII, came down with a severe case of it.  That cinched it.  From then on, it was “The Spanish Flu.”     Quarantine and masks were the order of the day. There is nothing new under the sun!

THE ONLY THING WE HAVE TO FEAR…

I confess I am a relentless optimist.  The joke of the two boys, one an optimist and the other a pessimist, portrays the difference quite well.  The pessimist got a pony for his birthday.  He sat looking at his new pony with large tears running down his cheeks. “Why so sad?” he was asked.  “All ponies eventually die!” he blurted out between the tears.  The optimist was given a room full of manure.  He was happily throwing the manure up into the air, giddy with joy.  “Why so happy?” he was asked.  “With all this horse poop around, there has to be a pony somewhere!” 

Despite all the pessimism we are steeped in, I am optimistic. One of our biggest fears is fear itself, as said so well by one of the icons of our nation, Franklin Delano Roosevelt, who uttered those words during another crisis our country faced, different but yet similar in terms of even greater risk to life, lifestyle, the economy, and need for regulation of its citizens.  A lot of damage has been done by the panic of the coronavirus, which I feel has been whipped up by the media and a lot of craziness in the social media. The rumors that the virus was created by the Chinese, the Russians, the Martians, the Jews, or the US military, with one of their weaponizing projects gone rogue, is just insane. First of all, we are not that sophisticated to create viruses (yet), although the Martians might be if they existed.  And this would be a totally new way of terrorism that has never been accomplished by humans before.  The global stock markets have shed 6 trillion dollars, while the US markets own 2/3 of that loss i.e., 4 trillion.  This seems like another over-reaction in my view. Coronavirus (COVID-19) is nowhere near the aggressiveness of other pandemics we have had.  The mortality is going to settle out at less than 1%, and the older population, especially the ones with comorbidities, are at greatest risk.  The 1918 Spanish flu, which was the H1N1 swine flu killed 100,000,000. Both MERS and SARS were more aggressive, but peaked out before widespread epidemics. China has peaked out and is on the other side of the curve both in terms of the disease and in terms of its economy. Even their domestic air travel is showing signs of recovery.   South Korea is close behind in beating the epidemic. The warm weather is coming.  All previous viral epidemics showed an amelioration when the temperature went up, and this will likely do the same with this epidemic (something good that can be said about global warming).

I do have concerns about the wisdom of shutting down the whole country with its obvious detrimental consequences to the economy, when isolating the likely susceptible at risk are the only ones that really need to be. The rest of the healthy younger population could be getting herd immunity. But all the smarter people than me with a lot of data from other countries that have gone through this seem to think that the social distancing, the school closures, limiting the number of people gathering at no more than ten, and working from home, etc. are what is necessary.  In the meantime, there are at least ten vaccine candidates out there with Moderna, Inc (Nasdaq: MRNA) in Phase 1 trials that have started today. Several anti-viral drugs that are already available have proven some efficacy against the coronavirus, as does serum from recovered coronavirus patients. Our President and Chief of Optimism thinks by July this will be contained. I do believe that everything that can be done is being done, and a lot of very smart people are involved. There are reasons to be optimistic. There really are no other choices. 

CORONAVIRUS FOR DUMMIES

My last two essays were, you guessed it, on COVID-19. That is all you hear on the radio or TV these days. In keeping with the trend, I am continuing to stir the pot. It has gone viral.  Coronavirus, true to its name, is a virus that has gone viral! 

Viruses grow exponentially (J-shaped growth curve), the fastest growth rate there is, the larger the growing population, the faster the growth, as long as the food holds out.  When the food runs out, the curve then changes to a logistic curve (S-shaped growth curve).  This curve shows a slowing down of growth. So what makes the curve slow down?  There are only two things that make the curve slow down: #1 fewer in the susceptible herd are available (either through the susceptible making themselves less available or the process makes the susceptibles less available ).  #2 the rate of growth slows down.  This happens when it takes longer to infect the next person.  This could be when people wash their hands more often, don’t go out to spread the virus, or at least sneeze into a napkin. Ultimately when the food supply runs out, both mechanisms are at work, reducing the susceptible and the rate of spread.

The number of new cases will slow down, guaranteed! But will we still be alive to talk about it? I think we will.  There are several reasons I believe this.  We are worried about it, in fact too worried! As evidenced by the stock market!  The virus is not as dangerous as the news media tells us.  The mortality rate is likely not 9% as SARS was, it is closer to 0.1% as the last flu outbreak was. The measures we are taking to reduce the number of people exposed, and the rate of spread will reduce the number of new cases.  It is common sense not to go out and buy cruise trip tickets.  It is common sense to limit your unnecessary exposure to large crowds.  It is common sense to wash your hands often.  It is common sense not to bring the virus close to the places the virus gains entry to your lungs, like your eyes, your nose, and mouth. The virus stays active for a couple of days on any surface, such as a door nob, so washing hands is not only hygienic but important.

I have been in the doctor business over two-thirds of my lifetime, and have washed my hands to the point that I have scrubbed off my fingerprints. 

They always have trouble when I need to give a fingerprint for a passport or other ID, because I obliterated them off over the years. I first learned to scrub for surgery in my third year of medical school at UCLA from one of the icons of surgery. He put soot on our hands, then blindfolded us, gave us a brush and soap, and made us scrub our hands. You would be surprised how much soot stayed on our hands and the places that were most likely to remain black, the back of our hands, the webspace between the fingers, and the space between the wrist and the palm.   For medical students, it was a minimum of ten minutes (first scrub of the day) to get our hands clean. But for our purposes, washing for 20 seconds is generally enough.  I learned a nice little trick from my grandchildren’s primary school teacher, singing the “Happy Birthday” song twice (at regular speed) is precisely 20 seconds. 

You get the virus from another person, either through direct contact or through a surface, the infected person has left some body fluids.  Avoiding other people is one way to decrease contact.  I believe that shaking hands was an ancient, rather strange custom.  It goes back to the Middle Ages when you met someone in the forest. You extended your right hand, as did the other person, to show that they did not have a dagger in it.  It was somewhat awkward standing there with both your and his hands extended, so grabbing and shaking seemed like the right thing to do. As we don’t carry daggers any more, this Middle Age custom has outlived its usefulness and needs to stop.  I vote for the Mr. Spock handshake: right hand raised at your side with the index and middle finger spread form the ring and pinky finger in a V configuration.  This is necessary because if you don’t spread your fingers, it looks like a “Heil Hitler.” And if you leave just your middle finger up, it changes the entire meaning.

Viruses, like white men, can’t jump. Therefore a yard distance between people should be enough although the CDC in an abundance of caution has now revised it to two yards unless they are coughing or sneezing. If they are, you need to get out of that room, because the sneeze generates particles that are as small as 5 microns in diameter that travel over 100 miles per hour, and can stay in the air indefinitely like any pollen sized or smaller particle.

Masks are not very helpful, except for the ill person who coughs and sneezes.  It keeps the particles that are spewed out more confined.  Regular masks, actually, are not very effective in preventing inhalation.  For one thing, the sides allow fine airborne mist to enter the space behind the mask, which is inhaled. To be effective, it has to be a special mask fitted to the individual that allows only air that goes through the mask to get to the person using it.  Those masks do not let fine mist or small particles to go through.  These are called N95 masks.    

Hugging is another one of those human customs that should go away.  I won’t even discuss kissing.  Hugging and kissing ought to go the way of arranged marriages and should be relegated to the XO on the written word.

Good Luck!! Gus Iwasiuk XOXO

LIES, DAMNED LIES, AND STATISTICS

Mark Twain by A.F.Bradley ©       Benjamin Disraeli  Photos.com/Jupiterimages ©

“There are three kinds of lies: Lies, Damned Lies, and Statistics.” The phrase is often claimed to be one of Mark Twain’s quotes, who, in fact, attributed it to Benjamin Disraeli, who served Queen Victoria as Prime Minister of the United Kingdom.  This quote is not found anywhere in Disraeli’s writings, although he may have said those words. Regardless of who said it, the sentence argues that statistics are often the worst kind of misinformation because they have the authority of numbers; the sources are hard to pinpoint and dispute and therefore are believed.

I fell into this trap recently and exposed my ignorance by quoting the Coronavirus mortality statistics, as given in large part, by the Chinese government.  The clue to me should have been “Chinese government.” The number of deaths I saw in the news was 3,132 deaths of a total of 92,303 (the newest numbers 3,886 deaths and 111,650 total cases). Nevertheless, mortality rates remain close to 3.4%.  The number of people that died is probably accurate.  It is hard to fake death, and counting the dead is likely to be reasonably precise. If they don’t move, they are probably dead.  The denominator has grown to 111,650 people that have the disease and are almost certain to be undercounted.  Mild cases are frequently not diagnosed or reported.  A runny nose is a runny nose, not COVID 19, in most people’s judgement, but then again, it could be.  The denominator is likely a much larger number judging from statistical analysis of previous epidemics. This would significantly revise mortality downward.

That, however, is not the essential source of misleading information. To accurately estimate disease mortality, raw numbers give the wrong impression.  In the seasonal flu mortality, we see every year, and the numbers are more accurately reported remaining under 1% because:

  • We are in the USA
  • Our health reporting is mandated by governmental agencies (not necessarily a strong point)
  • We try to be scientifically as honest as we can with checks and balances that report dishonesty or ulterior motives for inflating or deflating numbers
  • The people in charge of reporting don’t have quite the hidden motives or pressures as an autocracy generates, who initially punished reporting physicians
  • Our system has multiple sources of input that act as an automatic control mechanism
  • Our math adds the mild cases and estimates of asymptomatic people to the calculations (although this has to be retrospective)

Almost all comorbidities affect mortality rates: heart disease, chronic lung disease, renal failure, liver failure, obesity, neurologic disease, diabetes, cancer, immune deficiency, pregnancy, age, etc.

Without knowing the demographics of the population under discussion, raw data mortality rates are almost meaningless.  In the 2017-2018 flu season, which was one of the most severe epidemics in the last decade, if you were a healthy person, not pregnant, under 65 years of age, your risk of death was under 1%, but if you had a heart problem and were over 65 your mortality was over 10%.

How can we interpolate all this to the Coronavirus?  The 3.4% mortality rate is a raw number for many (but not all affected people); the mild ones didn’t even get counted.  I hate to use the term “fake news” because of its political overtones, but I think it is justified here.  The news media has “hyped up” this issue with inflated numbers for reasons that are suspicious to me.  To sell more newspapers? To be ahead in reporting doom and gloom? (which seems to be a habit of the news media culture). Or is it to affect elections? To create panic? To develop financial uncertainty? To…?  A recently published editorial in the most prestigious medical journal in the world, The New England Journal of Medicine written by Anthony S. Fauci (the nation’s leading expert on infectious diseases), H. Clifford Lane, and Robert R. Redfield, https://www.nejm.org/doi/full/10.1056/NEJMe2002387 has stated, and I quote, “the case fatality rate (of Covid 19) may be considerably less than 1% (the bold letters are mine). This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%).”  So take everything with a grain of salt!

 

 

 

 

 

 

 

COVID 19

In 2017-2018 45,000,000 people had seasonal influenza in the US and 61,000 people died of it.

“Coronavirus,” the cause of COVID 19 (Corona Virus Disease 2019) at this point has infected 92,303 cases worldwide with 3,132 deaths, which is a 3.4 % risk of dying.  Taking all comers, healthy people have a 0.9% chance of dying, while people with heart disease have a 10.5% chance of dying. The virus has an affinity for lung tissue because the viral surface has little projections that fit precisely into mirror image receptacles on the lung cell surface. If it gets into the lungs, it takes over the lung cell’s DNA by inserting itself into our DNA and starts reproducing, as viruses lack the ability to reproduce without using cells of other organisms like us.  It’s all about reproduction! That process kills the lung cell, and we are left with fewer and fewer lung cells to exchange COfor O2.  When there are not enough lung cells to exchange the gases, we become hypoxic (not enough O2 for the brain) and we die.  97% of us can beat the virus by making antibodies, and we recover. Depending on what kind of other diseases we harbor anywhere from 3% to 10.5% of us can’t.  Coronavirus is more virulent than regular flu, but not as virulent as some.  There are plenty of other viruses that are worse.  Ebola, for example, kills 50% of its victims, and smallpox had a 20% mortality in unvaccinated individuals.  But the 1918 pandemic (Spanish flu)  killed 100,000,000 people, the worst pandemic in human history.

So far, COVID 19 has not been all that impressive in the US, 121 cases with 9 deaths.  Of course, that is not what could happen.  If we don’t take the correct infection control measures, we will be in a world of hurt, so to speak!  The steps that have been made so far exceed anything that has been done in the past. I believe that if we take the common-sense steps we are told to do, we will remain relatively safe. Ultimately a vaccine is the answer. 

We owe vaccination to Edward Jenner, a physician, who noticed that milkmaids who contracted a benign disease called cowpox from the infected udders of cows did not contract deadly smallpox. During Jenner’s time 1/5th of the English population secumbed to smallpox.  In 1796 Jenner took some of the pus from a milkmaid’s hand that had the cowpox variola and scratched the skin of his first patient, the son of his gardener, placing a small amount of the pus on it.  It produced a local infection but never spread to the whole person. It worked, and no one that underwent vaccination got smallpox.  Jenner is credited with saving more lives than any other human being in all of history. The Latin word for cow is vaca.  Hence he called his procedure vaccination. In the early 1970s smallpox vaccination was stopped, and by 1979 WHO (the World Health Organization) declared smallpox eradicated from the face of this earth. The virus is no longer present in our world except in one laboratory that keeps the culture under close guard primarily for the study of this once deadly killer that potentially could be weaponized. Anyone older than age 50 still bears the telltale scars of the vaccination that left two pockmarks, usually on the right upper arm.   Smallpox vaccination is the first vaccine and the only disease that has been eradicated.

Coronavirus, too, will take its place in the history books of vanquished viruses, and it will not be because of avoiding Corona Beer as 30% of the population has done.   Multiple laboratories around the world are furiously working on an effective vaccine.  Apparently, Israel is ahead of most, claiming a vaccine will be available in weeks to months. After that, we should be able to go back to our routine lives.

COLON CANCER FOR DUMMIES

I do not intend to be condescending, but I do believe that most people are ignorant of the dangers of this killer.  I have spent a half-century grappling with most of the variations of this disease and have some idea how underhanded, furtive, and devastating it can be. 

Unfortunately, even fellow physicians have ignored patients presenting with symptoms that demand investigation, such as blood in the stool. But because the patient was too young, too old, just worked up a year ago and not found to have a problem, etc. it was ignored. As astonishing as it sounds, there are 26-year-old people that get colon cancer too.  Familial adenomatous polyposis, a hereditary condition, patients can develop cancer quite early and need to start screening as young as age 10.  Almost 100% of patients that have presented with colon cancer to me self-diagnose as bleeding from hemorrhoids.  The patients, or sometimes their primary physician, has treated the hemorrhoids for months for this benign disease while ignoring the tell-tale signs of the monster waiting to be discovered just beyond the finger. Furthermore having hemorrhoids does not preclude also having cancer.

The colon is one organ that does not inspire glamour. Politically the colon does not garner the publicity, the fundraising capability, or the interest as, for example, breast cancer.  It is after all the transporter of the end of digestion back to nature.  Its contents are often used as a four-letter word to curse or denounce a person, thing, or event, a word that is recognized in all languages as one of extreme displeasure. Even our closest cousins, the chimpanzee, share in this.  When they want to show their extreme unhappiness, they throw “it” at you.

There is a story of how the actual word originated.  I don’t know if it is true or not.  It is said that during our Civil War, wood and coal became a commodity that was increasingly difficult to obtain because the war consumed all possible sources of energy. Cattle feedlots produced large amounts of cow dung that, when dry, burned quite well.  It was packed and shipped to parts of the country that needed it most.  Some lethal accidents occurred when the cow dung got wet in a closed area, such as the hold of a ship. Methane gas was released.  When someone with a lit lantern went down below deck an explosion ensued.  From that experience, cow dung had to be shipped above deck.  The shipping containers were inscribed with warning signs, “SHIP HIGH IN TRANSIT” abbreviating it into its acronym created SHIT.   

1 in 20 Americans will be afflicted with colon cancer during their lifetime.  This year 53,200 people will die from it, the second leading cause of cancer deaths of both men and women combined. The lung is still number one. Happily, we are making an impact as the death rate (deaths per 100,000) in colon cancer is dropping, except in the population under 55, where it has increased 2% per year since 2007.  This has prompted the American Cancer Society to revise its screening guidelines to age 45 for people at average risk, that includes those people that do not have a family or personal history of colon cancer or polyps, hereditary colon cancer syndromes, or a personal history of inflammatory bowel disease.

Most colon cancer starts as a polyp.  There is a condition called Hereditary Non-Polyposis Colorectal Cancer (HNPCC) that skips the polyp phase and goes straight to cancer but is not very common (1 in 400 people have it).  But nevertheless, nearly all cancers start as a polyp.  There are different types of polyps, some more dangerous than others. In order of increasing risk inflammatory polyps are the lowest risk, then hyperplastic polyps, of which the serrated kind are more dangerous, and then the adenomatous polyp, and finally the highest risk are the villous polyps.  Size also plays a role, the larger the more serious. The question often comes up,  “When should I have my next colonoscopy?” It is a statistical answer that depends on age, family history, how many, what kind, and how big the polyps found were (about a third of the people I have examined I have found have had one or more polyps)  I would often enlist the patient’s input before I would give a semi-definitive answer.  Even the low-risk hyperplastic polyps, that are supposedly benign and offer no increased risk, but if there are lots of them, especially on the left side of the colon or have elements of being a serrated polyp on microscopic exam worry me, and I would see these people back in 1 to 3 years.

Additionally, many pathologists are not yet attuned to the serrated polyp designation that makes them a notch more dangerous. I always reviewed the pathology slides myself with the pathologist and recall seeing a polyp that was half hyperplastic and half villous which is just a step away from cancer, and raised my threshold of concern for the supposedly harmless hyperplastic polyp. Recently the ACS guidelines state you do not need a colonoscopy after age 85. But if you are healthy and likely will live another 10 years, why not?  Death from untreated colon cancer is quite unpleasant with colostomies and painful swollen bellies at the end. 

There are several screening exams that have their own risks, accuracy, costs, difficulty, and inconvenience.  The simple test for blood in the stool has no risk, although a little unpleasant. It is hower not all that accurate.  Only one-third of cancers will show a positive test, not a very good track record.  A more accurate test is the Cologuard stool test, although it is not a certainty that if positive you have cancer and if negative that you don’t.  13% of the time it is positive and the patient does not have cancer (false positive) and 8% of the time the test is negative when indeed the patient has cancer (false negative).  It has no real risks and is easy to do. Just collect a stool sample in the privacy of your home and send it off to the lab in the provided container.  It screens for DNA that is related to cancer or pre-cancer, such as a polyp. Many insurances pay part or all of the cost of $649.

Colonoscopy is the gold standard, but also the most expensive, unpleasant, and risky.  The radiologists have expanded on the old fashioned barium enema, or more sophisticated double contrast study, both of which are screening exams for colon cancer, but they too can miss cancer.  The newer version is the CT colonography.  By offering this exam the patient avoids the unpleasantness of a colonoscopy, but not the prep for it.  The patient must still have a pristine colon. Otherwise small bits of stool will be interpreted as a polyp, which will then prompt a colonoscopic exam.  The CT colonography often raises more questions than it answers and has not been the answer to how to avoid the formal colonoscopy.

Colonoscopy is a direct visual inspection of the entire colon and therefore is the most accurate.  But it too is not 100%.  The colon has many twists, turns, and folds where small cancers or polyps can hide, but if done correctly it is extremely unlikely that anything will be missed. It will surprise you that doing a colonoscopy too fast is actually a measure of poor quality.  At some centers, nurses actually time your withdrawal time and if you come out in less than 6 minutes you are “timed out” so to speak. 

The big risk is a perforation, followed by bleeding, a partial burn injury from polyp removal, infection, adverse anesthetic problems, complications from the prep especially in older individuals getting fluid overload, or sometimes dehydration, and cardiovascular problems. Still, perforation remains the most feared of the complications. The literature quotes a rate of 0.016% to 0.2% risk.  But therapeutic colonoscopies and large polypectomies have a perforation rate as high as 5%.  My own perforation rate in 40 years was 2 in about 15,000 colonoscopies (.013%), but I do remember both vividly, and both survived.

A word about the prep.  Having had several colonoscopies myself in my now 77 years of life, I must say that for science to have landed us on the moon, being able to transplant hearts, livers, lungs, we are woefully lacking sophistication in cleaning out the colon.  To say it was unpleasant is an understatement, and the most often prescribed prep, Go-LYTELY, is a misnomer in my book. Newer preps are available that make it a bit easier but at rather exorbitant prices. The old 1.5 oz. of Fleets Phosphosoda taken two times was still the easiest, quickest, and least unpleasant.  Unfortunately, it killed a few people and was removed from the market.