Sanity enters the Covid discussion

I could hardly believe my eyes and ears. After months of shaking my head and saying to myself (and others) “this doesn’t make sense. It makes no sense,” others are beginning to do the same and openly declaring some scientific truth in the discussion of Covid-19 and our unprecedented response to it. It strikes me a bit like the story of the emperor’s new clothes where people were hesitant to openly state the emperor had no clothes on for fear of being ostracized by their friends, colleagues, and family for going against the conventional opinions. I would say conventional wisdom but for the fact that true wisdom seems to have been sadly lacking in much of the discussion of the current pandemic and what to do about it.

We have been given basically two choices. One is to lockdown the country, socially distance everyone from children to the elderly, wear masks everywhere, and cower fearfully in this fashion until we are rescued by a vaccine. The second is to open up the country and risk millions of dead. To advocate the second choice was regarded as political suicide by politicians, professional suicide for clinicians, and social suicide for citizens. Those of us who claimed there was a better way were regarded as callous, cruel, even homicidal by some. To even suggest we allow herd immunity to develop was tantamount to saying we wanted to kill off the old and infirm, never mind that the lockdown has likely killed more people than the virus.

Social Media: the elephant in the room.

“Social media has such an outsize presence and influence in our daily lives that it has become the proverbial elephant in the room.”

Don’t throw the baby out with the bath water. Everyone knows what this means. In discarding something bad or undesirable, take care that you do not throw out aspects that are good or desirable. Few things are totally bad or totally good. Much of life is nuanced in this fashion.

When it comes to social media, the term would more appropriately be: don’t throw out the elephant with the bath water. Social media has such an outsize presence and influence in our daily lives that it has become the proverbial elephant in the room.

Speculation: the one thing we can all agree on regarding the Wuhan virus

It is hard to argue with the fact that speculation has been one of the most, if not the most, significant factors in the Wuhan virus pandemic.

There has been speculation as to the origins of the virus. Was it man made? Did it originate in a Wuhan lab or did it arise de novo from a Chinese wet market in the city? Despite over six months of more attention than any microbe has received in recorded history, there is still legitimate speculation about its origins.

Speculation has been especially prevalent in the modeling of the course of the virus and its lethality. Early models predicted 2.2 million deaths in the US and over 500 thousand in the United Kingdom, without mitigation, e.g. social distancing, wearing masks, etc. Experts now agree those numbers were wildly overestimated. We are now well over six months into this pandemic and the US only recently exceeded 200 thousand deaths and the UK is barely at 42 thousand. We mitigated. Now what?

The CDC and the 6% “solution”- is it time to start celebrating?

I have repeatedly said that to understand the numbers in discussing the Wuhan virus, you have to understand the context. What this means is that just giving out total numbers of cases, hospitalizations, and even deaths must be clearly understood in their proper context to be meaningful.

I have long felt that that the numbers have been misused and inflated/deflated depending on the agenda of whoever is reporting them. We have used them to justify the national lock down, promote unheard of policies like shutting down businesses, universal social distancing, and mask wearing for all. Never has an entire population of healthy individuals been quarantined or an economy shutdown to this degree for a viral epidemic. This did not happen with H1N1 in 2009, which infected between 700,000 and 1.4 billion people and killed between 150,000 and 575,000 people worldwide over 9 months. The wide range reflects the difficulty in getting good numbers, just as with Covid-19, because these depend on the reporting criteria, testing, etc.

 The latest “bombshell” is the CDC statement that only 6% of deaths have been purely from Covid-19, or around 9500 persons. All of the rest have listed co-morbidities in the cause of death. These are other medical conditions in addition to Covid that contributed to death. On the surface, this might be seen as cause for celebration and people like me, who have feel we have overreacted to this virus, should be declaring “I told you so”, but you have to understand this number before you jump with glee.

A Thought Experiment- musing on the November elections

Daniel Mintz, Chair of the Department of Information Technology at the University of Maryland Global Campus posted on Facebook a very interesting thought experiment. Mintz openly acknowledged that he suffers from TDS (Trump Derangement Syndrome). He describes the lead up to a Trump victory in November based on his speculation that Trump decides to control the election. The text of his post is below.

What would he (Trump) do? Among other things:

  • Has learned that undoing executive authority, even if unconstitutional, takes a lot of time (I think Mr. Mintz needs to read Defender in Chief: Donald Trump’s Fight for Presidential Power by John Yoo)
  • Say the election was going to be stolen by Democrats
  • Disparage the use of mail-in ballots
  • Attempt to establish that the opposing candidate is senile and outside of normal behavior (hates God for example) – opposing candidate helps make the case
  • Ignore the involvement of Russia and China in their attempts to manipulate the US election and insert misinformation since that adds to the chaos
  • At the same time put strong supporters in charge of the US Postal Service to control the flow of mail-in ballots, including replacing all career operational leadership (in August so that this is not in the news in October/November)
  • Keep up a drumbeat that local and state governments, especially with Democrat leadership are in favor of violent extremists
  • Establish that it is ‘okay’ to send in federal representatives to ‘support’ local legal authorities
  • Attempt to encourage local violence so that he can use those federal representatives to manage election polling locations, perhaps put such representatives in place to act as election judges (since there is an enormous shortage of polling judges across the country made much worse because of COVID-19)
  • And thus control all aspects of the vote count

Musings on Measles and Covid

Aerial view of Coral Gables, Florida

When I was a boy, I lived in a wonderful neighborhood filled with kids my age. One of these was Skipper Jaffe, who lived two doors down. When I was around 7, Skipper came down with measles. When the news got out in the neighborhood that the Jaffe house had measles, all the other moms did what most moms did in those pre-vaccine days: they sent their kids over there to play. Within days, every kid in the neighborhood had measles. In a week our neighborhood “epidemic” was over.

I doubt these mothers knew the statistics on measles, that the mortality for measles was around 0.1%, about the same as seasonal flu now, and that most of those were in children under 5. I doubt it would have made much difference. They knew that, absent a vaccine, their children were almost certainly going to be exposed to measles and the sooner they were exposed the better to establish future immunity. They did the same for chicken pox.

In 2018, even with an effective vaccine, 140,000 people died of measles worldwide and, again, most of these were children under 5. Measles is a terrible disease in the few who develop a severe infection with sometimes lifelong consequences. There has not been a measles death in the US since 2015 thanks to an effective public health campaign to vaccinate children, but the anti-vaccination movement is producing a population of vulnerable people that will be at risk for measles in the future (unapologetic vaccine plug). https://www.cdc.gov/mmwr/volumes/68/wr/mm6840e2.htm.  

Schools should reopen this fall

In the ongoing, seemingly never-ending crisis due to the Wuhan virus, SARS-CoV-2, which causes the illness Covid-19, the new battleground has become the issue of opening up the schools in the fall. Social media is rife with heated arguments for and against returning children to school, from elementary to college. In the elementary area, this has become especially contentious because of the critical nature of this period in a child’s life, both in obtaining a fundamental base of education on which to build and in developing social skills that will be crucial to their later role as socially competent, functioning adults. On the importance of this there is no real debate.

My children are grown and you could say I don’t have a dog in this particular fight, but I do have grandchildren that I love and have a great interest in. For them and their parents, this is an issue of major import.

The question of if and when to open the schools to children 15 years of age and under can be broken up into several component parts.

Why I love plastic surgery

Plastic Surgery Posters | Redbubble

“I am a surgeon. It is what I do.”

It is early Sunday morning, traditionally a day of rest for everyone. I am up and about, soon to head to the hospital to amputate a gangrenous finger on the hand of an unfortunate individual with end-stage kidney failure due to diabetes that is poorly controlled. This is not the scenario most people envision when they think of plastic surgery. I am surprised to feel mildly excited, looking forward to surgery. On reflection, I think, this is weird. Am I abnormal? How can I revel in such a sad situation?

I make my living performing surgery, so one could rightly say that I have a vested interest in people getting sick and needing surgery, or simply wanting surgery for some other reason, so that I can make a living. This particular accusation has been leveled at doctors and the entire medical profession by those who believe there is a financial incentive in all that doctors do. Many are advocates of alternative medical therapies. They fail to see the hypocrisy of claiming that traditional doctors have a profit motive as their primary imperative when they profit from their own alternative/non-traditional therapies as well.

Why nurse practitioners and physicians assitants aren’t the same as medical doctors.

Medical practice is not simply caring for simple, common problems.

There has been a strong and largely successful push by advanced practice nurse practitioners (NPs) and physicians assistant (PAs) to practice autonomously as primary care providers. The Florida legislature recently granted advance practice nurse practitioners license to practice independently https://www.usnews.com/news/best-states/florida/articles/2020-03-11/florida-oks-independent-practice-for-nurse-practitioners. That term, “provider”, has replaced the original, which was “physician”. NPs and PAs have now been elevated from their original designation as mid-level providers of care to acknowledge their more limited education and clinical experience, while primary care physicians have been demoted so that they are now lumped in with mid-levels as “providers.” Many patients do not know the difference and commonly refer to NPs and PAs as their “doctor”.

Musings on the Wuhan virus

“Absent an effective treatment or vaccine, and knowing that we cannot stay locked down indefinitely, our only hope for dealing with this virus is to turn to the most effective anti-virus agent known to man: a healthy immune system.”

I have no illusions about the Wuhan Virus, aka SARS-CoV-2. It is a dangerous beast to be taken seriously. What does that mean, exactly? When we speak of containment, mitigation, flattening the curve, what are we really referring to?

Let me say up front that it is a terrible thing and too many have died. For them and those they have left behind, we can only offer our prayers and condolences, and a promise to try to do better. With that said, how do we do better? As a physician, admittedly not an expert in public health, an epidemiologist, or an expert on viral pandemics, I have some observations and opinions. Take them from someone who has been in medicine for over 40 years. I am a plastic surgeon, yes, but first and foremost, I am a medical doctor.