Hear what I believe.

One of the most influential medical studies I read about was performed in the 1950s, predating the internet and thereby making the actual paper all but impossible to find. It also predates a lot of ethical considerations that we now consider important, like not physically or mentally harming your subjects.

The study was at the advent of psychosocial research after World War II as we struggled with the way entire populations were able to be manipulated into either turning a blind eye or being complicit in atrocities against their neighbors. While this likely could not be repeated today, we would do well to learn from the results and at least take away something of value.

The goal was to evaluate how we form and internally rationalize our belief systems. While the results are almost shocking, if you apply them to the world around you, they become genuinely obvious. The researchers split subjects into groups with similar deep-seated political and religious beliefs. They then presented various forms of evidence, some of which supported these beliefs, some of which refuted the beliefs. What they found was this: when shown evidence that supported deep-seated personal beliefs, the evidence would strengthen that belief. (No surprises here). But, when shown evidence that refuted these beliefs, instead of questioning them, people grew stronger in their convictions to an even greater degree than that generated by the supporting evidence. The more logical and irrefutable the evidence, the greater the effect. In addition, the person or persons presenting that evidence was discredited, and subjects no longer trusted anything further from them, no matter what.

This is not an easy thing to consider through introspection, but if you think of things like extreme religions or even cults, you can easily see the effects. Once indoctrinated, it is extremely difficult to pull people out. “Normal” people on the outside can present clear and logical evidence that categorically denies the tenets of these groups, but instead of people waking up to the lies, all it does is strengthen their resolve and prove the ill intent of the misguided masses trying to tempt them from the true path.

One hypothesis is that this is an evolutionarily beneficial trait maintaining tribal relationships imperative for survival in early societies. The problem with all of this is the subject doesn’t see what’s happening. As we go through our own relatively mundane lives, we rationalize that this type of behavior only happens in extremes and doesn’t really apply to us.

But remember, most Germans were just regular people. Furthermore, it’s not as if we have changed in the few decades since, so we need to be cognizant of our own limitations lest we fall into the same bad habits.

During the leadup to the 2016 election, I looked around and felt like things were starting to come off the rails. I interpreted our most glaring problem to be our trust in leadership from a government that was clearly broken and getting worse. Even then I put a significant amount of blame on social media, a societal force that was new and clearly not created for the dissemination of important facts in a logical manner. Back then, both political parties also admonished these out-of-control platforms: they allowed outside forces to muddle with public opinion and election results as well as facilitating the propagation of damaging “disinformation” about a variety of topics.

In the years that have followed, the outcry from the government about the impact of social media has dwindled. Why? Is it because the mischief has been managed? Or is it because these unruly forces that previously disrupted the impact of political messaging have been wrangled up and can now be harnessed to advantage?

Hmm….

Impossible. Let’s be realistic: in this modern world where so much information is at our fingertips, it is simply impossible to manipulate people – intelligent, educated, ethical people – into doing something that might bring harm to their neighbor without them seeing through the ruse. Unlike the people of Germany in the 1930s, we can no longer be misled, and certainly not to that extent.

Because this is all a bit of a downer, let me change the subject. Instead of dwelling on things we might not be doing so well, let’s instead look at something we have done extraordinarily well that you likely don’t know about: the Mectizan Donation Program.

We are all aware that big industry is – like it or not – ultimately driven by profit. Nevertheless, many large companies have made massive strides in improving the lives of people all over the globe. Though I personally rank the air conditioner as the number one invention of all time, it’s fair to say that the industry of medicine has made life on earth a completely different ball of wax for all of us. The Mectizan Donation Program is one in which a life-saving medicine has been systematically produced and distributed to millions and millions of needy people all over the earth, free of charge:  

“Most patients who would benefit from Mectizan live in developing nations. Recognizing that these patients would not be able to afford the drug at any price and no donors were willing to pay for it, CEO P. Roy Vagelos in 1987 announced the company’s commitment to donate ‘as much as needed, for as long as needed.’

In order to reach this goal, they recognized that many organizations with unique skills would need to work together as a team. To enable this collaboration, the company established the Mectizan Donation Program (MDP), a ground-breaking public-private partnership.

Today, the MDP program reaches more than 300 million people annually, with more than 4 billion treatments donated since it was established.”

This largely unheard story should be a model for all corporate leadership teams, as it clearly shows that benevolence does not have to jeopardize the ability to satisfy the seemingly insatiable needs of the stockholders.

What does this have to do with the original topic, you ask? Well, that depends on how you manage your own beliefs. As most of you have probably never heard of any of this, it is unlikely that you have any preestablished positions, and that leaves you open to rational discussion. If, on the other hand, you were already aware that Mectizan is widely known today by its generic name – ivermectin – you might be able to see the internal gears of cognitive dissonance begin to turn.

Across the globe, millions of people annually are alive because of the efforts of a corporate leader who over thirty years ago put in place an innovative program purely for benefit of humanity to distribute a medicine to fight debilitating and deadly disease. Today, the same company is arguing – loudly – that this same medicine is unsafe for humans, and we are all believing them. Across the globe, doctors – intelligent, educated, ethical people – are systematically withholding its use in the face of a pandemic citing safety and efficacy concerns. When shown overwhelming evidence of safety and additional evidence that it works – evidence that refutes their preformed internal beliefs – instead of questioning these beliefs, it strengthens their resolve and discredits the source of evidence.

Sound familiar?

The fundamental danger threatening our society is not being spread from person to person, it is the way in which we are connected and communicate. We are now living in a world where intelligent, educated, ethical people can be manipulated into believing things in the face of irrefutable evidence to the contrary, even when it facilitates suffering and death – and not of people in faraway lands where we can easily compartmentalize our anguish – this is the suffering and death of our neighbors. The people doing this are not bad people, but they believe these things so deeply that the doctrine is being mandated in a systemic fashion in which no discussion or dissent is allowed.

Again I ask, sound familiar?

Mixing Elixirs in a Sea of Bias

Man is required to deal with a multitude of challenges to live a healthy and happy life. Some of these challenges are environmental, some are physical. Some result from other lifeforms or even quasi-living things taking advantage of preexisting human systems for their own benefit.

One such quasi-living irritant has been the focus of our attention since late in 2019.

When we as humans make a concerted effort to combat the things that would derail our healthy and happy living, we usually go about it one of two ways: (1) we figure things out, or (2) we get lucky. Sometimes it’s a bit of both.

To figure out a monkey wrench for pesky irritants like this new thing we have going on, a group of very smart people created something I am going to call Elixir A. It was designed specifically to impede certain functions of the little bad guys without messing about with anything important in normal people. It worked great in a lab, but unfortunately, it hasn’t ever worked much in real life. Still, that hasn’t stopped us from trying.

Not long ago we opened up some bottles of Elixir A with high hopes and a compelling need: this was exactly what it had been designed to fight, and sweet-cheese-and-crackers did we need a win.

So, we did some tests. The first test was with a bit more than 200 people. Unfortunately, it didn’t work. That’s a really small group of people, so we did another test. And another. And another, but all with the same disappointing results. Not to be dissuaded by data, we have kinda ignored the fact that it has never really worked and is expensive and can only be used in a dedicated facility, and so it remains – inexplicably – a mainstay of treatment. (Ref 1, 2)

Like a lot of our attempts to science our way out of the pit of despair, life is often much more complicated and usually comes with a sizable helping of bitter irony.

Some 50 years ago, a couple of guys stumbled on a family of compounds that killed worms in mice. This would turn out to be a big deal, as they would go on to perfect this stuff – Elixir B – that would improve the health and happiness of literally millions upon millions of humans. In 2015, we recognized their work with a Nobel prize.

Elixir B has a specific mechanism of action against these worms, but it doesn’t do the same thing to people, so it’s been shown to be really safe. In fact, the company that makes it has given away hundreds of millions of doses in almost 50 countries since the late 1980s, an effort that is said to have cost a quarter billion dollars. It can be given safely to kids as young as five and is over the counter in some countries. (Ref 3)

But right now we are not really worrying about worms.

When things got really desperate early last year, a different group of scientists decided to see if they could get lucky. (No, not that kind of lucky). They started throwing things we already had into test tubes to see what might happen. It turned out the Elixir B looked like it might be the break we needed, a proverbial can of Whoop-Ass. (Ref 4)

Before you get too excited, understand that – like Elixir A – we were still just talking test tubes. It’s a long way from in vivo to in vitro, and sometimes you just can’t get there from here.

But with Elixir B there was one big difference: all those hundreds of millions of uses that led to that Nobel Prize thing provided a safety history, so moving from the test tube to people was straightforward, the only question was would it really work. Like Elixir A, the first trial was about 200 people. Unlike Elixir A, Elixir B worked. In fact, it worked really, really well. (Ref 6)

Hallelujah!

Still, 200 people is only 200 people, so we set up some bigger tests to figure out just how good it was and how to make the most of it.

Or did we?

Honestly, it’s hard to tell. For sure there are a lot of studies with positive results and a lot of people swear by it, but there are also some people saying it doesn’t work, or rather, it just can’t because that’s not what it was designed for. Some people are saying it’s dangerous (despite those hundreds of millions of past uses – billions, actually), and that danger means it has to stay locked up until it’s proven. So, the people in charge are asking – demanding – that we wait for more data. In a second helping of bitter irony, these are actually the same people who decide what studies get done. (Ref 7, 8)

That’s a bit like saying that no one goes home until the floor is swept when you are the one holding the broom.

With Elixir A, the study reports are readily available, no one is arguing the disappointing results, and yet it is the weapon of choice. With Elixir B it seems the more positive the results and the more utilization, the more vehement the resistance. In fact, the use of Elixir B is illegal in some areas and those who even suggest it could be of benefit are being called irresponsible and even accused of promoting harm.

It’s almost as if some people don’t want to solve the problem…

I wish I was exaggerating, but I am not. Not even a little. And to make matters worse (if that’s possible) the real issue has nothing to do with Elixir A or Elixir B or labs or science or any of that, it has to do with information. More specifically, how we get it and how it is given (or fed) to us. This pesky irritant is just another of life’s ongoing challenges, but what has changed is how we react to these challenges – or more specifically how we have willingly allowed the manipulation of information so that we can be successfully persuaded, en mass. Virtually all of the methods that connect us in the modern world are influenced by a variety of self-serving forces. We know this, and yet we don’t seem to mind. Some even deny it’s true, though as my mental health therapist once told me: manipulation doesn’t work if you know your being manipulated. And so, our most important connections – the things that allow us to work as a cooperative, to make good decisions, to act on logic and scientific data – are horribly corrupted.

How do we move forward? For starters, stop reading headlines and stay the course through the whole article. I remember a time when we scoffed at people who just looked at the shocking pictures on the front page of the National Enquirer. For sure, life and science has become exponentially more complicated, which means we must rely on experts to decipher the data and help us apply the nuanced results to the complexities of the wide variety of individuals. And so, if you are one of those experts, it’s your job to read the studies yourself, not just the summary or headline pushed out by someone else. Despite the power of the internet, I literally cannot find the credentials of the authors of the large review of Elixir B studies that the entire world is simply deferring to without reading the paper or even questioning the methodology that led to the published conclusions. (Ref 9) And that methodology is laughable, except it is not at all funny. The myriad of front-line experts who have both education and real-world experience in this arena are being systematically discredited, but no one is even asking who the people are that are literally crafting public policy which is subsequently accepted as gospel.

This is kinda important stuff. Like life or death. Shouldn’t someone be allowed to assume some personal risk if it might protect others?      

As for me, I find myself unable to blindly follow orders when I can see the corrupt motivations and believe there are safe things that we can be doing to genuinely help people and potentially save lives. Luckily, I am not alone. A growing number are banding together and sharing information and experience, extending options where possible and when doing nothing may not be the best plan. We are applying the available data to situations at hand as best as we can. (Ref 10)

This – not my specialty – is what defines being a doctor.

References

Curing Our Community’s Disease

People are suffering and dying, but you can do something about it. These are not people in a distant land, and they don’t have a communicable disease, these are people all around you, of all walks of life, of all races, young and old. Their malady will never be listed on a death certificate, not even as a contributing factor. But the suffering and death are just as real, as is our ability to fix the problem.

I am talking about a lack of transportation.

When people stack up in an ICU during a pandemic and the scenes are described and circulated on social media, the connection between disease and suffering and death is impossible to ignore. When the disease is insidious and invisible and has simply become an accepted part of life, it is almost impossible to see unless you find yourself in the same predicament.

And every single one of us will if we live long enough.

Over the past few months, our team has implemented a solution as proof of concept. In doing so, we have been exposed to the tremendous need, and we are on the verge of being overwhelmed. We are only six people, and we are starting to feel like providers in an overcrowded ER, surrounded by desperate faces, with more and more everywhere we turn. We can’t go on like this, but we can show you that the solution works. As a community, we have everything we need, right here, right now. We just need to act.

First, here is a list of things we are actively doing (this is not theoretical, this is ongoing): moving people to work; moving young people to in-person education; moving people to and from doctor’s offices, the cancer center, and the hospital; moving people to be vaccinated; moving people to shopping, whether necessities, food, or pharmacy. Most importantly, we are able to safely move people at the direction of others, whether that is a family member or caregiver such as a nurse or social worker.

You can’t do any of this effectively with a bus.

Though seemingly frivolous, the falcon doors on a Tesla Model X make it the easiest car to enter and exit for a person with limited mobility. For a variety of reasons, these are perfect for public transport. You are probably thinking they are far too expensive, so let’s look at some numbers. Operating one of these fully electric vehicles for 60 hours a week including storage, maintenance, power, insurance, paying a driver $20 an hour (yes, you read that correctly), and throwing in a few hundred extra for incidentals comes to almost $9000 a month. To put this figure into perspective, the next time you see an empty city bus, recognize that its monthly operating expenses are four times greater than a Tesla, each of which can do all of the things described above and more. More importantly, people will actually pay for this type of service, so the process is financially self-sustaining.

Or we can continue to pour vast amounts of money into a hole as our neighbors continue to suffer and die.

At the end of 2019, I submitted what seemed like a preposterous grant proposal to the VA Department of Rail and Public Transit to sequentially purchase 40 Teslas over 2 years at an estimated expense of 1.8 million dollars (including purchasing the cars). Not only is this less than 10% of the GLTC budget, I estimated that the system would be financially self-sustaining by Q2 the second year.

I was wrong.  It can be financially self-sustaining in about a month.   

To make money on a service, you need paying customers, but it’s not like there is a shortage. The problem is we don’t have a genuine solution for the most valuable market: non-emergent medical transportation. These desperate customers have no way to get what they need, regardless of the funding.

This is the secret to powering an effective, efficient, useful public transportation system that works for all of us.

Let’s run a few more numbers: a taxi in the City of Lynchburg is mandated to charge $2.80 a mile. For the average person going 12,000 miles a year, that’s $33.600, or more than enough to buy a nice, new car annually. Uber is about $2, so it’s still so expensive that the only people regularly using the service are people who can afford to buy and insure their own car. Meanwhile, our team is operating at our target of $1.25 a mile, but for us, this is not sustainable.

Non-emergent medical transportation – the kind of thing that commercial insurance companies and Medicare and Medicaid will pay for – reimburses at a much higher rate, because no-shows to medical appointments in the US cost an estimated 150 billion dollars annually just based on lost overhead expenses alone, not even considering the downstream adverse effects from people not getting the care they need. Which means if we have a service that can fill all of these needs, we can charge a livable rate for people in the city doing regular city things and recover the losses serving these more valuable needs while fixing a massive and continuous problem for the health system.

And then stop pouring millions of dollars into that same hole, day after day, month after month, year after year.

The only thing we need to do is be able to serve those insurance companies and Medicare and Medicaid, and that is something that my team is simply not able to do.  I am just a doctor with a few screws loose and some crazy ideas, driving around town with a handful of like-minded activists trying to push for change. We have put together everything needed to fix the problem, we have proven the concept, we are trying our best to meet the needs that we can meet. Despite years of pleading, we have no financial support from the local, state, or federal governments, no grants, and no help from the healthcare system. Furthermore, we are underinsured, and despite being overqualified and using vehicles that have been proven to be the safest ever tested, we cannot overcome the regulations and requirements to make contracts with healthcare systems and insurance companies.

But the Greater Lynchburg Transit Company can. Immediately.

All they need to do is to park a single bus and redirect a fraction of those funds to digitally-connected cars that can actually begin to meet the voracious needs of our community in all its diversity. And as the money for that service comes in, we expand the fleet, progressively disposing of these buses that we long ago proved to be ineffective. But my team can’t do any more than we have done; we can’t tell the GLTC or City Council or the VA DRPT what to do. We have brought them everything they need, but they are the ones that must seize this opportunity.

Imagine our city with 40 Teslas all working in synergy to cure this plague that is so ubiquitous it goes unnoticed yet kills with the same relentlessness as a novel virus. Imagine our city with 60 additional rewarding jobs that don’t require a decade of education costing a fortune, and yet serve the greater good on a very personal level. Imagine our city leading the way in adopting clean energy and fully autonomous vehicles. And imagine that this is all just the beginning of a system of connectivity that unifies instead of divides and enables the next generation to take control of their own destiny by building solutions that work.

If this seems preferable to turning a blind eye to our neighbors in desperate need, please contact City Council and insist that they act both locally and at the state level, enabling GLTC to not only serve our collective transportation needs but opening them to paying customers searching for solutions; and pressing Shannon Valentine, the Secretary of Transportation for the State of VA, and Dan Carey, the Secretary of Health and Human Resources to support these efforts so that the lessons learned here can be applied elsewhere in the state.

Lynchburg City Council

Shannon Valentine, VA Secretary of Transportation

Dan Carey, MD

To Dad.

My dad was pretty nerdy, so it’s not like I thought he was cool when I was growing up or wanted to be just like him. The fact is I would cringe when people said we looked alike or had exactly the same mannerisms. If you think about that way that a parent can embarrass their teenage kid with something they do or say, he had that in spades.

He was not a real extroverted person, but he was always capable of talking your ear off. Which is funny looking back because one of the things I remember the most about him was his ability to say absolutely nothing. Throughout grade school he and I had a ritual involving the newspaper and Cheerios. We would sit in silence on either side of the table, each armed with one page of the funnies from the Washington Post while eating bowls of General Mill’s finest, mine with a little added sugar because I also lacked his billygoat mentality. At some point during the meal there would be a silent acknowledgement and we would swap pages. No laughter, no discussion, then off to work and school.

He could also make a point with silence. More specifically, by doing, not talking.

My dad built a house overlooking the Occoquan reservoir when I was in high school. When I say he built it I don’t mean that he laid every brick by hand, but he went about as far as a dentist working full-time could go. He started with a floor plan from a book but then reengineered much of the layout, including learning the structural codes, creating the technical drawings, and submitting them for approval from the county. He subcontracted the entire project and – much to my dismay – did as much as was humanly possible himself with the reluctant help of his relatively lazy and useless son. This included things like prepping the subfloors for concrete with much digging and gravel and wire and rebar, typically after work and using the high-beams of our faux wood-paneled Grand Marquis wagon to extend the day until 9 or 10 o’clock.

The house sat on a narrow peninsula overlooking the water (of course it’s still there) so the decks that went around the back of the house were really the only “yard” we had, and they were built on awkward and rugged ground. On a Saturday am, my assistance was requested digging the footings for this deck.  In usual fashion, it had been ridiculously over-engineered, so the posts were 8 x 8 instead of 6 x 6 or (gasp) 4 x 4, and they were to be twice as deep and twice as wide as required. I remember spending what seemed an eternity but was probably 8- or 10-minutes chipping with a shovel at the solid earth in the indicated areas before declaring the task “impossible” and going rock-climbing with my friends.

When I came home that evening he was done, all the holes dug, the concrete poured. I was stunned. My mom: “I can’t believe you made your dad do all of that by himself.”  He never said a word, and I don’t recall him asking for my help again as he went on to complete the entire multilayer structure himself, including a clever and exceedingly dangerous use of a skill saw to make polyhedral caps for the rail posts.

He waited probably 10 years to tell me he rented a post-hole digger that was apparently quite effective…

And that’s what I remember most about him: he led – and taught – by example.  He served in the Lions Club his entire adult life. He never really talked about it, never dragged me to anything, he just helped out however he could, as much as he could. He never spoke about how hard he worked, and I only lasted one day following him around in his office, 10 hours non-stop excepting a 20-minute break to eat his peanut butter sandwich, another lifelong ritual. I didn’t appreciate the impact of his reluctance to hire dental hygienists (“People are paying me to take care of their teeth, not someone else…”) until much later in life. It was never about being better than the next guy and there was no such thing as work that was “beneath” him, there were just things that needed to get done, whether through ingenuity or extreme persistence.  

He was known as a Mr. Fixit because he saw every task as a challenge, whether in the home, the car, on the water, or even in the air (yes, he had a pilot’s license though I was too young to know if he tinkered with the plane). He made a (very professional) Shepard’s crook for my sister’s dance as Little Bo Peep long before the internet. He fixed the plastic flip-lever on the coffee pot at church by casting the broken part in some type of dental mold at a time when 3D printers were called “replicators” on Star Trek. He made a TV from a kit (I can’t believe Heathkit is still in business) and mounted it flush in the wall of the basement 20 years before flat screens were a thing. He was filming my sister’s high school activities with a video camera and VCR recorder that he powered with “portable” kit containing a car battery – yes, a car battery – when the only way to get such footage was to make the local news.

And he was utterly fearless.

This used to scare the crap out of me because I never thought of my dad as particularly athletic or somehow possessing action-hero skills. His calmly (I think he was actually quite enjoying himself) sailing our San Juan 21 through a brutal thunderstorm while my sister and I sheltered in the cabin, our feet braced on the opposite bench looking at the low-side windows which were intermittently under water, my mom fairly certain that this was the end, makes a good example. Fire, explosions, caustic chemicals, sharp things flying through the air, none of these things really phased him. Most of his projects included a bleeding injury that went unnoticed and unattended until the project was complete, excepting the time he near-enough cut off the tip of his thumb with a saw – a career-ender for a dentist – and reluctantly paused whatever endeavor and had my mom take him to the plastic surgeon to have it put back on.

“You can’t do that” was like a siren’s call for my dad.

He would never have retired had our mom not gotten dementia. Looking back, his response to this was no different than anything else: there is something that needs to be done, and I will figure out how to do it myself. Nothing scared him, nothing could stop him.

It is very difficult – maybe impossible – for someone like him to transition from being the one that gets it done to the one that needs things done for them. He gave back as long as was humanly possible, volunteering at the Free Clinic teaching aspiring dentists some of the things he had mastered – like the ability to deliver a shot painlessly, a skill for which he was genuinely renowned – and holding onto usefulness after many of his capabilities had slipped away.

Because he was not one to talk about the things he had done, the only way I knew to honor him was to show him that it had all been worth it, that finally, after decades of his leading and teaching by example, I got it. Put others before yourself. No job is beneath you. Nothing is impossible. Be fearless. Never quit.

I’ll never have the chance to show or tell him what he passed on – that opportunity was taken from us – so nothing left to do but get it done. Godspeed dad, I’ll do my best.     

Fighting for the real value of teachers.

The amount at stake with education cannot be overstated. This is our Normandy. To all of the teachers out there, this is a call to battle, to you and to our society as a whole.

Society first: we risk very real collapse without restarting our educational system. It will begin economically, brought on by the impoverished segment of our nation becoming unsustainable. In healthcare, we would call this an “unfavorable payor mix,” where the percentage of patients unable to pay their bills bankrupts the system. The analogy is appropriate because healthcare is precisely where it will show up. We don’t feel it when people can’t pay for cell phones or high-speed internet or a car or even water, we feel it when they show up in the ER with any number of medical conditions brought on by an unsustainable existence, and it’s not limited to things like overdoses. Type 2 diabetes and all of its complications should be enough on its own.

There were 15 million kids in poverty in the US at the beginning of the year. Not one of these kids stopped developing, because development doesn’t stop. What ended for them was the support of the educational system. What changed for them is their environment, the environment in which their continued development is relentlessly proceeding.

In 2018, twelve children and their coach were trapped in a cave by rising flood waters for more than two weeks in Thailand. Their rescue involved the unified efforts of some 10,000 people and cost the lives of two divers. The tide that threatens to drown millions of children that live right in our midst – right in front of us – is metaphorical but no less real. It is not the delivery of educational material that is urgent, as an open mind is capable of learning through the entirety of human life. It is the complicated and interconnected support systems that provide basic yet fundamental needs during this critical period of human development that cannot be disrupted without irreparable damage.

This is where we are making a grievous mistake that we cannot – both literally and figuratively – afford to make: education of our youth can pause. Support cannot

It is unfortunate but true: the value of the teachers is rooted in their ability to cultivate the growth of our children as humans, not as scholars. Millions of American children, for whatever reason, lack adequate resources in the home to provide an environment suitable for healthy growth. Public schools are our only hope of addressing these critical needs. We seem to have forgotten this: the first thing we should have done is be certain that all kids have the stuff they need before even thinking about working on lesson plans. At this time in their lives, socialization is just as essential as shelter and food and water, and extended periods without it will leave deeper scars.

And now I speak directly to teachers, and I am both pleading and warning: if you do not recognize where your true value lies and reapply the bandage to this wound, it will not only threaten the stability of our entire society, but the unmerciful reality of this new virtual world will expose the rapidly declining monetary worth of online education. Put frankly: we spend a lot of money sending our kids to school – over $700 billion – and employ over 3 million teachers. We continue to pretend this is for the educational material, but that has changed whether we want to admit it or not.

How many teachers would we need to put together a video curriculum that could be viewed quite literally by the entire world? A teacher’s value is face-to-face, as mentors, guides, and role models, providing encouragement, discipline, and advice. In this regard, our society cannot afford to go without you. But if you try to compete with our exploding digital capabilities, you will lose an economic battle that you don’t have the resources to fight. I know this, because doctors have been under assault from these same forces for decades.

If we made a digital, artificial-intelligence-driven online “doctor” that was better than your family physician, what do you think would happen? Luckily, the hands-on part of medicine remains essential (thus far). But creating a digital, artificial-intelligence-driven online teacher? That’s a much easier task, and right now there is big money in remote education. Not only that, by building online teaching systems you are doing the grunt work for them. You are literally working to create your own replacement.

Since finishing residency, the threat of digitizing medicine and sending it through wires to someone in their basement who would do the job for less money has been increasing, and doctors have been continuously fighting to protect their turf (that is to say, their patients). Now the pandemic has completely reshaped the arena, decreasing protective regulatory barriers and opening the playing field to circling technology giants who are eager to capitalize on a need. Our primary weapon in this battle: you can’t replace hands-on contact with a video screen.

Teachers: if you give up the most core element that is your true value to society, you will lose. And we will lose. Dearly.

The fact that you are grossly underpaid for literally keeping our free society intact is a travesty. The fact that you are ill-prepared as individuals to face a pandemic on the front lines and have little organized support from the system in which you are the critical component is a devastating reality. But that reality is life, and life is not fair. It wasn’t fair that over two million young people had to land on beaches in Northern France to protect our way of life, with hundreds of thousands of casualties. The battle we are facing now doesn’t have the same clear-cut cause and effect, nor does it have two sides facing each other over a ribbon of sand. But it is no less real, and the stakes are every bit as high.

Heroes are not made without assumption of risk. Though we are on the brink of a catastrophe, the ones who have the ability to save us are not those who would wade into a storm of gunfire, but those with the courage to sit in a classroom of kids, five days a week, 25 weeks a year, and provide for them the essential support that will enable them to develop in a positive environment instead of one of isolation and fear. We can easily educate kids online, and we don’t need you to do that, and you will not win the economic battle that the current void will create. But we cannot replace your face-to-face impact, and we aren’t going to survive without it.        

Moving air in a good way.

Everything in medicine has ups and downs. Look at masks. No, I am not going to get into data about masks, I am just going to point out that despite the simplicity there are very real negatives: they are a pain to wear, they reduce social connection in a time of isolation, and because things have become politicized, they are now – like it or not – divisive. These are very real negatives and they are adding to our misery in a relatively miserable time. But so long as our treatment options are limited, anything we can do to help our situation with fewer negatives is a good thing.

This virus spreads in the air. We know that. And now we also know that asymptomatic people – people who are not coughing and hacking – these folks can still spread the virus to without even knowing it to others who don’t realize they are at risk. This is one of the reasons I worry about masks, because this is the very setting that regular masks are the least effective (but I promised I wouldn’t talk about that so let’s move on). 

It spreads in the air, and that makes air a big deal. What if we could reduce the amount of virus we are exposed to? Isn’t that the whole point of masks? (OK! I’ll let it go…)

There is a reason that the virus doesn’t spread well outside: it is quickly dispersed in the moving air. The further you are away from other people, the more the virus is diluted as it floats around. But inside, especially in a small, closed space, virus can linger and concentrate. We have all heard the examples of dozens of people being infected on a plane or some similar closed space. Many don’t realize that the air management in hospitals is very deliberate, with high turnover rates and everything being filtered and exhausted to the outside as opposed to being recirculated. But your house? Just the opposite: we try to keep air trapped so that it is efficient to heat and cool. Schools? The air management in many schools combined with the usual practice of keeping windows and doors closed is keeping me up at night.

I give you the fan.

I’ll also say this wasn’t my idea. Both Ferrari and McLaren are building cars with “virtual” windscreens. No, these are not your average grocery getters (both have 7 figure price tags) as these cars don’t have roofs at all or any type of windshield. Instead, they use directed airflow to divert the wind around the occupants. And if it works for them, why can’t it work for you and me?

Am I sitting here and claiming that fans are the cure for COVID? No. But reducing viral load in any way is a good thing. If we can do this with minimal side effects and help mitigate the risks of things like sitting with friends at a restaurant or teaching kids in a school classroom, then it’s a really good thing. So, why not use the same advanced tech that McLaren and Ferrari are using to better protect ourselves?  

If I am teacher in a closed classroom and a kid in the back is slowly shedding virus, that’s a bad thing. If that virus just hangs in the air, the amount is concentrated, even if they are across the room. Think of a smell. (No, not that. You are so juvenile). Think of a smell like paint. An open can of paint can slowly fill a closed room with fumes that can become progressively noxious, which is why you are supposed to make sure wherever you are painting is well ventilated.

With a simple fan, I can create a very effective “virtual” screen by creating a flow of air in front of the teacher, reducing their exposure. It’s actually a real thing, the industrial term is “air curtain.” A small fan on a table in a restaurant could protect people on one side of the table from those on the other and help keep the air moving, diluting any virus, no matter where it is coming from. The trick is to use the fan like a virtual shield – a virtual mask, as it were – by creating a perpendicular flow between people who might have a virus and people who don’t want to catch that virus. Resist the tendency to point the fan right at yourself, the idea is to make a barrier of moving air.

How effective could this be? Quantification of something like this – assigning real numbers like you have a clue – is completely unscientific, as there are many variables. But without question it would reduce people’s exposure, and any reduction is a good thing.

The more important question: what are the downsides? And this is the big upside: virtually none, and certainly less than masks. Plus, nothing says you can’t wear a mask in addition. It’s cheap, it’s safe, it’s easy, it allows anyone to more safely do something that many feel is quite risky right now.

While restaurants are tricky because you are talking about a huge variety of spaces all laid out completely differently, classrooms are pretty standard: a teacher in front of a group of kids. Setting up a $20 fan that creates a barrier of moving air between the teacher and the students is simple, effective, and with virtually no downsides. Don’t aim the fan at the desk and blow all of the papers that aren’t weighed down by apples and yard sticks all over the room, direct it across the space in between the teacher and the students (see the amazing diagram – it’s completely to scale – at the bottom). Even better would be keeping the door open and directing the air out, potentially with an open window to create a cross breeze.  It doesn’t have to be a gale-force wind, just steady movement.

Here is case study that is easily as good as some I have seen in peer-reviewed journals of late.

Not teaching kids is not an option. The success of our society depends on the education and growth of our next generation. We are social beings, and limiting our face-to-face interactions is not sustainable, no matter the risks. Anything we can do to reduce the impact of this disease while we work to regain the things that make us human are worth the effort.

Do as I say. No really, I mean it.

My whole world now revolves around designing and implementing a therapy for poverty. How this relates to an app that facilitates transportation and deliveries is a bit much to get your head around, but the best part is that if it works, you won’t have to understand why. It’s kinda like a virus in that regard.

Along this journey, I had an important figure in local government make a statement – twice, actually – that left me speechless (both times). I am reluctant to repeat it here for fear that it will somehow be attributed to me or that I will be accused of spreading fake news, but it’s public record, so here goes nothing. This person (I will try to deidentify them as much as possible) said to me: “There is no reason to try to eliminate poverty, because the cause and cure is well known: graduate from high school, work a forty-hour week, and put marriage before the carriage.”

This, in my opinion, shows a lack of understanding of human behavior.

Human behavior is a tough nut to crack, and it is a constant struggle for doctors. Look at diabetes and even obesity: we have cures for both of these, and yet they directly result or significantly contribute to the lion’s share of our healthcare spend. In a perfect world, we would have exactly zero complications from either of these diseases. If you are carrying a few more pounds than you would like, then you at least understand that people don’t always act in their own best interest.

The more separation between someone doing what they want to do but shouldn’t do and whatever bad thing is going to come of it, the harder it is to curb a behavior. One more slice of cake won’t hurt anything…

And now we are seeing this behavior in a bit of a worst case scenario, and we seem to be handling it about as well as we usually do. The most frustrating part of all of this is watching the ones who are supposed to be setting policy that will generate the greatest collective good just botch this all up like a proverbial train wreck.

When you tell people to do something they don’t want to do, you are not going to get 100% compliance. Ever. The more you push – and the more dissociated the negative consequences – the more people will rebel and tell you to pound sand. And once you lose them, you are not getting them back. This is true whether we are talking about staying in school or working a job or screwing around or eating too much.

And it’s just as true when you are talking about a virus, especially one that doesn’t affect them very much. If you say, “Stay home, and stay away from other people,” some people will tolerate this just fine, but many will not. So what will happen? You aren’t going to have 100% compliance. And when people do get together and break their isolation, then what? For the vast majority, absolutely nothing.

OK, what if you scare them with stories and data about how they are going to die? Will that get everyone in line? It works for smoking and drugs, right? Well, no. For some strange reason (called human nature), some people just don’t seem to get it, especially when their whole world is shut down.

What happens next? Some people start yelling at other people that they aren’t doing what they are supposed to do, and since we said this was going to kill people, well they are really upset about it. That just made things worse. So then we threw in masks, because wearing a mask is easy, right? And to try to make things better, we said that doing this simple thing – so simple that surely everyone will go along – we said that doing this will protect other people.

Perfect. That’s going to go over as well as me saying you are fat because that guy ate too many donuts.

Who thought we were going to get 100% compliance with masks? Which person that is supposed to be smart enough to understand virology and public policy thought everyone out there was going to do this just because you asked them to and because you said it was important? At what point in the history of our country has this every worked? Not only was it not going to work, it was without question going to create two groups of people that we can now see: one group in masks, one group not in masks. And they are not going to get along. As if that’s not enough, we started blaming the effects of a virus on the other group: you shut down the world and are killing us! No you won’t wear a mask so you are killing us! It’s all your fault, you clueless shithead!!!

Our current situation was so predictable that suggesting it was not anticipated and is being used to advantage by politics and industry is ludicrous.

The whole debate about masks was never about whether or not they work, it’s about how people work. It’s not about what people should do, it’s about what they will do. People don’t always act in their own best interest, and trying to shame or force them to do something they don’t want to do backfires every time, whether it’s school or work or sex or smoking or donuts or socializing. Or wearing a mask. Every. Single. Time.

Once you lose them – once people decide they are not going to follow your lead – you will not get them back. Doctors know this: once a patient stops listening to you, they might as well find another doc. You can’t use fear and undo it. You can’t use hatred and take it back. There is no way to get the people to just shake it off and come together and work together, especially with a big election on the horizon and social media amplifying our division. No, this train has done come off the rails, and there is nothing much to do but sit back and watch what happens.

And keep working on my therapy for poverty, because it is designed to take advantage of how people actually work, so I have that going for me.

Beating COVID with masks that work.

What are we doing wrong, and what can we really do to move forward?

If your knee-jerk reaction is, “make everyone wear masks,” then you are headed for disappointment, because what we are doing now is clearly not a solution. Think of the two biggest problems: continued isolation in nursing homes and total disruption of education. If masks are a solution, then why don’t we all put them on and just go back to regular life? Maybe it is because they don’t actually prevent people from getting sick?

No, it’s because people aren’t wearing them, and if everyone would just do this, the virus would go away, and then we could get back to life.

Even if the statement were true (which it’s not), the fact remains that you are not going to get everyone to wear masks, and now that masks are a sociopolitical issue, I am genuinely worried we are headed towards very real violence, and I think we should try to avoid this. So let’s take a few minutes (OK, it might be more than a few) and think it through:

What are we doing wrong, and what can we really do to move forward?

First, let’s recap what we know about this virus, because our knowledge continues to grow. It is clear that the number of infectious virus particles a person is exposed to is incredibly important. It is also clear that there is a wide range of susceptibility, and while some of that is predictable (increasing age being the most important risk factor) we don’t have all of this sorted out. But for sure: a lot of virus will make most people sick, a little virus can make some people sick. One (big) problem: a little virus tends to just sneak around from person to person with the vast majority being asymptomatic, but some unpredictably getting very, very sick.

How is this happening, and how can we stop it?

We know this is a respiratory virus that spreads through the air in two ways: big drops of spit (with virus in them), and tiny aerosolized particles that can hang in the air and float about. So, which is the bigger problem? Though every time someone coughs now, anyone within earshot visibly reacts, it is clear that these big drops – the ones that can only go a few feet at most – are not the problem. I had been discounting the floating virus particles, but this is clearly the main vector. The big droplets don’t go far, and asymptomatic people by definition aren’t coughing, which means the biggest issue is aerosolized virus particles.

By the way, this aerosolized virus goes right through a cloth mask like it’s not even there. Particles that are suspended in the air flow like leaves in a stream wherever the air goes, through the holes in the mask or gaps around the sides. These masks are only effective for larger droplets, and thus don’t do anything for the primary method of transmission, and particularly that from asymptomatic people. Yes, if a sick person is coughing or you are talking face to face with someone a cloth mask will help keep drops of spit from flying out of their mouth and into yours, but you will get infected regardless.  

If someone around you is giving off floating virus, then the farther you are away from them, the less you will get. Think of a sprinkler. Luckily, asymptomatic people give off lower levels of virus, so even being up close for a brief period like passing in the aisle at the grocery store is extremely low risk, but that risk is not zero. Furthermore, keeping your distance is not a perfect solution: in a closed space like a plane or a car or even a room in which the airflow happens to be just so that you are downstream from some virus shedder, you can be infected, and there are well-documented and widely-shared examples. In these settings, the airflow or lack thereof concentrates the floating aerosolized virus, dramatically increasing the inoculum. In all of these scenarios, susceptible people – and we don’t know exactly how to predict that – have to be extra careful, and you cannot rely on a standard mask to protect you.

To sum up: standard masks are not going to prevent the low level, aerosolized spread from asymptomatic people to others, nor will they protect susceptible people from being infected.

This is a real problem, because it means as the world starts to open back up we are going to see an increase in cases and hospitalizations and deaths.

Sound familiar?

But other countries have managed to do this successfully, and they all wore masks, so that’s gotta be the secret.

You are sure that’s causation and not just correlation? No other variables? Are you willing to gamble your life on that logic? How about the lives of your loved ones?

I am not.

This picture is Dr. Fauci boldly caring for Ebola patients, which is flat-out scary and damn impressive, even in a full-on containment suit. But this is not only demonstrates our ability to make effective protective gear, it also shows how completely irrational our current strategy really is.

We should be making the right tools for the job.

Not all masks are created equal, and for many years we have had masks that are proven effective to prevent the wearer from being infected by tiny, aerosolized pathogens. The difference in performance of N95 masks in terms of filtration and protection are orders of magnitude beyond cloth masks, especially when there is literally zero standardization or performance requirements beyond the casual observer’s ability to see your face.  Literally: all they are required to do is cover your face. When viral load at exposure is a critical factor and when we are talking very small aerosolized particles that can hang in the air and easily flow through or around these visual barriers, choosing them as a primary method of defense against a pandemic that has brought the world to its knees is laughable. Except none of this is remotely funny.

Here is the FDA’s documentation on masks. You should read it. Note that the first line states:

The Centers for Disease Control and Prevention (CDC) does not recommend that the general public wear N95 respirators to protect themselves from respiratory diseases, including coronavirus (COVID-19).

Instead, regular people are supposed to wear, “simple cloth face coverings.”            

Why?

N95 masks “are critical supplies that must continue to be reserved for health care workers and other medical first responders, as recommended by current CDC guidance.”

So let me get this straight: we are already testing vaccines – and spending billions upon billions of dollars in this arena – but we can’t remedy a shortage of masks that are proven effective at protecting vulnerable people from getting sick? Come again? We funnel all of our resources, efforts, and money into something that is unlikely to be as good as the one for influenza and is unlikely to be able to protect the most vulnerable (elderly) and is likely to be opposed by many people due to a lack of testing, all so that we might hope to achieve some level of herd immunity, because it will reduce but hardly eliminate the infection and hospitalization and death of susceptible people? And all the while we are virtually ignoring the proven method of directly protecting anyone that really needs to be protected?

And anyone pointing out the flaws in this logic is irresponsible?

Why are we not actively working to make more comfortable, easier to use, longer lasting, purpose-built, tested and certified masks that can actually protect a person without any adverse side effects either to the individual or society at large?  Why are we not distributing these to teachers so that they can simply go back to work? To our elderly, so they can be protected when around healthcare workers that have to see multiple people or when being visited by their families, so they don’t suffer and die in social isolation?

Meanwhile, our guidance for how to actually carry out a sustainable existence, one that includes the ability to interact with other people – an essential component of life for the majority of people – can be summed up in one  word: STOP. That’s not guidance, that’s panic.

We need to be applying those resources, efforts, and money to critical areas of our lives so that we can restart them safely, intelligently, and now. Things like airflow. Hospital air management includes careful consideration of the flow of air into and out of various rooms to prevent things like cross contamination, and to assure adequate turnover. We never had to do that to schools in the past, but perhaps we should be hard at work fixing these things, especially when we know what we need to do and have the expertise. Yes, this would cost money, but at least the money would do something effective, as opposed to the incredible costs of shutting everything down to clean surfaces which will do exactly nothing.

Some things will have to be remote now, so why are we not mandating internet and cell phone connectivity for all? In what world is it fair that public schools have a major remote component when there a literally millions of kids who will be unable to participate? In America, educational neglect is a crime.

But protecting people effectively – and we can do that right now, whether you are a doctor or a nurse or a first-responder or a teacher or a cancer patient or elderly – that trumps everything else.   

What we are doing wrong is trying to mandate a plan that is never going to work for two irrefutable reasons: it is not a logical plan based on current scientific knowledge (cloth masks will do nothing to prevent the spread of the virus), and it is not a logical plan based on societal realities (you cannot force people in a free society to do anything without massive repercussions).

Everything changes if we have an effective way to protect anyone from this disease. If a person is adequately protected even when exposed to potential dangerous levels of virus, then the behavior of others (which you will never control) is no longer a factor. Furthermore, we remove the social division and conflict that invariable accompanies mandates of any kind.  We are at each other’s throats because of a misconception that one person’s actions are impacting the health and wellbeing of others when we have a proven method of prevention of spread and we are failing to administer that method.

What we could do about it is start distributing effective protection to those who need or want it along with proper education on how to use it. We could be taking some of those billions and incentivizing our innovative to improve on the current offerings and tailor them to this specific threat, as well as to increase production so that there is adequate supply. No one loses with this plan, which would allow healthcare providers to expand the use of better PPE in broader situations and in greater comfort. A teacher who is worried about COVID – or any other respiratory disease like influenza that is still going to kill thirty thousand people in a good year including a higher percentage of young people – could be effectively protected. Immunocompromised such as cancer patients would have a much better way to safely mitigate risk, as would their loved ones who need to be just a vigilant.

And we could focus our efforts on collaborative solutions that effectively protect others, instead of ineffective mandates that inevitably divide us.

Rescuing the elderly from solitary confinement.

This is a call for Americans to demand revision of the current mandates from Center for Medicare and Medicaid Services (CMS) in regards to nursing homes. Understand, CMS provides the lifeblood (money) for any healthcare institution of any type, including nursing homes themselves, which means that no hospital, no physician’s group, no treatment center in the US is going to take a stand against anything they do, as it literally means being shut down. It is up to us to call out this injustice. Every single one of us could find ourselves directly affected by this type of policy.

You don’t need a medical degree to understand that humans don’t do well in isolation. The part that you do need to understand is how the primary way by which the novel coronavirus is spread: close human to human contact; not surfaces, not casually passing in the hall, face to face contact for 15 minutes. This is extremely important because the current mandates are in place due to fears about spread from surfaces and casual contact, meaning no one can be near anyone else: total isolation. By specifically addressing the primary method of transmission, we can end the suffering of our must vulnerable. We can also better manage those who do contract this illness but do not require hospitalization. 

The current CMS Guidance for Infection Control and Prevention of Coronavirus Disease for Nursing Homes which mandates enduring, universal isolation of residents without consideration of their wishes is categorically unconstitutional.  

A large percentage of the mortality from COVID-19 in the US has been in nursing homes. This delineates two important issues: first, these are the most at-risk, and second, whatever we are doing, it’s not working very well. To be fair, we were operating on very little knowledge at the beginning, but we now have much better data on which to create effective policy. Furthermore, the pandemic has exposed a completely unethical governance: the complete loss of personal freedom of residents. Just because someone needs assistance with activities of daily living or even has cognitive impairment does not mean they should relinquish the ability to make decisions for themselves, even if those decisions are taken from advanced directives.

When an elderly person enters a nursing home, they are choosing how they wish to live the final stages of their life. I have been involved in this process with family members more than a half a dozen times, and I don’t ever remember someone saying, “if we decide it is for your safety, we may remove every form of meaningful contact with the outside world – including your family – and there is nothing you can do about it.” If this were a clause in the contract and you were the client, I am betting you would have second thoughts. Think about it: would you voluntarily be admitted or admit a loved one to a nursing home right now? If you think you will never be in a position where this is an important topic for you, think again.

They say tomorrow is promised to no one. The older you get, the more accurate that statement becomes. Right now, we are so concerned with the safety of our elderly that we have forgotten that they are living human beings that deserve a voice, particularly in regards to their own lives.

Advanced directives were created because of the emotional difficulties in managing the care of a loved one in a life-threatening situation. We are all encouraged to make our wishes understood – preferably in a legally binding document – well before they are needed. If there is a takeaway from all of this, it is the necessity to include how you want to be treated during a global pandemic in that document. 

The foundation for development of policy and regulations of nursing homes should be based on respect for the personal wishes of the resident wherever possible (quality of life) balanced with the maintenance of safety of all residents. This philosophical guidance should not be superseded by sociopolitical climate, no matter how dire the situation appears.

The current facility mandates from the Center for Medicare and Medicaid Services (CMS) do not follow these tenets. The living conditions mandated due to the COVID-19 pandemic are not just uncomfortable, they are cruel. Furthermore, the most egregious regulations do not meaningfully increase the safety of the residents nor take into consideration the real-world limitations inherent in the system, limitations that will not be overcome with more stringent inspections or financial penalties, particularly in the midst of a crisis. They also provide no guidance for facilities on what to do if a patient becomes infected.

Here are the CMS mandates. (They are referred to as “guidelines” but they are not. Failure to adhere to these standards means fines or loss of CMS certification and inability to collect money from Medicare and Medicaid).

This is a big document, but the most important statements can be easily summarized:

  1. No outside visitors.
  2. No communal dining or other internal or external group activities.

Briefly, residents are isolated in their rooms, indefinitely. This is no different than solitary confinement, the serious adverse effects of which are well documented. When a person is moved into a nursing home, the purpose is to care for them. Placing them in isolation – even in short duration in an attempt to protect them from harm – should be avoided at all costs.

The current CMS regulations mandate universal isolation of all residents regardless of their wishes. This is forced isolation, and it without question unconstitutional, even in the face of a pandemic.

There are better ways of alleviating isolation, mitigating the spread of the virus, and allowing individual resident preferences to be met. In addition, simple changes could prepare a facility for management of patients that do become infected but whose disease does not require transfer to an acute care setting such as a hospital.

Current understanding of COVID-19:

  • The virus is primarily spread by close person-to-person contact defined as face to face contact within 6 feet for greater than 15 minutes.
  • Surface contamination, though theoretically possible, is not considered a primary means of spread. Furthermore, this risk can be easily mitigated through routine handwashing.
  • Casual contact such as passing in a hallway is not a primary method of spread.
  • The presence of an infected person within a room or space such as an elevator does not pose a significant lingering risk to others who might enter the same room or space at a later time.

Some Important considerations:

Nursing homes do not have the same capabilities as a modern hospital. Because the work is difficult and the pay is low, they often operate below optimum staffing, the educational levels of employees is similarly limited, and important supplies such as PPE may be scarce. These are chronic, systemic issues that will not be corrected through increased inspections, fines, or other regulatory pressures that are intended to assure quality. Failure to work within the realities of these facilities will have direct negative impact on residents. For example, closing a facility that is operating below an expected standard may leave those residents with no place to go. Though not an optimal situation, the overall benefit of the residents much be the primary concern.       

Recommendations:

  1. Individual decision concerning method of isolation (internal vs. external). To minimize the spread of viral disease, some restriction on person-to-person contact is necessary. However, a restriction of all person-to-person contact is proven to be mentally and physically injurious, therefore residents shall be given the option of limitations on external contact (no outside visitors or non-essential caregivers) or reduced internal contact (no communal meals or activities). Residents are divided into two groups, and they choose which group is best for them:
    1. External visitation: Continued visitation from outside family and friends and/or household caregivers such as sitters/companions. These residents are expected to stay in their room excepting necessary appointments such as physical therapy, and these will be done in isolation.
    1. Internal visitation: Continued communal meals and activities as desired. No outside family, friend, or non-essential medical visitation.
    1. Requirements for all visitors and staff:
      1. Temperature taken on entry – no one in with temperature >99.0 F.
      1. All outside visitors are to wear medical-grade surgical masks (provided) when travelling in the building and to go promptly to the destination room.
      1. Maintain strict social distancing (>6 feet) whenever possible including while moving through the building.
      1. Outside visitors are not to mix with residents or staff in small spaces (such as elevators).  
  2. Staff precautions.
    1. Where possible, staff will be split into 2 groups in proportion to size of resident group census such that residents choosing External Visitation will work with one staff group and residents choosing Internal Visitation will work with a different group. Though it is unlikely that facilities will be able to strictly apply this policy, it will still reduce the risk of cross-group contamination.
    1. Staff that work at multiple facilities should be preferentially assigned to the External Visitation group.
    1. All staff working with External Visitation residents will use N95 masks at all times in the presence of these residents.
  3. Residents testing COVID positive whose condition does not require transfer to another facility shall be placed on External Visitation guidelines, with strict requirement that all visitors (family, friends, medical) wear an N95 mask during the visit.     

These recommendations would not only mitigate the spread of COVID-19 better than current mandates, they allow residents to continue absolutely critical meaningful human interaction, they restore resident control and individualization in terms of how they want to live, and they provide a simple and workable solution for residents who test positive so that they are neither unnecessarily discharged from the facility nor allowed to put other residents at risk. Furthermore, the recommendations are simple and easily implemented, even in facilities with significant limitations in terms of staffing and resources.

John M. Salmon IV, MD

References:

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html

https://www.usatoday.com/story/opinion/2020/06/15/coronavirus-dangerous-for-uninfected-elderly-column/5322589002/?fbclid=IwAR1ALBvwRKF6hJPox6ZYFKn4hIodeC4xPAtWjuqHrLdV2FpMU6jocfFMgZo

https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks

https://www.psychologytoday.com/us/blog/out-the-ooze/201611/the-perils-social-isolation

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html

https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page

https://www.cms.gov/files/document/covid-nursing-home-reopening-recommendation-faqs.pdf

Is that a mask you are wearing, or just a placebo?

This is for my medical colleagues who are struggling to understand what could possibly motivate me to take the irresponsible position against the mandates, or even – in light of our current sociopolitical climate – the recommendation of wearing masks in public. Before you write me off, I deserve a chance to present my argument.

Let’s start with the irrefutable: the more distance and obstructions between an infected person and a non-infected person, the lower the chance of the healthy person getting sick. Period. Not a debate, don’t need a study, don’t need any experts of any kind. One person wearing a mask, less chance of infection. Two people wearing masks, risk reduced further. So why is this continuing to be such a heated issue, and how could any medical provider with a shred of a conscience oppose the use of what may be our only effective weapon against a pandemic of historic proportions?

Because life is complicated, and there is more to it than a virus.

Yes, masks are effective, but think of the scene I have just described as use of a mask in a lab – the in vitro scenario. But the application of any treatment in the real worldin vivo – becomes exponentially more complex. No matter how well things work in a petri dish, there are always side effects. Always. Masks are no exception, and so, we have to balance the benefits with the negatives.

And yes, there are very real negatives.

But first, the benefits. Masks are effective at reducing the spread of infection, but not all masks are created equal, nor are the people wearing them identical. Like many treatments that are promising in early testing, we have had ongoing issues proving the true efficacy in the real world. When specifically designed for and utilized in a particular setting, they have proven to be highly effective, but the effectiveness of random types of masks in an endless variety of settings in a world as varied as the people inhabiting it has proven to be more difficult to validate. This is the difference between what is theoretically possible and what really happens.

From one of the many recent publications:

“Face mask use could result in a large reduction in risk of infection (n=2647; aOR 0·15, 95% CI 0·07 to 0·34, RD −14·3%, −15·9 to −10·7; low certainty), with stronger associations with N95 or similar respirators compared with disposable surgical masks or similar (eg, reusable 12–16-layer cotton masks; pinteraction=0·090; posterior probability >95%, low certainty).”

How can anyone argue with this data? How about the fact that of the 44 comparative studies used to generate it, only one is community based, and that one has a significant selection bias?  (It is here).  

Also notice the rating of the strength of the statistical analysis (low certainty). Why? Because there are many variables and side effects of societal mandates of public masks that are inseparable.

What we cannot separate out is a placebo effect.

For my non-medical readers, the placebo effect is the somewhat dismissive term given to effects from a therapy that cannot be attributed to the treatment itself, like what might happen if you were given a sugar pill instead of an antibiotic. It is actually a manifestation of the poorly understood mind-body connection that we all have but is frustratingly difficult for physicians to manage. In this case, the placebo effect would include changes in mindset and related behavioral adjustments that a person might adopt while wearing a mask or even while seeing someone else wearing a mask. Some of these are good (reminder to maintain safe social distances in public places; inability to put your finger in your nose). Some of these are bad (reduced ability to meaningfully connect with others; continuous reminder of potentially deadly risk).

I’ll use myself as an example: I have had borderline high blood pressure since medical school. When my father developed vascular dementia – a disease that can be attributed to chronic hypertension – the stress of recognizing that I just might follow his footsteps along a path that I would very much like to avoid, that exacerbated the situation. Which is to say, I kinda freaked out. In an attempt to potentially stave off a loss of cognitive function (that some may say is already in evidence), I decided to start treatment, but with an unconventional regimen: I tried a very small evening dose of a beta blocker, a drug that works by dilating blood vessels and slowing your heart rate. I figured that lowering my blood pressure at night was better than nothing, and I found that it helped me relax and sleep better.

It also made me feel like I was doing something – a placebo effect – reducing the cyclic anxiety that came from worrying about my blood pressure.      

And it worked. For a while. One day, as I struggled on a bike ride to get anywhere near my usual performance capabilities (I felt unable to catch my breath), I decided that the cardiac side effects of this drug were just too much. I’d rather take the chance of dementing illness than lose the joy of one of my favorite activities

(I wonder now if I didn’t have COVID. No, I am not kidding).  

Not only is this a demonstration of the placebo effect, it shows a difference in one person’s approach to life vs. another. We are all different, and we all deserve the freedom to navigate this world as we see fit, so long as our choices don’t impact others. Which brings us back to masks, to the side effects, and to these placebo effects that are inevitably tied to their use, and to why something seemingly simple and effective is so much more complicated in vivo than in vitro.

Any issues associated with my blood pressure are all mine. Any risk of doing nothing is for me to endure. If I choose to take medicine, everything involved including the need for a current prescription, the cost, having to regularly go to the pharmacy, plus all of the effects of the drug – physiological and placebo – are what I must balance as pluses and minuses in my life.

I get to choose how I want to live.

Over the past few months, there have been massive changes in the world, and every single person is facing new challenges. As a society, our biggest hurdle appears to be the same one that has tripped us up for eons: a reluctance to allow others the freedom to live as they want to live, to have different opinions, to find strength in different ways, to face challenges on our own terms, to seek and find joy and happiness in widely varied places. This is where the use of a simple face covering becomes inextricably linked to an individual’s freedom to choose how they approach life and all of the adversity that it entails.

At present, this virus is quite literally inescapable. It is possible to avoid being directly affected or infected or symptomatic, but the effects of the pandemic are ubiquitous. Nevertheless, we make different choices: some choose to meet this virus head-on with the goal of minimizing any impact in hopes of establishing a new – albeit different – path forward: a new normal. But some don’t want a new normal, and instead prefer to continue on as before, not oblivious, but accepting the new risks associated with human interaction.

These are both valid, and we have to learn to coexist despite our differences.

For some people, masks provide a benefit, both physiologic and placebo. They provide some protection against a hidden threat and a psychologic feeling of security. The problem here is that this placebo effect with masks is extremely powerful, but it is not always beneficial, and it is not limited to the person wearing the mask.

Doctors have a natural tendency to approach diseases first and foremost through the delivery of healthcare: we focus on treating disease. We also struggle with the real-world issues that confound our scientific treatments. Look at diabetes, which is essentially cured yet remains one of the leading causes of morbidity and mortality. What doctors refer to as “non-compliance” is really just people being people. We are again facing this problem of people being people, and as usual, we can’t take our eyes off the therapy: if everyone would just put on a mask, we would have better outcomes.

But many people – myself included – want to choose a different way to fight this fight, and our viewpoint is not only just as valid, the deleterious side effects are every bit as real as those from a virus that can maim and kill. Statistical data evaluating the benefits of mandates for the public wearing of masks can be shown to move the needle a percent or two. When the numbers of the dead are in the hundreds of thousands, the effects appear dramatic enough to justify the imposition of freedom for the betterment of society. But this analysis is focused on one thing only: outcomes from COVID-19 (and even there the real-world data is weak). When you expand your field of view to include the deleterious socioeconomic impact preferentially affecting those in poverty which – even limiting our headcount to the free world – number in the hundreds of millions, that same 1 or 2% is 1000-fold greater.

The placebo effect of masks is very real. To some, it provides a sense of security, but to others it causes very real harm. It removes an absolutely vital component of life: human connection. It increases paralyzing fear, like that which shaped the unconscionable CMS mandates for nursing homes. These mandates are worse than prison, cutting off “residents” not only from from all outside visitors but also ending communal dining and activities so they are completely isolated, both inside and out. Continued fear is preventing us from doing essential things like educating the next generation. There is no logic in this, no concern at all for anything except statistics related to a single disease. And now – because masks have been made into a political and ethical symbol – those who would choose a different tactic are also feared and shamed.

This is wrong. As a physician, I refuse to condone the shaming and ridicule of people who would choose to live their lives on their own terms, those who are willing to take on substantial personal risk to try to restart the world for the betterment of others, those who value human connection enough to stand strong for our children in the face of a disease for which we have no treatment but cannot be allowed to go on wreaking havoc. There are other ways to fight this fight, more effective ways, more sustainable ways, ways that bring us together instead of driving us apart, ways in which we support each other as we all try to carry on the best we can.

Life is much more complicated than a test tube, and if we don’t include all of the other complexities in our analysis and recognize the differences between in vitro and in vivo, we may end up losing both the battle and the war.