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.”            


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.       


  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


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.

More Fear than Logic.

“Multiple Florida Hospitals Run Out of ICU Beds as Coronavirus Cases Spike.”

This headline is just as criminal as yelling “Fire!” in a crowded movie theater. (You might not remember, but movie theaters are these places people used to go and watch these stories told with pictures that move and have really loud sound and popcorn. Ah, good times…but way too dangerous now)

It’s Italy all over again!  Except, no, it’s nothing like that. “Multiple” in this case means two.  Two of seventeen.  Florida ICUs are at 75% capacity.  And the Florida Department of Health has said that the 17,000 new cases are due to expanded testing, and Newsweek didn’t bother to wait for them to comment, likely because an accurate headline wouldn’t scare you at all:

“Increased Florida Hospital Utilization Signals Return to Normal Operations While Testing Capabilities Expand with Expected Results.”   

It is fear – not science – that is driving the use of masks in public. It is fear – not science – that is threatening to disassemble our school systems. It is fear – not science – that is the rationale for restrictions on how people choose to live their lives. Meanwhile, you aren’t being given usable information, you aren’t being told anything helpful for how to safely navigate this new world, and the fear is tearing the fabric of society.

One statement at a time:


There is no good data for the use of cloth masks in public, and there never will be.

Here I go again, a dangerous idiot. Who is more dangerous, the one telling you not to feel safe based on completely flawed data (that’s me), or the one pushing ineffective policy that feeds on your fear by telling you something you want to believe?

All I know to do is apologize for the scientific community, because we have let you down. We have always known there are good studies and bad studies, we were even taught how to pick them apart in college and med school. And yet we continue to propagate this utter crap, partly because it gets attention, partly because of politics, and partly because many of the scientists both in and peripheral to healthcare are also scared.

Did you know that scientific articles now come with a real-time measure of online impact, like tweets?

One more time: there is no good data for the use of cloth masks in public, and there never will be.

There are too many variables to know if mandating the use of masks that were never designed to prevent the spread of a virus and which have absolutely no construction specifications or any kind of certification work in the way you are hoping they might work. And yet opinion pieces continue to site “data” as if we know when we really don’t.

Even as I was writing this blog, I found two new studies that claim to prove the effectiveness of masks in all of this, even siting specific numbers. Masks “reduce the daily growth rate by 40%”, which is pretty impressive, since the study was performed primarily using data collected in Jena, Germany, a city with a population a bit over 100,000 and 144 total cases. The other “landmark” study based its findings on curves on graphs of case incidence, as if nothing else could possibly affect rate of infections: 

“We quantified the effects of face covering by projecting the number of infections based on the data prior to implementing the use of face masks in Italy on April 6 and NYC on April 17 (Fig. 2A; see Methods). Such projections are reasonable considering the excellent linear correlation for the data prior to the onset of mandated face covering (Fig. 2 B and C and SI Appendix, Fig. S1). Our analysis indicates that face covering reduced the number of infections by over 78,000 in Italy from April 6 to May 9 and by over 66,000 in NYC from April 17 to May 9.”

I am sorry, if I have to explain to you why these are poor models, I am just not going to get through to you. Maybe you are hearing what you want to hear; maybe you are hearing something that helps mitigate your fear. But this is the kind of “science” that is being held up by scientists, the very people you hope to look to for guidance. This is not guidance, this is pandering to sociopolitical opinion, and it’s every bit as destructive as causing a deadly riot.    

Look at this study, but you don’t even have to read it. It’s the “landmark” mask study done on hamsters. Now ask yourself this: why would anyone do a mask study on hamsters? Because, as I have said it is (unfortunately) impossible to do a solid study on the use of masks in the general population in regular life.

Think back to what science really is: the systematic study of the structure and behavior of the physical and natural world through observation and experiment. There are some guidelines we like to follow to do this right, like having a control group to compare to and designing a study that eliminates confounding variables, so that you don’t mistake the results of one thing for another. It is impossible to do this with masks in the general population in regular life. You simply cannot control for the variables. You just can’t. I am sorry that this doesn’t make you comfortable, but it is true. For one thing, you can’t reliably control human behavior. You also can’t control for the type of mask. You can’t control for the type of exposure, the environment, the weather, the amount of virus, etc. Hell, we don’t even know who has been infected and if they are immune… so many things – so many variables – that you have no idea.

To really do this, you would have to control for these things, but the real deal-breaker is this: you would have to put real people in harm’s way. To test if more people get sick with or without masks, you would have to put people at risk for getting a virus and dying, and that’s not going to work in the modern world. A couple of hundred years ago we might have been able to split a few dozen less desirables into two groups and throw them in with some sick people, some with masks, some without, then count the dead bodies at the end, but we look down on that sort of thing these days.

Which is why they went with hamsters, because you are allowed to put hamsters in harm’s way. But this introduces a few other issues, like the fact that hamsters aren’t people, and even if they can get the very same virus, there are one or two differences about them that might be important. Like the inability to wear masks. Which is why the hamsters didn’t wear masks but were separated by cloth barriers with fans that were supposed to simulate masks. But this doesn’t really simulate wearing a mask, does it? It simulates people living in different rooms separated by cloth barriers with fans blowing on them. And that’s not quite the way most of us live. And hamsters still aren’t the same as people.      

But people say wearing masks is better than nothing and it’s not that big an ask, and that entire concept is built on fear, and ignores the fact that it can be worse than nothing, and it does indeed perpetuate fear. People are afraid of a virus and they know it comes from other people so they want to block it from coming out of those other people so that they can feel safe. That’s fear. Fear that is stopping us from re-opening society to save the ones languishing in isolation and poverty, to try to begin the painful process of bridging enormous learning losses and widening educational gaps.

Meanwhile, if we use science, people who need to or just want to would wear a purpose-built mask proven to protect them from harm, regardless of whether the other person has a virus – any virus – or not. (More on that later).

Now let’s turn to schools: 

All the data – data that we are just too afraid to believe – shows that young people are largely unaffected and don’t seem to even be vectors for spread. More kids under 20 died from influenza last year than people under 30 have died from COVID19. We keep forgetting influenza, almost like we don’t want to admit how bad it is, because remembering influenza throws into question why we are so upset about COVID, especially in young people, the very people whose lives we are ruining. We have even “updated” all our stats from two years ago. I find the timing of these updates interesting, as they have occurred while everyone is so busy focusing on this new threat that I wonder who had time to devote to this, especially during the deliberate and unconscionable cessation of testing and tracking of influenza, like the old data was more important than current data? And by the way, whoever was tasked with this did a rather sloppy job; changing the data in the charts (even though this is supposed to be the original data) but leaving the original numbers in the text. The archived page here says it was updated in November 2019, but I referenced it in a blog post I wrote in March… This is kind of stuff that fuels conspiracy theories.

Schools are the most important organized component of modern society. There is no data to support the impending devastation that will come from rendering them useless, and all the restrictions are based purely on fear.

But we have vaccines for influenza! And treatments!

Yeah, and people still die by the thousands, including kids.

But that’s because they are too stupid to get vaccinated!

OK, then why can’t I be too stupid to stay away from other people?

Which brings us to: What I do affects you.

This is really the root of the problem, this concept that my behavior endangers others, specifically you. We like to deflect that last part, because concern for others is noble, whereas concern for one’s self is, well, selfish. This entire fiasco – our societal shutdown – is driven by the fear that what I do endangers you. But it just doesn’t, and at some point, you are going to have to let it go. I suggest you let it go sooner rather than later, because the damage we are doing is far beyond the virus itself, as I have tried in as many clever ways as I can possibly dream up to illustrate this. I don’t really look forward to the graphs and pie charts comparing the numbers of dead from the virus and the numbers of dead from things like cancer or child abuse or drug abuse or suicide or any other medical condition that is going unmanaged, and these charts will only show the tip of the poverty iceberg that is solidifying with every passing day.

If you are so smart, what are we supposed to do?

I am glad you asked.

First: stop relying on others to keep you safe, take care of yourself. That means learn how this stuff really spreads, and how to really protect yourself. Focus on things that actually work in the riskiest situations, instead of focusing on things that aren’t proven to work in situations that are relatively low risk. Yes, this virus is different than influenza, but not in the way it spreads, and we have had standards for how to deal with flu for years and years. Those standards still apply.

Far and away, the most common is person to person from a symptomatic person. Fear of unlikely (and unproven) catastrophe like an asymptomatic person passing it to millions of others has diverted us from focusing on this most important problem, especially when we refuse to recognize that this is not that easy. We are not a people that stays home when we don’t feel well, and this should be the number one thing we change. Instead of trying to force everyone to wear panties on their heads and feeling good about it, strongly encourage people to stay home if they don’t feel well, and force employers to implement this as policy. If you are sick but are out and about using some sock as a pretend virus shield and people think this is a good plan, it’s just not.

Data suggests that this virus is more infectious earlier in the course of disease than others, which means if you don’t feel quite right, stay the f#@& home. Give it a day, and if it turns out to be nothing, well there you go. And no, testing is not the answer, because I don’t give two shits if you are COVID free, I would still prefer to not die of influenza. Especially now, because no one will care (or know, because they won’t test for it).

If you are vulnerable or just worried, get a real N95 mask, have a professional explain how it is to be used, and then use it all the time when you are around people that could give you a virus that could kill you. And those people could be wearing cloth masks, so don’t allow this completely unregulated crap lull you into letting your guard down. Effective isolation means 100%, and COVID is not the only virus that can kill you.  

And let kids be kids. Every spec of data supports this, and that is not even factoring in the immeasurable damage from things like shutting down schools.  

If you want to stay home, stay home. If you don’t want to go to a rock concert, don’t go. If you want to wear a cloth mask, go ahead. If you need to wear a purpose-built N95 mask, please do. If you want to wear a space suit, be my guest. Every business that is open and every employee that is working is doing so of their own volition. Every person that walks in the to a retail business or a restaurant or a gym or a school is doing this by choice. Someone else wearing a cloth mask doesn’t protect you, so don’t pretend it does, and if you don’t feel well, be a good sport and stay home.

With everything open and working it makes it a lot easier to allow you to video conference or get delivery or have someone else help you stay effectively isolated. And nothing I do affects your safety in any way, it just scares you that I am living in a way that you are not comfortable with, not unlike seeing someone sit on the edge of a cliff. So stop telling me or anyone else for that matter what we are allowed to do. If I want to be an idiot and end up getting an infection that kills me, that’s not going to affect you one iota if you just do like I just told you to do.

All of this is fear. Fear of a virus, fear of it spreading, fear of it killing. But fear is what is spreading, and fear is what is killing, and recovering from the fear is going to be a lot harder than recovering from the virus.

And the dead won’t care why they died.     

Weak sauce and the spread of COVID-19.

This study is representative of the data that is driving public policy today. Let’s look at it. Before we start breaking it down, here is the exact wording of the “meaning” of the study, which is to say the author’s interpretation of the significance:

“High transmissibility of COVID-19 before and immediately after symptom onset suggests that finding and isolating symptomatic patients alone may not suffice to interrupt transmission, and that more generalized measures might be required, such as social distancing.”

Now let me be blunt: I don’t agree at all with the “meaning” in this study. In fact, I believe it makes flawed assumptions and the wording is totally inflammatory. I am going to walk you through and explain. And by the way, this is complicated, but it’s also kinda important, so please read. This is the thinking that is dictating our complete socioeconomic shutdown, so if it’s not based on fact, we are making some pretty massive mistakes.

This is a study performed in Taiwan between January 15 and March 18 on 100 confirmed COVID-19 patients. The intent was to look at how the virus spreads. The methods are solid, and we would be unable to duplicate it in the US due to differences in personal freedoms. Very detailed contact tracing was performed on all 100 patients starting 4 days prior to development of symptoms and continuing to every contact up to confirmation. The testing was RT-PCR – it is virtually 100% specific, which means if it’s positive, the patient does indeed have infection. The 100 primary cases were all identified by testing (this is going to be very important).

Nine of the patients were and remained asymptomatic, but their contacts were included in the study.   

OK, so now let’s look at these contacts: in-depth tracing identified 2761 that were considered close contacts. Think on that: that’s more than twenty-seven people per patient that were identified. Every single one of these people was quarantined – truly isolated – for 14 days. That’s a lot of people; even so, you were not considered a close contact without fifteen minutes of face-to-face contact. Let me say that again: twenty-seven hundred sixty-one people were painstakingly isolated and monitored who had been in right up in the grill for fifteen minutes of someone with confirmed COVID-19. Many of them had much more contact, like they lived in the same house.

If you passed them in the hall or the grocery store, you didn’t get a second look. If you touched the same railing in the building, no one cared. At the time, most regular people were not wearing masks. This is important: we are all wandering around concerned about getting within 6 feet of each other for ½ a second, and there is a big, big difference between engaging in a one on one conversation for a quarter of an hour.

So, what happened?

Of the 2761 isolated patients, twenty-two developed COVID-19.  That’s 0.7%, or 7 out of a THOUSAND people who had contact better than 15 minutes all up in there actually caught the virus.

Not one of contacts of the nine patients that were asymptomatic developed any symptoms or disease. Does this mean you can’t get COVID-19 from someone who is asymptomatic? Nope. In fact, I don’t think it means anything. Furthermore, they didn’t do additional testing on asymptomatic contacts unless they were high risk, so it’s possible that any number of them actually got infected but evaded detection. Nevertheless, we seem to have this idea that asymptomatic patients are not just potential culprits, they are in fact the most important, but, no one that had it with no symptoms led to another person becoming symptomatic.

Moving on, what can we learn from the people who actually got sick from being in contact with one of these 100 people?

One of the big questions has been: when in the course of the illness is a person most likely to spread the disease? This is a type of tracing study is much more powerful than mathematical models based on lab data like duplication rates, or even on viral load. There is more to being infective than just test results, and this type of study considers all of those real-world variables.

This is a really important chart, because this graph holds the evidence for pre-symptomatic infectivity that is shaping our lives now, and it can also demonstrate the flaws in the logic.

These graphs show the time the two cases were in contact based on the onset of symptoms. What we are looking for is when the people interacted: was it before they knew they were sick, was it about the same time, or was it later in the illness?

It’s worth mentioning that SARS has a different curve, and it seemed that sick patients are most infective about 10 days after developing symptoms. Not so much here… but it is worth noting that viral load studies (which are not the be all end all) suggest the highest infectivity with COVID-19 is about 5 days after onset of symptoms. Faster, yes, but still not pre-symptom.

And this data appears to confirm that COVID-19 patients are infective earlier in the disease as compared to SARS. However, the investigators here have focused very hard on the contact prior to symptoms.  10 of the 22 patients had significant contact with a primary case before the person was sick. What does that mean? 

Well, nothing really. That’s right, it doesn’t mean anything. And the authors know this, they even recognize it, but they don’t elaborate on it (partially because it calls into question a lot of things…)

First of all, 8 of those 10 patients had continuous contact both before and after developing symptoms, so there is no way to know. However: two patients only had contact prior to the primary case patient’s development of symptoms. So, there is no way to explain how these people could have gotten the disease any other way, right? Not so fast…

Allow me to introduce you to patient twenty-three.

Contact tracing actually discovered twenty-three patients, but number twenty-three was excluded. Why?

“One of the 23 cases was excluded from subsequent transmission-pair analysis because the documented day at exposure occurred after symptom onset of the secondary case.”

Read that again, then one more time. What they are saying is that the timing clearly showed the primary case was in fact a secondary case. In other words, the messed that one up, so they threw it out. But then they kinda ignored the fact that they might have the order wrong in other cases, too.

See, we can’t really say anything about the order of infection. Just because we identified these 100 patients as COVID positive in a lab, that doesn’t mean we know where they got it, or who got it first. Many of these people were close family, many living in the same house. They got it from someone, so it is just as likely a close contact got it from the same person.  We don’t know for sure if the primary cases are actually primary, or if they got it from a third person that gave it to the contact. And in at least one case the patient we identified as primary was clearly secondary, but this was never further acknowledged as a study limitation, because it would really screw up the data.

Now, no investigator likes to point out limitations in their study, but this is a pretty big deal. The idea of asymptomatic and pre-symptomatic spread is not just being consider as a possibility, it is assumed to be a major risk, and this fear has brought our world to a halt. Those fears are completely unfounded.

And here is where I really take issue with the author’s interpretation, so let’s look at it again:

“High transmissibility of COVID-19 before and immediately after symptom onset suggests that finding and isolating symptomatic patients alone may not suffice to interrupt transmission, and that more generalized measures might be required, such as social distancing.”

First, HIGH transmissibility? Fifteen minutes minimum face to face contact with an infection rate of 0.7% is HIGH?  But wait, in the body of the paper you said:

“In the contact tracing cohort, we observed a relatively low transmission rate of COVID-19.”

Well, which one is it?

I had to put my dad’s tax return in a box for 72 hours before the accountant would touch it, and I am still not allowed to carry my fathers’ belongings into his room, even if they clear the halls.

BTW, at the time of this study, the general population in Taiwan was neither wearing masks nor operating under any government recommendations of social distancing.

And then there is this word before, as in: transmission before symptoms.  That is totally unproven, and they know why, and they still say it.  BS. Before is not proven, and though I am sure it’s possible – most anything is possible – it is clearly not a scenario that should be driving public policy, and all of the damage done from these devastating mandates is clearly doing way more harm than any spread from asymptomatic or pre-symptomatic patients.    

So, one more time, and this time I put the fallacious interpretations in bold, because everything after that is dependent on this being fact: 

High transmissibility of COVID-19 before and immediately after symptom onset suggests that finding and isolating symptomatic patients alone may not suffice to interrupt transmission, and that more generalized measures might be required, such as social distancing.”

I am sorry, this is bad science. This virus is real, people are getting sick, it’s new, it’s weird. It’s also just not all that. And now we have scared the shit out of everyone, and we can’t undo it. The damage from shutting down society is at least an order of magnitude beyond the virus, and most of what we are doing to “fight” the virus is completely ineffective and unnecessary. We are chasing our own tails, many are afraid to speak up because they are painted as uncaring and reckless, others simply refuse to admit they made mistakes, and some are using this all for personal gain. Meanwhile the fear and fighting are fueled by social media, and we seem incapable of taking a few deep breaths and thinking this through.

How many times do I have to say it: shutting down the world is not an option, no matter what. Life is interconnected, and we are hurting and killing many more than we are saving, and the stuff we are doing that is the most damaging is also the least effective. Furthermore, many of us are at the end of our ropes, and you just don’t have a right to tell us how to live, especially when your rationalizations are dependent on this type of weak sauce.