Effective Transportation in Smaller Cities and Rural Areas

Bullet points:

  1. Fixed-route buses and on-demand systems are not effective in smaller cities and rural areas and are expensive to operate.
  2. Pre-scheduling rides assures minimal waste but is more challenging to implement.
  3. Customers will pay for service that meets their needs, but will not pay for substandard systems, so make sure what you do is effective.
  4. Effective public transit in smaller cities and rural areas is more about customer service than it is about technology.  
  5. The lower the population density, the more important it is to be able to use every available resource, including those not traditionally under the public transit umbrella (volunteers, rideshare, non-emergent medical transport).

Our city – Lynchburg, VA – has a typical public transit system that is largely ineffective because of the relatively low population density. While everyone acknowledges this, little work has been done to try to improve the system beyond adjusting bus routes and stops. Meanwhile, people in the more rural surrounding counties have no public transit at all. Over the past seven years, our team has worked to build a financially sustainable system that has proven to better meet the needs of the community. We did this by flipping the business model of public transit on its head. In fact, approaching the problem from outside the existing public transit system has been fundamental to our success.

As an analogy, think of transportation as a sandwich shop. The goal of public transit is to be sure everyone has a sandwich, so the typical approach is to make as many sandwiches as possible at the lowest unit price in the hope that everyone will at least get something. The use of large sandwich machines (buses) allows high production at rock bottom prices. To evaluate how well this is working, the standard metric is how many sandwiches are eaten (utilization or ridership). While this approach works someplace like New York City, it has serious limitations when the population density drops.

First, counting the number of sandwiches that get eaten is not a good metric, because you can have a lot of satisfied customers and still have people starving in the streets. Even worse, if your sandwich isn’t very good, the only people eating it are literally the ones starving, so increased consumption may actually be an indicator of critical unmet needs.

Second, while the unit cost per sandwich may be low, if most of your product gets thrown away then you are generating tremendous waste. While each sandwich may be inexpensive, making 100 for every one that gets eaten is incredibly expensive. When you see a big bus that is largely empty, you are seeing mass quantities of sandwiches (and taxpayer money) being thrown away.

Finally, these cheap sandwiches are incredibly hard to sell, meaning the business never makes money. It’s normal for a public transit sandwich shop to bring in less than 10% of its operating costs from customers (fares). Reliance on continued investor support (government funding) is part and parcel to the business model.    

From the very beginning, we imagined a different approach: instead of continuing to operate an ineffective, expensive system with substantial waste, why not build an attractive, effective system that is financially sustainable because the product is something people will pay for, and then leverage that system to better meet the needs of the community? Going back to our sandwich shop analogy, we decided to make the highest quality sandwiches using only the best ingredients at the lowest cost, but make every sandwich to order. This assures there is no waste, and while the sandwiches may each be more expensive, every sandwich gets eaten.

But the most radical shift is that we don’t give away any sandwiches – that’s right, there are no free sandwiches – and this is how we achieved financial sustainability in a market that has completely given up even trying to have a sustainable business. Even so, we are able to meaningfully assist our most at-risk neighbors when the available options have proven completely ineffective.

How is this possible? Because while we don’t give any sandwiches away, we also don’t turn anyone away.

If you walk up to the public transportation sandwich counter you will be offered a sandwich, but if it won’t do, you are out of luck. If you walk up to our counter and ask for a sandwich, we will make sure what we put together is going to work for you. If you can’t pay for it, the reality is that you need more than just a sandwich.

In the world of social services, people’s needs are complex. Effective programs provide wrap-around support that is customized to the individual while requiring an appropriate level of accountability. Without this support, freebies get squandered. With it, basic transportation becomes a simple but effective tool for helping people get back on their feet. So, we don’t give out free sandwiches, but we do direct people to programs enabling them to overcome their barriers, and then those programs pay for the sandwiches.

Why? Because without an effective transportation solution, even the best wrap-around care programs will fail when people can’t get to where they need to go.

Our experience with Lynchburg Adult Drug Court offers a real-world example. A program of the Virginia Department of Health (VDH) overseen by the city court system, Adult Drug Court provides a comprehensive rehabilitation program for nonviolent offenders who meet certain requirements. It is an appointment-heavy program where participants have multiple supervisors and requirements including social work, peer support, and routine drug testing. Progression through the multiple stages is dependent on the success of the individual and the duration can exceed two years. However, graduates evolve into mentally strong, productive members of society as opposed to serving multiyear sentences and emerging as convicted felons.

At the request of the VDH, we began providing transportation support for participants at the end of 2022 at a contracted price matching our local taxicab fare: $2.80 a mile. Over the next nine months, we worked to meet any unmet needs of the 18 enrollees and ultimately billed the program $5071. The presiding judge passed on that he was sure at least four people would have failed out without our help. This would have resulted in their being returned to prison to serve out their full sentences at a cost to the city exceeding $500,000, meaning the city saw a 100x return on their $5000 investment while increasing the program success rate by 22%. We have had similar success serving the Department of Social Services with their Temporary Assistance for Needy Families (TANF) which is thrilled to pay us for transit services when it means they are much more effective.

The same approach works in most markets: schools can’t charge tuition if students can’t get to class, and businesses suffer if employees can’t get to work. The US healthcare system loses $100 billion annually on no-shows directly related to lack of transportation.

The most important component to achieving financial sustainability is only making sandwiches to order: pre-scheduled rides. This is how most paratransit systems operate, but the bulk of public transportation is either fixed route buses or various forms of curb-to-curb “on-demand” service. Like fixed route programs, on-demand service is very wasteful because it requires an excess of capacity so that someone is always ready to go. This is why you are always on hold with customer service, as no business can tolerate the expense of paying people to sit around “just in case.” It took us about a day and a half to understand the inefficiencies and unsustainability of on-demand transportation outside of a major metropolitan area.

A word of caution: pre-scheduled rides take a lot of work, as does addressing the needs of everyone that steps up to the counter. This is problematic for public transit systems as they are not setup to do this type of work. Furthermore, flashy smartphone apps make many promises, but technology has to follow what we actually do, not the other way around. While we purpose-built our IT solution to help us manage our specific operational process and are proud of its unique capabilities, the reality is that we are able to run our entire system with notepads and cell phones. In many ways, we are much more like – and work much closer with – the department of social services than we are a typical transit company. Big buses may be complicated but people are another animal entirely.

Tables 1-3 summarize financial and effectiveness data from a microtransit pilot program in Maryland (The Flex) as compared to similar datasets from our program titled ACTiN (Advanced Connected Transportation Network) from the beginning of Q4, 2023. While there are a lot of publications relating to microtransit, the vast majority are planning studies and there is very little true outcomes data to be found. Note the Maryland Department of Transportation’s Performance Standards in Table 1: Any Farebox Recovery Ratio of >12% – which means losing less than 88% of your money – is exceptional. The Flex recovered 2%. Our local bus company typically recovers about 6%. The microtransit program in Wilson, NC recovered 15% by charging $1.50 for rides that cost them $10.50 each. In October – the first month we were fully operational – we recovered 71%. In November: 108% – we brought in more than the cost of our operations, proving financial sustainability, and we continue to improve. By the way, please forgive the not-so-flashy charts, as my training is in medicine (and now transportation), not graphic design.

Table 1. (Click to go to full study)

Table 2: ACTiN Data, October 2023.

Table 3: ACTiN Data, November 2023.

One component that helps us achieve this goal is our vehicle of choice: 2020 Model X Tesla, which has an operational cost of only $7 per hour. While buses easily cost over $100 an hour to operate, our target is $35 an hour, and of that expense, $28 goes to the driver, so even that goes back into the community. The lack of routine maintenance – there is no gas or oil or water – even extends to regenerative brakes which reduces brake pad and rotor wear significantly. While there is an argument that making the battery for an electric car negates the environmental benefit of not burning gas, reducing the use of other gas-powered cars evades this conundrum. Every community is different, but a busy driver working a 40-hour week can manage 3000 miles of transport a month, saving about 100 gallons of gas. Sharing the car with two drivers doubles these results.

The unintuitive but critical benefit of the Model X is actually the unique “falcon” doors. Public transportation has to meet strict requirements of the American Disabilities Act, but this actually leaves out people with limited mobility. If you have never helped a little old lady into a vehicle, you may not realize that even a minivan requires you to bend your knees and twist your body at the same time, significantly increasing the potential for a fall. This is not the case with the Model X, as standing someone at the threshold – even when they need assistance – is all you need to do to get them in safely. And in a society where liability is literally crippling, this is priceless.

All that being said, the reality of transportation – especially in rural areas – is that you have to be able to leverage every asset you have. This is where public transit (and pretty much every other organization in the US) falls down: no matter how effective the group or business or service, we are not good at handing our customers off to a competitor. Uber is never going to connect a rider to a taxi, and a taxi driver is never going to suggest you take a bus. This is another reason public transit needs to move away from utilization as its metric, and we have suggested shifting to ride completion rate. By focusing on enabling effective transportation as opposed to being the solution, public transit can adapt to the particular needs of the community to assure even the most complicated are being met. One of the tremendous powers of technology is being able to connect to people and enabling them to make their requests known, whereupon those in charge of managing the resources can help apply the most appropriate assets to get the job done.

In summary, transportation is a critical need in our society, a fundamental social determinant of health. Smaller cities and rural areas with lower population densities require a novel approach. By focusing on high quality, made-to-order services and minimizing waste, it is possible to build effective, financially sustainable systems that meet the needs of the community.

A Convener Of Stature

A couple of weeks ago I got to listen to a brief lecture by Mike Leavitt, former governor of Utah and Secretary of Health and Human Service under Pres. George W. Bush.

Governor Leavitt continuously championed collaboration throughout his career, and he authored a book entitled “Finding Allies and Building Alliances.” In the book, he outlines the commonalities of successful alliances from analysis of hundreds of organizations and programs at both the state and federal levels, in government and private sectors, spanning large publicly traded industries and nonprofits. His analysis identified eight elements that are essential for success. Some of these elements are almost obvious, like committed leadership or a common pain point for involved parties, but one in particular is not only critical but is often the most difficult to secure: a “convener of stature.”

He defines this as one who commands the respect of everyone involved such that they all are compelled to sit down at the table. The example he used at the time was the writing of the constitution where all (quarrelling) thirteen states needed to come together, and George Washington – despite not being directly involved in the drafting of the document – served as this convener of stature.

Though I had never used the term, I have looked for a convener of stature for the past five years. I was initially convinced it would be Centra Health, and my app was even designed from the outset with their colors in preparation for what I believed was inevitable integration. I have subsequently asked four consecutive CEOs of our health system to enable Centra to fill this role and have never received even a statement of support. My most recent meeting revolved around that fact that the health system wanted to improve transportation, but it was only interested in regard to its own patients getting to its own providers, or its own employees getting to work.

I looked to the city, because transportation is the number one community health need and is critical to our economy. When that didn’t work, I looked to the bus company, and then to the VA Department of Rail and Public Transportation, with the Secretary of Transportation at the time the wife of a Lynchburg physician. At their direction, I applied for what are called Demonstration Grants beginning in 2017 and then annually for the subsequent two years. Lacking city backing – without a convener of stature – I never received any support.

I approached Roche Diagnostics who had a navigation platform called Navify, supposedly with the intent of enabling more patient centric care for cancer patients and for whom transportation is always an issue. I suggested that if they solved the critical problem for the community, cancer patients – and all other patients, honestly – would look to Roche as an essential component to quality care. I was invited to Indianapolis to sit down with their North American CEO, but it turned out that what they really wanted was for me to use my role as lab director to convince the hospital to switch to their instrumentation and get them a valuable reagent sales contract.

I approached Abbott Laboratories because they built a cloud system called AlinIQ that was designed to enable community connectivity similar to what I was working on. I was invited to their headquarters outside Chicago, and this time I met with an entire team that had been assembled to design systems that could build what they termed a “Healthy Community.” This led to a 3-day work session where a team of five including several VPs flew to our little city and met with a variety of stakeholders and community leaders to discuss the possibility of investing significant capital and resources into Lynchburg as a pilot. I was truly disappointed when not a single representative from Centra Health showed up, but in the end it didn’t matter: The meeting was at the close of 2019, and our world was getting ready to change. Even before the shutdowns, Abbott redirected all of its resources to develop Covid testing platforms (and they sold a lot of them) and dissolved the entire community health initiative.

The list of influential stakeholders that I have approached to serve in this role is grows almost continuously. One thing I have learned is how to more effectively weed out those that have an ulterior motive, and also how to tell when an entity will feign interest simply because our mission statements clearly align, and the community expects that they are actually trying to search for effective solutions. Often these groups, despite their apparent goals, do not actually share a common pain point: the bus company does not suffer when they are unable to provide effective transportation for people in the region, as the people who lack this resource become the justification for ongoing federal and state support. If the problem goes away, so does their reason for existence.

The search continues, as does the development of the comprehensive system that we have designed. In the end, the driving force will be the desire of people in the community to live better, and someone of the appropriate stature will ultimately stand up and enable us to work together and reach this goal.

ACTiN Frequently Asked Questions

What is ACTiN?

Actin is a contractile protein in muscle that is essential for movement, and ACTiN is an Advanced Connected Transportation Network. It is one of several interconnected networks that allows a community to interact with every conceivable transportation asset – including new ones – all in one place. To do this, we use a specially designed smartphone app called MoveUP.

What is MoveUP?

MoveUP was designed as a digital infrastructure for a community that removes the barriers between different types of organizations or even competing organizations, whether for profit or nonprofit. It is an app on the App Store and Google Play (MoveUP – Rides and Deliveries) that is uniquely designed to allow communities to build multiple “Networks” that serve multiple different needs in multiple different ways. MoveUP can manage diverse methods of transportation, deliveries, communication, and even e-commerce, all in one app.

What do you mean by “Networks”?

Transportation needs are just as varied as people, so to serve all those needs, you need different options. MoveUP allows multiple groups of similar assets – such as volunteer drivers – to be coordinated together on what we call a “Network.” A Network has rules and requirements that are chosen by that community so that organizations that use the network can function as they need to. For example, a community may want drivers to have a certain background check process performed before being allowed to transport people, even as a volunteer. MoveUP allows them to set standards like this, or any others that are important to them, or even required by law.

So, this ACTiN is just one network?

Yes: it is what we call the “professional” transportation network. ACTiN has been designed to serve Lynchburg, VA’s public transportation needs. These include rides to medical or other healthcare appointments (nonemergent medical transport), but also rides to work, school, grocery or other shopping, pharmacy, business and entertainment.

Wait a minute… public transportation? Isn’t that why we have buses?

These types of trips are often trips that our current bus system simply cannot do effectively, so it is extremely difficult to live a healthy and happy life without a car. Because of this, transportation remains the most important community health need or “social determinant of health.” If we can fix this and enable effective, safe, reliable transportation at a cost that is lower than what it costs to own and operate a car, this will be an incredible asset to our city, especially for people who can’t afford a car or are unable to drive.

Tell me about these different “Networks”

For this pilot project we are using four main synergistic networks: (1) ACTiN, which is our “professional” transportation network; (2) a Workforce Network; (3) a true rideshare network which we call the Community Friends Network; and (4) a Volunteer Network.

Here are details on each network:

ACTiN Professional Transportation Service:

This network is committed to being able to provide the absolute best service at a very reasonable price. The fleet will be exclusively Model X Teslas. This is for several reasons, but the most important is that the “falcon” door creates the safest way to load or unload a passenger with limited mobility, expanding the customers that we can serve. In addition, the cars have enough space to move 5 adults and they are statistically one of the safest vehicles ever made. The fully electric drive is significantly less expensive to maintain than a conventional internal combustion car or hybrid. Finally, the drivers are salaried and paid at the top of the industry, so there is no concern about whether the trip is “valuable” or not, you will always have a premier experience.

ACTiN Workforce Transportation Network:

The federal government allows employers to fund employee transportation outside of payroll (saving on payroll and income taxes) as much as $270 per month per employee. The problem for smaller cities and rural areas is that we currently lack any effective system where this money can be spent. ACTiN provides that network. We can enable an employee transportation spending account that is only utilized when the ride starts or ends at the user’s place of employment. In this way, the money can be used to pay for one of our pro-run Teslas, or it could be used to pay a driver or coworker who is part of the Community Friend’s Network.

Community Friend’s Network: A True Rideshare. 

A true rideshare network is when people can do just that: share rides, and share the use of their vehicles. Many people think Transportation Network Companies such as Uber and Lyft are “rideshare” companies, but this is not really true, they are actually more like digital taxi companies, as they control the connection between the rider and the driver, they set the price, and they take their cut of the fare. The Community Friend’s Network is very different, as it is really an online or in-app “community” of drivers and riders who can use the technology to better communicate for shared use. First, to get in, everyone has to agree to the rules, which include that no one is a professional driver like a taxi or other transport service. Second, you must obey all laws, and also must be courteous to others. If you break the rules or treat people poorly, you may be kicked out.

Drivers must pass a background check, which is done through the app by our partner company Digisure. The is a rigorous criminal background and driving record check, so you can be sure drivers have been properly vetted. This background check costs $15.

Even riders need to have an in-app verification of their identification, and this is through another of our partners, Persona. This ID verification costs $3.

Once in the network, riders are free to ask their friends for assistance on trips, whether on-demand or prescheduled. We have found that prescheduling rides is much easier in smaller cities and rural areas where there aren’t as many people. Drivers may ask the rider for compensation and the app makes this simple, but there is no preset fare, everyone agrees to the conditions ahead of time, and the network doesn’t have anything to do with it – it’s between the rider and driver.

Because no one is taking a cut and no one is a professional which requires special licensing and insurance, this is the lowest cost transportation system, excepting only the volunteer network.

MoveUP Volunteer Transportation Network

Every community has people in need of transportation for which there is no good solution, and the MoveUP Volunteer Transportation Network is designed to put a dent in this need.

Like the Community Friends Network, drivers must pass the same Digisure background check (you only need to do this once – it is applicable in either network). A major difference is in how the ride requests are entered: in the Volunteer Network, rides can only be requested by designated members of a local participating nonprofit. As an example, the director of Meals on Wheels might request a ride from a client that needs to get to an important appointment. In this way, the drivers know that any requests are legitimate community needs.

Am I only allowed to use one network at a time?  

This is the power of MoveUP’s network architecture: a rider could literally access all 4 networks, all at the same time. For example, a student of a nonprofit vocational education program such as Legacy Education may need a ride to work. If a representative at Legacy entered that ride request, it would be seen by all the drivers on the volunteer network, by all of the drivers in the Community Friend’s Network, it would be eligible for payment through the Workforce Transportation Network, and the professional ACTiN network could be used if none of these other systems had a willing driver. This maximizes the chance that the ride gets done and minimizes the cost.

MoveUP – Connecting the community, one ride at a time.

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.