Musings of a Radical Cooperatist

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Current understanding of COVID-19:

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

Some Important considerations:

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

Recommendations:

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

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

John M. Salmon IV, MD

References:

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

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

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

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

What Does Solitary Confinement Do To Your Mind?

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

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

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

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 world – in 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; p_interaction=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.

“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:

Masks:

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.     

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.

If I see another headline talking about increasing COVID cases, I think I may lose what little is left of my sanity. Why do you even put that out there? That’s a rhetorical question. We all know why you do it: because it’s scary and gets people to click on your so-called news page, even though you are telling us nothing of value but are instead trying to stoke the smoldering remains of a fire almost put out by riots.

Lets look at a case study: my dad.

My father is now a statistic in all of this: he is a recent COVID case that required hospitalization. At 80, his reported survival prognosis should have been about 50%. But he didn’t die, he beat it. Except he didn’t, because the whole thing ruined him. A few months ago, we would sit and talk about this and that, and I would keep him up on his grand-kids. He was having more trouble getting around, so big trips like the one we took in the fall to watch our friend win a national championship in a Formula Mazda, those had given way to local visits at family homes.

Now he can barely walk. And I have no idea how much he understands of what is going on, because I am not allowed to see him. Yes, I can Facetime or try some other so-called connection, but these things don’t work for people with dementia, and the subtle facial movements that let me know he understands what I am saying, I have to be sitting there to register those. And that’s not allowed.

All because of this virus. Except it wasn’t, because nothing that has happened to him has been a result of the virus. Everything has been result of our reaction to the virus.

COVID cases are increasing, and my dad is one of those. He got the virus and had to be hospitalized. Except he didn’t have to be hospitalized because of the virus, he had to be hospitalized because of our reaction to the virus. Because if you test positive, you have to be isolated, even if you are already isolated. Well, just because.

Here is a more appropriate headline: “The widespread torture of the elderly through forced isolation enters its forth month.”

When I went to deliver a TV to my father last week, another female resident was pleading with her husband by telephone through the closed glass entry door to get her out. I wasn’t there long enough to know if he was going to acquiesce, but the fear in his eyes when I walked past them makes me think she remains trapped. This mandatory isolation is what led to the dramatic decompensation of my father, and we were forced to transfer him to a memory care unit that is capable of better managing dementia patients. And that transfer required a COVID test, and he tested positive, so we added some insult to injury and put him in lock-down in the hospital. And he left what was left of him behind.

Of course, this isolation is necessary to keep everyone safe, but someone explain to me this logic: the bulk of my father’s belongings – including his bed and recliner and personal photos – are trapped in his old room because they are afraid that allowing a moving crew in could also bring in the virus and kill everyone. Wait, that’s because we terrified everyone by saying that the virus would live on walls for days and days (which is complete BS).   

Is my father the only person suffering from dementia? That’s a rhetorical question too: there are about 1.5 million people in nursing homes in the US, and something like half of them have dementia, which means we have similarly devastated something like 750,000 people, and the women in the foyer is part of the other 750,000, and she didn’t seem overly thrilled with her plight.

But hey, it’s all been for the greater good. I mean millions would have died if we hadn’t shut the world down, so while we continue to torture and kill, we need to remember all the people we saved! Because that’s what the math models said, and that’s what the experts told us, and they are already celebrating the stats of the people whose lives we made so much better.

Like my dad. Because, while this isolation nearly killed him, at least the virus didn’t, and that’s why we did all of this, to keep him and all the other residents safe.

Except none of it did shit.

Everything bad that has happened to him, the loss of mobility, the agitation and inappropriate behavior, the doubling of his meds and the quadrupling of the dosing, the loss of months of his life – including the only chance I had to show him that the app that I built in his honor when it went live – all of it is a result of our reaction to a virus, our attempts to stop the spread.

And none of it worked. He got it anyway. Right under your nose, right through your futile mandates, without any of the symptoms you have used to scare us all into submission, and without so much as causing a sniffle in anyone else around him. This disease has killed people, but it has also been used to promote careers, to sway voter opinions, to fund useless industry responses to pointless government grants, to generate headlines and advertising revenue, and to do immeasurable harm to millions and millions of people many orders of magnitude beyond the capabilities of the disease itself. Our reactions have been a combination of societal fear and a drive to capitalize on that fear.

Allowing others to be hurt to protect yourself – that’s cowardice. Allowing others to be hurt because you don’t know what you are doing and refuse to admit it – that’s pure incompetence. Hurting others to advance your career or for financial gain…

To the cowardly, incompetent, self-serving policy makers that are responsible for this fiasco: I am coming for you. I am going to show people how we can stand strong together without you, how we can do things cooperatively using logic over fear, and how we can degrade our dependence on you, so that you can’t use us like this anymore. You know who you are, and I am coming for you, and you will never know what hit you, because aren’t smart enough to get it.

And I want my father back, you sunovabitch.      

Here comes the first of those angry rants I promised, and you people deserve it. I have been sitting by as you tear my world apart with the same endless fighting, so I am done pulling punches or being politically correct. I don’t care who you think you are, but I have news for you: not everyone thinks like you. And when you try to make them, it only makes it worse.  So just stop already.  Politics, religion, healthcare, and racism.

Healthcare?  We are now fighting about healthcare???

We have been fighting about politics and religion since the dawn of man, and we have managed to twine them together throughout. I have been arguing with the same friends over the same issues since college (I don’t think I really gave any of it much thought before then). This isn’t going to change, so stop trying to get it to change. No one is going to win – we aren’t going to fight the ideological differences out of our philosophical foes. Yet we continue swinging with this false pretense that we have two parties with two philosophies so if we argue about it all we will somehow meet in the middle.

Except meeting in the middle is not an option. No one from either side is allowed to meet in the middle on anything, even if the result is something that works, because that’s not what its about. It’s about winning, it’s about imposing one way of thinking on the other side. Because our side is the right way, and if you can’t see that, then you just need to be stopped.

Healthcare? We managed to bring healthcare into this??? Oh boy did we ever. And this time, it’s not just about how we pay for it (which was bad enough but is really just an extension of the whole politics and religion thing), no, now it’s how we actually treat a disease. We are fighting – literally swinging punches and even shooting each other – over how we should treat a disease.

Do you know how much trouble I am having leaving expletives out of this? If anything counts as free-society shitting the bed, this is it.

Let me say it again as it relates to the treatment of a disease: not everyone thinks like you. And when you try to make them, it only makes it worse.  So just stop already.

What really pisses me off is when people try to act like the damage from the fighting is not their fault when it was obvious it was coming, like they deserve to stand on the moral high-ground that is their ideology above the carnage and absolve themselves of any responsibility. If you have put yourself in a position of leadership, then lead, dammit. And leading means understanding where the path you are leading us on actually goes. If it will descend into a massive societal brawl, you need to think about that.

I argued against mandating the wearing of masks primarily because the guaranteed outcome: people were going to fight about it. Well guess what, they did. And how. And those that supported the mandate will say that the actions of the ones who actually did the fighting are to blame, that they went ridiculously off the rails.  

No shit. That’s precisely how violence goes. No matter how right you think you are, other people are going to think differently. When you try to force them to be like you, they are going to fight you.

Then we brought race into it, which is pretty common because as much as things have changed in America, we can still draw solid correlations with all sorts of inequities along racial lines, including healthcare. But this time we are taking it to the next level: we aren’t just going to make it about fighting racism, it’s going to be about how we fight racism. There is only one true way to eliminate racism, and if you think you have some other ideology, please allow me to beat those thoughts from your head.  

Human nature is what it is. It’s not going to change. You aren’t going to fight it out and end up with a bunch of people that all think alike, you are just going to keep fighting. You are all acting like bunch of toddlers right before naptime, and you should all be ashamed. No, you don’t get to watch a well-edited video of your favorite leader spouting off about how they have the right way and if only these other misguided losers would stop fighting us the world would be a better place, because you are just as much a part of the problem as all of them.

What we need now is real leadership, and that’s obviously not going to come from the people we have been looking to as leaders. Which leaves us only one choice: we do it ourselves. I know this seems impossible, but it’s not. It is going to require that we wake up and stop being manipulated into fighting for something – no matter what it is – because none of it is helping the situation for any of us. We need to connect, but not through the toxic cesspool that is social media, we need to meet as people, different people with different ideologies and philosophies and backgrounds and struggles and goals and dreams, and we need to start actually living again.

We have dug ourselves into a pretty deep hole now, so the sooner we recognize the depths of our predicament, the sooner we can start trying to get out. And to do that, we are going to have to stand on each other’s backs, no matter what we think.  

There are no non-essential jobs. Period. Life is more than just being alive; it is truly how you live it. Your job – what you do and how you fit into the complex machine that is society – is fundamental to who you are. Having recently left a career behind completely – something I had no intention of doing – I can tell you that I am not sure I will ever truly get over it.

Watch this video, all the way through.

Since the very first time I saw this story, this guy has been an inspiration to me. If anyone could have gone through life completely dependent on others, it’s Richie Parker. But instead, he used his brilliance and determination to not just become completely independent, but to excel. I don’t care if the guy ended up selling dead flowers on a street corner to make it work, his would still be an amazing story, so don’t try to tell me that what he does is not essential.

I know others. Like Richie, Marcus was missing something at birth: the lenses in his eyes. This rendered him, for all intents and purposes, blind. And like Ritchie, Marcus could have gone his entire life dependent on others. But he didn’t, instead he has gone well beyond just being independent with a job and a home and hobbies but working to help others who face this same disability. Like Ritchie, he is more than a gear in the machine; his cog spins a little faster than the rest, pushing on the works, adding to the momentum that keeps it all moving.

Marcus’s father was a teacher. How many kids did he help develop their own independence? I think we would all agree that the job he did was essential, but who are we to say the work he did – the people he helped grow into independent adults – who are we to say those people don’t matter? That the places they have found in the complexities of our world are unimportant? If we don’t let them live, what was it all for?

People like Richie and Marcus and Steve inspire and enable others to do more and be better. That’s how society works. We are all interconnected, and these connections are what make the difference between just being alive and living. There are no non-essential jobs because the people doing those jobs are essential. Somehow, we are going to have to get past our fear of death so that we can let people live again, to let the works of people like Richie and Marcus and Steve of the world continue to spin the gears a little faster.  

I spent most of my career in cancer diagnostics. Yes, there are other types of biopsies and surgical specimens looking for a variety of infectious or inflammatory diseases, but the bulk of the focus of surgical pathology is ruling out, screening for, or helping to direct the therapy of cancer.

Cancer is a scary disease. My mom was terrified of it. I am sure it didn’t help that it took both her parents. Back then, chemotherapy was not too good. At the beginning of my career, I quickly adopted the mindset that no one was ever going to give me chemotherapy. Feeling really shitty for weeks or months before dying anyway was just an ordeal I would gladly skip out on. But that’s just me, and different people have different ideas.

I use my wife and I as examples of different polar-opposite philosophies: my wife’s life revolves around her girls (so I constantly compete with the dog and the cat for the third wrung on her ladder). If faced with a terminal diagnosis, her primary goal would be time. She would want to watch the events in the life of her children unfold, and she would fight like nobody’s business for every precious second.

I would go with the squirrel suit.

My goals are different, and I want to face life on my own terms. I want to teach my kids by example, to encourage them to look where they want to go and reach for that goal with fierce tenacity. And that’s how I want them to remember me. Hence the squirrel suit. I’d really like one of those jet wings, but I hear they are tricky to fly and I have no experience so the tumble followed by vomit followed by my death and the destruction of some contraption that can’t be cheap…a man’s got to know his limitations. The wingsuit is a pretty binary trip that either ends well (in which case it was awesome and you get to go again) or it just ends.

I never really thought about dementia until it hit my mom. How ironic that she was stricken young with the one disease that is arguably worse than the cancer she feared. And now as my dad suffers with a different flavor of the same shit sandwich, I find I fear cancer very little now. Diseases like cancer are terrible and cause tremendous suffering and death. But there is one crucial difference: control.

The horrifying reality of dementia is that the victim is powerless. By the time you have any idea what is happening, the ability to decide your own fate is passed. I would prefer to avoid both suffering and death, but I would accept either or both in order to maintain control.

My hypothesis on poverty can be over-simplified as a lack of connections, but I find myself wondering if lack of control is another component. For sure, no one wants to lose control of their own fate.

And maybe a little of that is happening to us all right now.

We have been at this for weeks, trying to assess this new threat, how bad is it really, who is at risk, what will it do to me, how do I keep from getting sick. People deal with these things differently and for a variety of reasons. Some want to take shelter and wait it out, suffering now in the hopes that the storm will pass, biding for time. Others want to stare it in the face, and if it doesn’t go well, at least they go out on their own terms. And the more the stakes rise, the more polarized we become. Unlike some theoretical discussion about an issue that doesn’t genuinely impact our lives, this shit is very, very real.

Many have prioritized keeping people safe, but maybe what people really want is a bit of control. Is that too much to ask?

When you have lost almost all your control, sometimes it’s the little things that help you keep some semblance of self. Maybe what your neighbor needs right about now is to feel like they still have some say in their own destiny. Maybe sheltering at home is not the way they want to face a crisis. Maybe what’s best for some is simply allowing them some shred of independence. But it’s not about you, it’s about protecting others, right?

My dad has lost every spec of control. For two months he has been locked up in assisted living, suffering in isolation. He had already been having difficulty expressing himself, of finding the words he wanted to say, but now he can barely complete a sentence. Still, I don’t need the words to know what he is thinking: this isn’t what I want, this isn’t how I want to go out. And he is not alone, as many of our most vulnerable would choose to face life on their own terms, even now. I know I am really struggling with this strategy of sacrificing our kids to save our elderly.

It all reminds me of a bit by George Carlin: “Live and let live, that’s my motto. Anyone doesn’t agree with that, take ‘em, out back and shoot the MF.” Isn’t that what I am hearing?

I’ll put it in print now – like an advance directive – so when the time comes it’s all recorded: don’t even think about doing this for me, because if I had control, this is not the choice I would make.

A wise friend recently pointed out that my blog is linked to the MoveUP’s Facebook page and suggested that mixing politics and business may not be a good plan. This is not the first excellent advice that I have chosen to ignore, however the intention of all of this writing is to be the mission statement for the company we are building. The hope is that we will look back and see the philosophy that shaped our work as opposed to a marketing statement crafted post-production to try to instill faith in a customer base. Everything that has influenced how we got where we are today and our path to the end goal is here.

MoveUP didn’t actually start as a transportation solution, it started as an individualized solution for connections. Connections are valuable. They are powerful. Enabling people to make connections on their own terms for their own benefit, that’s MoveUP. It just so happens that the value of connections extends to transportation, where a person might connect with someone who is able to get that someone – or someone else or even something – someplace else.   

The name MoveUP doesn’t refer to moving people or even stuff, it refers to this idea that we might evolve as a society by improving how we connect. We believe that intelligently designing and implementing a platform that allows us to live together cooperatively could facilitate reaching our maximum unified potential.

To illustrate this, I want to introduce the next phase of MoveUP’s development: PHISion.

PHISion is a Personal Health Information Solution. It is a way for you to collect and manage various data that might be important to your health, all completely controlled by you. It also allows you to connect this data to whomever you wish- family, friends, or maybe a doctor – on your terms, and with the utmost in security.

This is far from the first health app, but it is completely different because it was designed from the beginning to enable you to live better on your terms. Every other system was designed from the beginning to have some control over your data, because that data – and the ability to connect it to other things or share it with other people – that has value. We will let you be the one to realize that value.  

Like every component in MoveUP, PHISion’s functionality will expand over time, but its core components are: weight, resting heart rate, and gps location history.

Today, the discussion of weight is consumed with obesity, but the untapped potential is monitoring for unintended weight loss. Most lung cancer patients present with unintended weight loss, and other types of cancer may do the same. No, unintended weight loss does not mean someone has cancer, but in today’s society, losing weight without trying raises a red flag. PHISion will allow you to easily store your weight securely where only you can access it. Meanwhile, an algorithm steadily monitors how you are doing and can alert you if it appears there could be a problem. How that works – an alert just for you, or maybe a simple message to a loved one or your doctor, or maybe a combination depending on the level of concern – that’s completely up to you. Note that the actual data – how much you weigh – is not important (nor is data like your address or SSN). It’s just a screen to safely and easily help catch potentially serious diseases a bit earlier.

Resting heart rate has similar potential, because unexplained increases can indicate an underlying health problem like evolving anemia or poor management of a chronic disease like diabetes. Resting heart rate is like an engine at idle and can be measured by most health trackers. The data can be stored securely, and a similar algorithm can initiate a very similar alert with the same flexibility, security, and individual control.

Though a potentially powerful tool, storing historical gps data – tracking your location – is a very sensitive discussion that raises numerous ethical issues concerning privacy. PHISion eliminates those worries by giving you complete control over your data in such a way that no one can access it without your consent. Furthermore, it allows you to share that data in a deidentified form on your terms. For example, allowing researchers to see if there is overlap in location between one person with a disease as compared to other people with the same disease can unlock patterns of spread or contributing factors that can to effective strategies of prevention or even management. Notice that it doesn’t matter who the people are – the data can be stripped of names and other sensitive information – it is simply a matter of connecting the dots to the diagnosis.

There are important considerations for all of this, and PHISion will walk you through things you may not have thought about, like how to read a consent form for a research study before turning over your potentially sensitive information. A gps data file can never be truly de-identified because it will include information like your home and work that someone could use to figure out who you are. That means you want to be careful about who you share this information with, what they intend to do with it, and what assurances they can provide you that you and your information will stay safe. These are the types of issues a medical research team is required to manage, but industry often lacks this level of oversight. PHISion and MoveUP were envisioned to help you understand how to get the most out of what you have with unmatched safety.

As usual, I made myself the test subject and have been tracking my own weight and resting heart rate for several years. I wanted to evaluate the overall cost and difficulty, because it doesn’t matter how powerful a tool is if no one will use it or many can’t afford it. And these three metrics are just the beginning: the underlying architecture will allow for you to manage anything related to your health, from medical records to laboratory data, even social history that updates in real time using secure connections to other family members.

Because all of this was integral to the fundamental intent, it all comes down to connections: connections to what is important to you, to who is important to you, to the what’s and where’s and when’s that are important to you. It’s all designed so that we can MoveUP.

There are a lot of diagrams out there trying to make complex stuff easier to digest. It’s got benefits, but one of our biggest problems is this need to have everything explained in a headline or fit on a single slide, and the world just doesn’t work like that. To explain, I made my own diagram.

Actually, I stole someone else’s and modded it. (Maybe that Fast and Furious marathon wasn’t such a good idea).

This is intending to explain the complexities of public health. The most important lesson: it’s complicated.

On the left you will see a wonderful rendering of blue and green peeps participating in increasing restrictions to prevent the spread of COVID. The first modification I made was to remove the numbers as the original diagram had percentages that were supposed to be the exact risk of transmission in each of these scenarios. I did this because these numbers were not what we would call in the scientific world “significant figures.” I am taking a lot of license with that term here, but let’s just say there is no way anyone should regard the reported figures as factual for a couple dozen different reasons. But don’t worry, because no one will deny that we have ranked our blue and green citizens in decreasing order of risk of transmission, starting at no-holds-barred rock concerts ad nauseum and ending with our unfortunate neighbors hermetically sealed in their homes.

The original document also attempted to discriminate between uninfected and asymptomatic carriers, a distinction which is theoretical at best in the real world. On this, let’s just agree to disagree and instead recognize that one cloth mask between our subjects is better than none, and not as good as two. And with a few quick clicks in Microsoft’s ubiquitous Paint, we have arrived at a universal consensus, at least as it applies to the transmission of virus. 

But, as I stated, it’s complicated.

The next column refers to the social mandates required in a free society to achieve these scenarios, and then a list of major categories of repercussions: public fear, the public impression of the government, the economic impact, the psychosocial impact, the impact on education within the community, and the impact on the management of all of the other disease processes like cancer, heart disease, and diabetes.

The goal with our decisions is supposed to be the best overall outcome. The problem we often face with a complicated chart like this is that you can’t just look at one column and select the best answer, because you have to balance the real-world repercussions of that choice. Furthermore, we have to let go of the ideal: regardless of what anyone thinks should happen, it’s what does happen that matters. So even if you believe that everyone should get on board with a particular idea, if that’s not going to happen, then it doesn’t matter why, it’s just not going to happen.

There has been a lot of discussion of public fear. I want to point out something on this little chart: note that I estimated fear higher in the situation where we do nothing. That’s because the scary ship has sailed. People are already afraid, so if we just shrugged and said, “Move along, please, nothing to see here!” That would actually make things worse. People want guidance and reassurance, and things like masks make some people feel more comfortable. That’s real, and we shouldn’t pretend there is no risk when there is risk.

Well then, what is our leadership to do? We are now slipping below the murky surface in the turbulent sea of politics. I often say that we need to stop looking to our government as a source of solutions. That doesn’t mean that no one in government is a good person or wants to do good things or has great ideas, it’s that politics is truly two big parties that are entities in their own right, and individuals are no more capable of controlling those entities than an individual cell in your body. Which means these parties are going to act in their own collective self-interest regardless, which is extremely unfortunate, because it’s times like these when we need to have truly effective leaders.

If you really want good outcomes, then you want everyone (or as many people as you can) united, and that’s the problem with our current system. When the pollical party’s primary objective is to win an election, then the outcome only matters as it relates to that election. We all know that a massive disaster can be a huge boon for a pollical party so long as the public blames the devastation on the opposition. Our current situation has become political, so what our leaders do has an effect, not just because of the policy itself, but because of the public reaction. That reaction is real and it has to be considered in the equation. And no, you don’t get to say, “but this way is the right way!” Because it doesn’t matter. If a policy is going to result in rioting in the streets, then the rioting and the resulting destruction has to be included in the discussion. If locking people in their houses slows the spread of disease but results in a violent divide of the people, then these factors have to be weighed.

I am not going to spend much time on the economic component in this, except to say that if you are reading this from the comfort of your own secure home, you are probably going to need some empathy to contribute in a meaningful way.

The social – or really psychosocial – impact is one that is hard to quantify but may be the most important of all. If you look at societal issues like poverty, you come to the realization that a lot of measurables – incomes, cost of living, resources, employment rates – these don’t necessarily correlate with happiness. But if you think on the goals of the founding fathers, it was prominently featured: life, liberty and the pursuit of – you guessed it – happiness. This is so hard to achieve in the real world, where people’s views and perspectives differ, and it’s all been muddled by the insertion of for-profit social media platforms that capitalize on our innate attraction to issues that resonate with our fundamental beliefs, profiting from our texted, emoji-laden conflict.

Public schools and small businesses have a lot in common: both are major cogs in the machinery of society, and they both struggle in the best of times. Neither is capable of successfully adapting to the pressures we have placed on them. If you don’t understand what I mean, go to your favorite establishment and watch them try to modify their business model from one of multiple servers waiting on a variety of customer tables to a single input of a phone line while attempting to manage curb-side or delivery service as a primary mode of business when it represented a sliver of what they did in their prior life. I am going to vehemently disagree with the people who think the failure of restaurants is just part of the circle of life, but when it comes to schools, a lack of appreciation of the importance of having an educated society marks you as a irrecoverable dullard. Schools already have an impossible task, but forcing measures like a continuous maintenance of six feet between students at all times will render them completely ineffective, and the most severely impacted will be those already at the bottom of the pile. The repercussion of this will be almost irrecoverable.

The other health concern column is intended to include things like cancer screening and care, which has been supplemented by our focus on the care of patients with COVID. If we keep you safe from this virus only to have you die of some other (potentially preventable) disease like suicide, what do we put on the scoreboard? 

When you put it all together, you start to see why a little compromise goes a long way. Again, if you just focus on one issue and demand an extreme – everyone should wear a mask all the time and I just don’t give a damn if you don’t like it – there are very real and devastating repercussions that come when you force the issue. It all depends on whether the best public health outcome is your goal, or whether you absolutely have to win this particular issue, no exceptions.

So, what’s it gonna be?

By the way, there are times when you don’t really want to be right, and this would be one of those times. In the 36 hours since the completion of my last blog where I discuss at length the risks of ineffective facsimiles, my father had a routine screen prior to being transferred from his current spot in an assisted living center to a true memory care center where his dementia – markedly exacerbated by isolation – can be better managed. And he tested positive for COVID-19. Which landed him immediately in the lock-down ward in the hospital, which will turn this isolation thing up to eleven. Though it might be that his condition, his rapid decline, and the lost social interactions – like my being able to explain to him that I published the app I envisioned to help him have a better life – these were insignificant loses next to the need to protect his vulnerable neighbors. Perhaps, but these are very real to me and I want them to be reflected on that hypothetical scoreboard.  

Whereupon you scream: How is this even possible, his facility was locked down!

No, it just looked like it was locked down – an ineffective facsimile – because we don’t do real lock-downs here, it’s just not possible.

Well, you say, who is to blame?

Who the actual-F cares? Policies were put in place – relative isolation – in an attempt to protect the very vulnerable inhabitants, but these only delayed the inevitable. To truly stop the spread of a virus in society, we have to literally stop society – see the bottom row on the chart – and that’s not compatible with life. If you fixate only on one column and ignore the rest, you lose sight of all of the devastation that happens as you fail to achieve your goal.

But someone must have violated a policy! 

Yeah, I imagine they did, but only because the plan wasn’t realistic. At the end of the day, it doesn’t matter what you are trying to achieve, the only thing that matters is what actually happens.

The better plan is to accept the realities of the risks and dangers inherent in life and try to establish practices that do the most good while causing the least amount of damage.

There are no guarantees in life, but letting people live as they want to live is generally the safe bet.