The Weird State of The Covid-19 World

With all the information out there regarding Covid-19 I feel like this platform can be most useful for (1) reporting on the under-reported stories; (2) reflection on social responses; and (3) point readers to what I find are the best resources amidst the crisis.  

In that spirit. Here is what has my attention today. 

My parents were still shopping and not ordering groceries online or accepting offers from neighbors to get groceries for them a mere two weeks ago. My father is 82 with occasional high blood pressure. My mother is 76 with asthma.  

I was livid with what I viewed as cavalier behavior regarding their own health. I had a weird sense of role reversal as I scolded them like the parent of a know-it-all-I-feel-invincible-teenager might. But under that anger I know there was sadness, grief, and fear. 

Sadness as anyone who has to contemplate losing one or both parents might feel. But in addition to that, the real worry that if something didn’t happen, that the usual rituals of mourning and honoring the dead—key parts of the healing process after loss—would be unavailable to me. Among many things Covid-19 has taken from us, it is the opportunity to grieve together in traditional ways. 

As for my fear, well I was terrified really—terrified and frustrated at my own helplessness. Helpless is a feeling I think a lot of us are dealing with. I know it’s irrational but I (along with other friends trained in public health) as much as we feel some gratitude for our training and tools which allow us to be a service at this time, there is likely an unhealthy sense of personal responsibility. Part of this is our common neurosis within helping professions, our desire to “save the world.” But it’s more acute than usual. As many of my friends grapple with even our own family members who might not be taking the outbreak seriously, we turn to self recrimination: did I not provide them enough information? Was I not clear enough about the risks? Was I not forceful enough, should I have raised my voice more/less? If I can’t “save” my family, what good am I?  

But a lot of this second guessing is based on the premise that we’re a lot more “powerful” than we really are. As I should remember from my public health program, you can provide all the information in the world, but that doesn’t necessarily mean people will make healthy choices. 

Sigh. 

That said, here are the guidelines for safe shopping in the age of Covid-19.[1] Spoiler alert: if you don’t have to, don’t. If you do have to, order what you can online so your trip to the store and up and down the aisles is short as possible. That classic harm reduction principles.  

Be kind. This is a triathlon, not a sprint.

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[1] Readers old enough will remember when the term “safe sex,” seemed novel.

9/11/2001: 3K deaths united the US. 4/17/2020: 125K deaths and we still can’t agree on whether or not it’s a hoax.

With all the information out there regarding Covid-19 I feel like this platform can be most useful for (1) reporting on the under-reported stories; (2) reflection on social responses; and (3) point readers to what I find are the best resources amidst the crisis. 

Reflection: Crises often reveal who we really are. As a country, I feel that we’re struggling as to which America we want to be, a city on a hill or a pit of corruption and moral bankruptcy. The Eric Liu’s excellent piece in the Atlantic last week really got me thinking about how the US markets the former but sadly reverts to the latter. In 2019, as part of the 75th anniversary of WWII and D-Day, I wrote about this dualism in our national character in my book Finding St. Lo and the tension that results.

I didn’t have too many answers in that book, except hope that angels of our better nature would win out.

But as I reflected on Lui’s piece I couldn’t help but remember that on September 12, 2001 I saw a picture of a banner in a Midwest town reading: “WE’RE ALL NEW YORKERS TODAY.” Back then, three thousand deaths united us. 

Contrast that with today when even after a hundred and twenty five thousand deaths (and climbing), we have vast swaths of the US who still believe Covid-19 is a hoax generated by a “deep state.” It speaks to a division that should deeply disturb us.

In 2001, conspiracy theories (like the US gov. being behind the attacks) were confined to a repudiated fringe. In 2020, we have conspiracy theories flourishing in the mainstream and coming from members of US gov. It all makes my head hurt and heart break. That speaks to a disagreement on reality that should alarm us.

But in hopes that this can still be a crisis that serves as a reckoning and course correction (although some days I feel discouraged it won’t be) here are two hopeful trends and one observation. 

Prison Reform: As states are resorting to releasing inmates early from their sentences because they cannot protect them from rampant spread of the virus within prisons, one might hope that this could lead to the shuttering of some prisons altogether. The US incarcerates more people per capital than any country and perhaps as we consider wider amnesties of this sort, we might start asking (1) why are so many people in prisons in the first place and (2) why people of color are so disproportionately over-represented. It’s not like we don’t know the answers to these questions, but this could be an opportunity for true reform of the prison-bail bond-parole-industrial complex that is so deeply flawed and profits off the incarceration of poor people and people of color, without giving them real options for rehabilitation as productive citizens.

Health care reform: The growing number of people losing insurance because of unemployment as well as the sight of makeshift morgues, has to affect public opinion regarding health care. I anticipate more Americans will be in support for the Affordable Care Act a.k.a. Obamacare, and even further expansions of Medicare and Medicaid. There might be further movement on separating health insurance from employment all together. If we’re lucky, this all leads to a more robust and just health care system and even the acknowledgement that health care is a right. Additionally, I was heartened to hear at least some leaders, like Governor Cuomo calling out the fact that fatalities for people of color have been much higher than for others and that its an issue that must be addressed. It’s been encouraging to see this being picked up by new agencies throughout the US.

Venmo and other Digital Apps for Transferring/Spending Money: If you didn’t know how dirty money is . . . you might not want to. Covid-19 has made us hyper vigilant for all the surfaces we touch, screens, knobs, crosswalks, etc . . . An hyper-awareness of how dirty money is, I believe, is likely to follow. This will accelerate the already growing use of apps like Venmo. Sadly, this is another one of those changes/reforms which are more likely to benefit only one side of the digital divide. Having a phone, paypal account, or credit card, are privileges the poor are less likely to have. Being on the wrong side of the digital divide already compromises economic and educational opportunities, now it will pose greater risk to health. 

Be kind. Wash your hands. This is a triathlon, not a sprint.

Hate in the time of Covid-19. A health crisis is not the only one we face.

Dana Milbank, a regular columnist for the Washington Post shares this in his article addressing the heinous incidents of “zoombombing” taking place across the country: 

Rabbi Jeremy Kridel, whose flock in the capital includes several members of my family, was leading a recent Shabbat service for Humanistic Jews. About 10 minutes into the service, one man unmuted himself and started shouting “Jewish scum” and “Heil Hitler.” Before he could be blocked from the call, he lifted up his shirt to reveal a large swastika tattooed on his chest. 

Other hooligans began interrupting, and while the rabbi shut down the virtual service, another man dropped his pants on camera. Remarked Kridel: “This is just another indication of the fact that the current crisis isn’t the only one we face.”  

As disruptive as this crisis has become, it is incumbent upon us to remember that we face other social sicknesses which we cannot ignore. Perhaps, as we settle in to our new norms of social distancing and quarantine to ride out the worst of this pandemic, we must (re)focus on other underlying, chronic, social illnesses.  

And it is not as if social issues such as racial inequalities do not compound the current crisis. All one needs to do is look at this repost from Austin Channing Brown alongside the breakdown in mortality rates in terms of ethnicity from Covid-19 and it is clear the contours of the epidemic follow the fissures of racial and economic injustice.

Wash your hands. Stay Safe. Be kind. Normally I’d say this is a marathon, not a sprint, but perhaps triathlon would be a more apt metaphor, as there are multiple races here to be run.

Covid-19: The Inextricable Link between Health and Social Justice

With all the information out there regarding Covid-19 I feel like this platform can be most useful for (1) reporting on the under-reported stories and (2) point readers to what I find are the best resources amidst the crisis.  

In that spirit. Here is what I’m following. 

Impact in Low Resource Settings: The Washington Post has been a leader in putting these issues out in front. Great article here on impact in developing countries. Coverage of slums, refugee camps, and other informal temporary, but high density settings where predominantly poor people live, has been getting a bit lost in the crush of domestic coverage. Times like these, isolationist folks might ask “Why should we care what is going on in those other countries, we need to pay attention to our own.” It is true we have plenty to worry about here, but as the virus tears through already unstable countries, the ensuing chaos has a way of spreading across borders and affecting us all. In a crisis, desperate refugees are not stopped by national boarders, and we already know viruses and germs are not either. One of my favorite writers, Fareed Zakaria writes about the coming cascade of global crises: “Expect political turmoil, refugees, even revolutions, on a scale we have not seen for decades — not since . . . the Soviet Union collapsed . . . Without some assistance and coordinated effort, countries such as Iraq and Nigeria will explode, which will likely mean the spread of refugees, disease and terrorism beyond their borders.” Full article here.

More than ever, we’re all in this together, whether we admit it or not.

Racial Inequalities: This article relays how hospitals are trying to come up with unbiased decision trees that provide guidance on rationing care amid overwhelming demand. While it is crucial and admirable that medical professionals are doing what they can to eliminate racial bias, the sad truth is, at the individual level they won’t be able to. This is because we already know that underlying health issues, comorbidities such as hypertension, asthma, cardiovascular disease, cancer, etc. . . already are over represented in the poor and especially communities of color. This is one of those prime examples where making decisions on the microlevel do not account for the upstream, macro trends that put people of color at higher risk for disease in the first place. That comes as a result of structural racism reinforced by racist polices and the racist legacy in the US. Already we are seeing troubling examples of how African American’s are already overrepresented in Covid-19 cases link here and here. NPR provides a story on how long standing biases in care are still cropping up and compounding suffering for communities. While anecdotal evidence can be limited in its broad applications, in my own life, of the 13 people within one “degree” of separation from me who have tested positive for Covid-19, 12 of them are black. The Data Research Center has released research connecting the higher death rate from Covid-19 in New Orleans to the complicating factors of poverty and ethnicity.

The take home: social inequalities are drivers of disease. Preexisting injustices which already contribute to health and wealth disparities—suffering for people of color—will contribute and complicate the spread of Covid-19. The fight against “isms” racism, sexism, ableism, is also a fight for the health and thriving of us all.

Comorbidity: Building off the above point, as we learned in the HIV/AIDS epidemic, the other under reported phenomenon right now is the interaction of two or more conditions with Covid-19. In regions of Africa it will be how Covid-19 and Ebola, Covid-19 and malaria, and/or HIV/AIDS interact and complicate the mitigation and treatment picture. Add to this social marginalization and even migration if major areas become unstable due to social unrest, the secondary and tertiary effects will be significant.  

Be kind. Wash your hands. Wear a DIY face mask. This is a marathon, not a sprint.

Covid-19: Politics, Projections, and Mortality

The confluence of politics, culture, and disease is unfolding in real time. The overlap of regions following social distancing guidelines and those which are not, with voting trends and support for the Affordable Care Act and Medicaid expansion is striking and will have life and death consequences.

With all the information out there regarding Covid-19 I feel like this platform can be most useful for (1) highlighting under-reported stories and (2) pointing readers to the best resources amidst the crisis. As a reminder to readers who don’t know. I have a MPH and worked in public health in over a dozen countries for nearly 20 years.

In that spirit, here is what I’m watching. 

Death Rate: The doubling in the US death rate from 1000 to 2000 in just 24 hours was terrifying for me. Doubling in just 24 hours is a red flag. (For a great video on exponential growth in outbreaks check out this link.)    Since then, the rate seems to have “slowed” to doubling roughly 48 to 36 hours. This is still worrisome. The death rates give us some limited data that allows us to extrapolate the prevalence, since mortality is pretty unequivocal and does not require a testing kit. That said, the “hopeful” bit of news here is that mortality rates have a 2 to 5 week lag due to the incubation period of the virus and the time it can take to be fatal. That means patients passing away now are folks who might have caught the virus as long ago as president’s day weekend (mid February). So there is reason to hope that social distancing and enhanced awareness of sanitation and hygiene measures will help. The impact of these low tech solutions is of course blunted by the second phenomenon I’m keeping an eye on.

Patchwork Coverage and Politicized Responses: Initial data is beginning to demonstrate that in at least the Washington State outbreak, the curve have been flattened—at least to a greater extent than New York State’s. However, as there are dozens of states and even more counties without social distancing measures, one region’s success might be compromised by a neighboring one’s delay in acting. 

It’s undeniable, and sobering, to see how the two maps here reflect the extent to which politics will have impact on how the virus spreads. It’s undeniable that (1) regions that are traditionally conservative and “red” states have continued with business as normal approach without limiting travel or implementing social distancing; (2) these are also regions where conservative leaders have resisted expanding Medicaid. At this point the numbers and nature are unstoppable. These regions are going to be walloped. Not to be glib, but the liberal critique that conservatives have been convincing voters in these regions to vote against the ACA and other policies which would be in their best interest, is going to have grisly consequences. The optics of long lines outside hospitals and more makeshift morgues might alter some of the cultural/political/ethnic tribalism politicians have whipped up in order to stay in power in these states. It will be interesting to see where public opinion moves.

Projections: Last Monday’s projections of 100K to 240K deaths have already been revised upwards. This doesn’t surprise me as even those initial projections were “best case” scenarios and the sad truth is that we have not had the proper preparation for a “best case scenario” response. I believe we still need to brace ourselves for anything within the original range presented by the Imperial College of London. Refresher: they projected 2 million deaths in the US alone if nothing was done. 

For best understanding for crisis facing hospitals click here. 

For best explanations for what to expect over the coming months click here. 

Stay tuned. Wash your hands. Stay home when you can. Order groceries by delivery if you can. Thank the grocery clerks, trash collectors, and of course hospital clinic personnel—from nurses/doctors to social workers and admins working who must remain working at this time.  

Be kind. This is a marathon, not a sprint.

Covid-19: Please leave the messaging and modeling to the experts

Readers of this blog would be forgiven for forgetting that I have a Master’s in Public Health. I worked in the field of public health in over a dozen countries for close to twenty years. With that qualifier, please read my message to non-public health scientists jumping in on health messaging during the Covid-19 crisis.

If you are a scientist in a field other than public health, posting your opinions on social media and contributing to the dialogue around Covid-19 as an “expert,” I have a message for you: please stop. Despite your desire to help and your considerable training, in these matters you must hold yourself to the same standard as our colleagues in the medical profession: do no harm. If you can’t be certain your messaging or posting will meet this criterion, then for the good of others, stick to your own discipline and don’t share. Here’s four reasons why. 

1. The right words save lives; the wrong words kill people. This is the excruciating balancing act public health officials assume every time they speak. The stakes are high and we know it. Last week, here in Seattle, meteorologist Cliff Mass decided to use his popular weather blog to second-guess the analysis of epidemiologists. While Cliff Mass’s blog is a local favorite, in his field, if Mass gets a prediction wrong, lives are not on the line with the same urgency. With due respect, he’s not accustomed to these stakes. 

Public health professionals think twice about second-guessing data or offering assurances without basis. We know a misstep is costly. As a result, we parse our messages carefully, or try, as time allows. We have practice being deliberate. Our president does not. He extemporaneously and recklessly riffed on chloroquine as a “treatment” last week. Now people are dead from chloroquine overdosing in Nigeria and Arizona. That is a direct line of causation from his “musings” to their actions. Words have consequences.  

Want an example responsible and reassuring public health communication, one that’s downright inspiring? Look no further than Dr. Emily Landon’s appearance last week at the Chicago mayor’s press conference. She did more good in eight minutes than our president has done in eight weeks. She has practice and experience. It shows. 

2. Non-experts have major gaps in their public health knowledge. This results in bad analysis and poor advice. I don’t ask a carpenter to fix my car. Even if non-experts like Cliff Mass provide caveats that they are not epidemiologists, it’s insufficient. Casual readers grant them more credibility than they deserve. You might like the sound of your own voice. You might be accustomed to people turning to you for advice (I know I am). But ask yourself if your uninformed opinion is truly helping or if it could do harm. A lot of non-experts weighing in muddles public health messaging. We need clarity. When in doubt, stick to your lane. 

Dr. Michael Levitt, (a Nobel Prize winner in chemistry) did not. His recent analysis covered in the LA Times is interesting but of dubious value. It may do harm by providing false reassurance. That bias might kill people. Dr. Levitt’s knowledge of chemistry and biophysics is expansive. That expertise is not transferable to disease outbreaks and health education. His models may be incomplete. We don’t know if they account for the irrationality of human nature or the behavior of panicked crowds. Levitt and Mass have not studied the lessons learned from thousands of previous public-health messaging campaigns or disease outbreaks. If either man had, they would be cognizant of the delicacy and clarity needed in these moments. But they’re not.  

This gap becomes obvious when Mass makes comparisons between traffic safety and virus preparedness. He cites that a few thousand traffic fatalities each year do not lead us to shutting down highways. This is correct but misleading. The threat of deaths from Covid-19 is in the millions, not thousands. Three-hundred and sixty-four deaths were enough to remove the 737 Max from service. The traffic fatality analogy might satisfy the writer’s own need to be heard, but it is flawed. A vulnerable public deserves better. 

3. The challenge in public health is that when it works, nothing happens. To paraphrase Dr. Emily Landon, if this all ends up seeming like it was for nothing, then that means success—because nothing happened to you or your family. This is the sad irony of public health. It’s why we take it for granted. Success is normal, mundane life. We take the kids to school. We drive to work. We drink in bars. We eat in restaurants. Water flows from taps and toilets flush. Those things make for terrible Hollywood movies.  

But public health comprises all the vital background things we need so we can enjoy bars, restaurants, and movies. Public health workers are the unsung heroes. They aren’t portrayed in long-running dramas on NBC or CBS the way doctors are. When public health works, it’s boring to the rest of us. We should all be so lucky. With their intellectual peacock displays, outside “experts” undermine the men and women of public health departments—and certainly those workers are too busy right now (and too humble) to tell meteorologists and biochemists how to do their jobs. 

4. Optimistic comparisons from China and South Korea are not analogous to the US. I understand the motivation of the op-ed writer in the LA Times who cited Dr. Levitt’s research and his choice to use the Nobel laureate’s quote “We’re going to be fine.” Messages to remain calm are valuable. But we also have to be cautious about drawing too many conclusions from China and South Korea. Both countries had wildly different initial conditions than we have here in the US. China is an authoritarian government that thinks nothing of trampling individual rights. The draconian measures there are not possible here. South Korea benefited from wide-spread testing. They also benefited from a fast-acting government. In the US, we don’t have either. What we do have is an unscrupulous administration led by a president with a long list of lies, who displays pathological deficits in his ability to process empathy or shame.

To non-public-health scientists: you have scruples, you have education, you have an ability to reason and to listen. If you didn’t, you wouldn’t be where you are. Don’t put yourself in the same category as a historically bad and amoral president. Please, with urgency and respect, stick to your own discipline. Do no harm. Leave the messaging and modeling to the experts.