CORONAVIRUS UPDATE ARCHIVES

COVID-19 Update 10: Re-Opening v. Continued Lockdown and Pandemic Politicization May 15, 2020

This is an opinion piece, so it is critical to know about the source of the opinions. I am a board-certified Infectious Diseases specialist, med school graduated in 1975 and full-time in practice 39 years. I was fully engaged in the HIV epidemic since it started 9 months after I opened my practice. For the first few years, we did not know what caused the illness and even after we did, with only one effective medicine, it was a virtually 100% fatal illness if you acquired HIV. At the time, we were unclear for years on whether we were at substantial risk, as we managed the sickest people you can imagine with pneumonia, bloody diarrhea, and multi-system organ failure on whom one performed spinal taps, bone marrow procedures, and other sampling procedures that exposed us to their blood and other body fluids. We were in this “at risk” exposed position for years, not months, as with SARS-CoV-2. Some physicians refused to see such patients. We were not called “heroes”. During COVID-19, I have maintained an open office, even performing SARS-CoV-2 diagnostic testing. I suppose all of this qualifies me as a first-responder. I am uncomfortable with the “hero” label being thrown about, as I am sure are most military people. We do what we do out of duty and sense of mission. With respect to COVID-19, I am 70yrs-old, and so in the “at risk for death” group. Enough about me, other than that COVID-19 is a daily part of my reality, not just a “News Alert” banner on TV.

I think it is time for the medical profession to comment on the facts and to not allow politicians to manipulate a public health crisis for their political power self-interests. Our profession cannot stand by silently on this, though we are trained and so, inclined, to stand neutral on all things that would in any way bias us (gender, sexual orientation, race, etc.) in rendering care and performing professionally. However, there is a point where silence is agreement. If the messaging by the media and public policy leadership appears to distort or exploit facts, medically, economically, and societally in ways inimical to the public’s best interests, then the profession is obligated to join in the conversation. This is the spirit of this communication.

The Facts

In earlier COVID-19 Updates, I made it clear that our biggest problem was that we were in uncharted territory. We had a novel virus with incredible transmissibility; rampant, multi-focal worldwide outbreaks; and the only data from China, with their track record of disinformation, misinformation, and oppression of free speech. Could it be worse?

Well, we have now had our own epidemic with our own data. What can we say about COVID-19?

1. The overall death rate is probably 0.6% or less (we cannot know until we have tested a large part of the population, since up to 80% infected have little or no illness); that’s 6 per 1000 infected, or less (seasonal flu is about 0.1%).

2. 48% of deaths are people over 65, almost all unhealthy prior to infection. The average age of COVID-19 death is 82 yrs– a little higher than normal U.S. life expectancy.
   Most deaths have been in extremely old people in nursing homes, most of whom are “existing”, if we are honest. Between 25-44 yrs-old, about 1.25% death rate; 45-64 yrs-old, about 8%

3. There is virtually no death risk to medically normal people 18 yrs and younger; less than 1% are hospitalized.

4. For about 80% of COVID-19 infected people, it is a non-event.

5. This is more than likely the worst of the COVID-19 phenomenon, even though there will surely be several more waves of outbreak over the next 2-3 years, until the virus is no longer novel. The only exception to this statement is if the virus mutates to a different form. The mutation rate of COVID-19 is several fold less than seasonal flu. And, mutation tends toward less formidable forms of a virus for its host– humans in this case. Why? A virus that kills its host kills itself- a suicide virus. So, it is in the biological interests of a life form, such as a virus, to grow to a symbiotic (collaborative) relationship with its host.
   As the virus passages through more and more human bodies, those humans should acquire immunity, so less humans to infect. So, subsequent virus outbreak waves should be less severe. And, as time goes by and better diagnostic testing is readily available; the healthcare system has a rapid, organized response to new case hotspots; and treatment options have been found, time is on our side to manage COVID-19 without drastic societal containment measures like lockdowns.

6. Most COVID-19 infections are likely acquired in the household, not when we are out and about.

7. Herd Immunity: It is likely that if a population can have been vaccinated by infection with COVID-19 (the virus as vaccine) such that 60% or more have protective antibodies, COVID-19 will no longer be novel and humanity and the virus will have reached a balance of co-existence, as is the case with many infectious diseases. Our entire current “crisis” is due to the biological “novelty” of COVID-19 virus.

When the above facts are appreciated, it is impossible to justify putting our entire country and way of life at risk to deal with it. Currently, we seem to have lost the original goal of the mission. We were never intending to do the impossible- eliminate such a highly transmissible and widespread virus. The cat was out of the bag when it reached the U.S. It was getting here from China, or any of a number of countries, and there were thousands of Americans infected before the first case of illness was recognized. Our aim was to “flatten the curve”; to slow the rate of increase of new cases to match the population’s illness burden to our hospital beds, ventilators, medications and supplies, and medical professional staff. We wanted to never have to ration care – to need to choose who would live or who would die based on limited medical equipment, supplies, or facilities, as happened in Italy’s socialized healthcare system.

Well, we flattened the curve, even in the worst epidemic hotspots of New York City and New Jersey and elsewhere. Yet, there are continued assertions that we must stay locked down, else be labeled cold-hearted murderers of the elderly. Moralistic rhetoric is used to intimidate the US citizenry into conformity and compliance with governors’ executive orders (but not laws). Weaponized morality is at play. I will discuss this further toward the end.

Let’s look at the likely picture of continued lockdown versus controlled, responsible re-opening or our society.

Lockdown

1. Jobs lost, possibly permanently, as some businesses cannot restart. If only 25% of the over 33 million newly unemployed, that would be just over 8 million people dependent on government entitlements and impoverished indefinitely (and soon accustomed to ongoing checks from the rest of us).

2. Major lost tax base of the population, and so funds to support Social Security, Medicare, Medicaid, military services, etc. What happens when the Treasury is empty?

3. Hospital and medical practice closures, with a much lower quality and accessible healthcare system. Employer-based health insurance policy losses now are projected to be 27 million. Where do they go? What about those non-COVID-19 medical emergencies that could cost a life?

4. Major disruption in the education and career development of our children and young adults-our future.

5. Homes, vehicles, and lifetime savings lost.

6. Collateral loss of lives– due to suicides, substance abuse, alcohol abuse, criminality, violence, decreased access to emergency medical care (strokes, heart attacks, trauma care, etc.). In the last year of the Great Depression, there was a 28% increase in yearly suicides; would be about 8,800 extra deaths with today’s population (about 46,000 total).

When public officials assert that opening society will cause deaths from COVID-19, they never mention the collateral damage and deaths from extreme, protracted containment efforts. Why? See below.

Those who insist on lockdown moralize that “every life is precious” and one life lost is too much. Such language is crafted so you cannot disagree with it (or be labeled “murderer”), and so with their agenda. It is the same game played with the “racist” label. Well, then, if every life is precious and invaluable, we need to immediately stop all smoking, go back to alcohol Prohibition, make the speed limit 5 mph (40,000 vehicular deaths/yr.), and lockdown every flu season (average 25,000- 62,000 deaths, annually). They are selling “risk-free” living propaganda. There never has been such a thing. And each of us, living in a community, among and dependent on others, subconsciously accept risk to ourselves and our children- whenever we are in a public gathering, go to school, enter a vehicle, dine out, take a swim. Communicable viral and bacterial respiratory illnesses, food poisoning, vehicular trauma, violence, undergoing medical/surgical treatment and on and on… with serious illness or death always in the background. We just subconsciously suspend reality (as in watching a movie) because it is not a functional way to live, always in dread or anxious about risk.

Further, we sent 405,000 young people, many of whom had never really started their lives, off to World War II, never to return, to defend and save our way of life and our country. My uncle Jimmy died at 20 yrs-old and is buried in a military cemetery near Anzio, Italy so that Axis Powers would not occupy our country. Because of him I am free to write this piece. Were Americans murderers for offering up those lives?

Controlled, Responsible Opening

1. COVID-19 will spread, gradually. There will be new cases and there will be deaths, mostly in high-risk groups.

2. Herd immunity will be established over the next 1-2 yrs. In fact, the more locked-down and quarantined, the larger the group of COVID-19 susceptible (not yet infected) people for the next viral disease waves– so they will be more severe and medically costly and societal disruptive.

3. New case hotspots will be rapidly identified with testing and contained to stop spreading, without generally disrupting the society and economy.
   It is too late for severe lockdown to work. SARS-CoV-2 is widespread across the population. Lockdown will just increase death tolls, “deaths of despair”. The focus should be on containment of flaring new case hotspots (positive tests with or without illness), distancing, targeted quarantines, cleansing, and masks. We can be careful and prosperous; it is not an “either/or”.

4. We will have a healthcare system expertly trained and experienced to deal with the minority of cases needing hospitalization, and possibly new drug treatments for those seriously ill.
   Parenthetically, do not count on a vaccine, which may never happen or may take years to arrive. National leaders should move away from this misleading idea. If it happens in the next year, it is a godsend and a medical miracle.

5. We will reach a natural co-existence with COVID-19 in the next 2-3 years, with this pandemic a stark memory of our vulnerability to Nature, but only a memory. No one is offering this message of realistic optimism and hope. Only dire warnings and admonition on “extreme caution”, to serve the political agenda. (see below) Fearful people are controllable.

6. People will continue to mask, cleanse, and distance where appropriate until COVID-19 becomes a usual infection.

7. Continued rigorous infection prevention and containment measures will focus on those at high-risk for death and those working obligatorily in very close quarters.

8. Routine, regular COVID-19 screening tests of elderly in nursing homes and assisted care facilities; healthcare workers; and those in large gatherings, such as schools, until there are no significant COVID-19 disease waves.

9. Re-opening pace and extent must be determined at the local level, depending on the community’s disease activity, population density, concentration of high-risk groups, and numbers of essential businesses. Correctly, there will be myriad different proper models.
   Rational review of what we already know and what we can project from it leaves us with only one choice: responsible, intelligent, controlled re-opening.

Media, Messaging, and Pandemic Politicization

On May 11, Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, said we must proceed with “extreme caution.” He also said that our schools and colleges might need to remain closed next Fall. Really? When there is near no risk of fatality in those age-groups and we need to move toward herd immunity (by deliberate, controlled infection of as many low-risk-for-death people as possible)?

The media reveres Dr. Fauci’s positions. He seems to have been elevated to Pandemic Chief Executive. However, in January, he said COVID-19 was not a major threat to the U.S. In March, he said we need not wear masks (now reversed that). On April 7th, he said we should drop handshaking as a social behavior, forever. On May 10th, Dr. Deborah Birx, White House Coronavirus Response Coordinator, his colleague on the COVID-19 Pandemic Task Force, said she cannot trust what the Centers for Disease Control and Prevention (CDC) says. Both of them are responsible for vehemently insisting that President Trump impose a national shutdown based on a pandemic model suggesting up to 2.2 million U.S. dead. Current epidemic models now estimate 90,000-150,000 deaths. Not a small number, but many-fold off the prediction that caused measures that have devastated our economy and threaten to wreck it if we do not act decisively and fast.

Dr. Fauci, before the U.S. Senate, on May 12th, suggested we need a COVID-19 cure and/or vaccine before we can safely re-open our society. He just moved the goal-posts. There is no place for his “extreme caution” rhetoric if you consider all the facts. Dr. Fauci and Dr. Birx are accomplished and esteemed public healthcare leaders and physicians. They are bona fide experts. And, they are fallible and have been wrong, and critically wrong in matters that not only can result in individual deaths, but also many COVID-19 collateral “deaths of despair” and the ruination of our country. Like any who are experts in a narrow discipline (like me), they can have a natural myopia and tunnel vision for things outside their narrow expertise. The President and his Administration and other political leadership must limit the scope of influence of these individuals, taking their counsel in a most limited and measured way. Dr. Fauci and Dr. Birx are over their heads. The problem is, I believe, their language and positions have been influenced by their sudden, unanticipated celebrity.

So, what is really going on? Let’s look at a list of things that may help us understand how we got to where we are and where some wish to take us

1. “Blue” (Democrat leadership) states have been the most autocratic in their imposition of lockdown and its unrelenting continuation.

2. Blue states (many of which were heading for bankruptcy from government mismanagement prior to COVID-19) are petitioning for federal money to avert bankruptcy – so, they get to continue in lockdown with no productivity and saying their people need to remain safe at all costs, while Red (Republican) states go back to work and pay for Blue states’ protected, safe time-off: California, Illinois, Michigan, New York, New Jersey, Maryland. And, Blue states propose using money from all the states to correct their books from years of financial insolvency.

3. Speaker of the U.S. House of Representatives, Nancy Pelosi, delayed at least a week on a vote to pass the original stimulus bill to provide emergently needed money to small businesses and individuals. She kept the House unadjourned while the country was heading over the cliff and working people and business owners were frantic about pending insolvency.

4. Speaker Pelosi only allowed the stimulus bill to pass after Democrats coerced funding appropriations for their self-interests, such as $35 Million for the Kennedy Center for the Performing Arts in Washington, D.C. What did that have to do with people not able to make their mortgage payment or to meet payroll? What did that have to do with a pandemic? The Democrats held the course, willing to allow the middle-class working people take the hit, so they could use the desperation of citizens to milk the bill for Democrat agenda items.

5. There has been a push by Democrats to go to mail-in election ballots, more open to fraudulent voting without photo I.D. verification, based on alleged COVID-19 risk going to the polls.

6. Democrat state leaders and judges are releasing violent crime prisoners en masse, but then non-sensically threatening COVID-19 jail time risk for non-criminals defying their lockdown edicts (such as the hair salon owner in Dallas, TX).

7. Democrat bill being put up for a vote on May 15th is a $3 Trillion stimulus bill liberal bonanza which includes $1200 checks for each illegal immigrant (up to $6,000 per family), plus amnesty (which will become permanent) for all illegals; work visas for immigrant healthcare workers (more Third World future Democrat voters); while American medical workers are being laid-off or fired because of financial failures of hospitals and practices prisoner releases (mostly minority Democrat voters); and many other programs directing money toward Democrat Party donors. All of this during a national medical/economic crisis. This is disgraceful exploitation.

This rush to raid the U.S. Treasury must be directed at essential, business and life-preserving financial priorities, not Left-Wing and socialist agenda items. After the earlier, $2 Trillion, pandemic stimulus bill alone, it was estimated that each American would have a $37,000 tab to be settled eventually- surely through future taxes on our kids and grandkids, and maybe even levied against our Social Security, Medicare, and IRAs/401Ks. And, this crisis is being seen, by Democrats, as an once-in-a-lifetime chance to fund their supporters and voters to assure their hold on power, irrespective of the long-term financial fallout on everyone else.

By the way, many of the small businesses going under (estimated to be 100,000 at this time) are largely owned by conservative voters and funders — no loss to Democrats, in fact a gain.

Look all this over and you must be disgusted by profane exploitation of a public health and economic crisis and vulgar and dangerous politicizing of the situation. The same bipartisan divide in this country since President Donald Trump was elected is playing out in the COVID-19 epidemic. Be clear that we are just 6 months from a presidential election with an incumbent who is an outsider who had an unbelievable record of accomplishment until January, 2020 and COVID-19, while under unrelenting assault and resistance by his adversaries. A President the Democrats still do not consider legitimate, though duly elected. The Democrats had no agenda but to “get Trump”. No vision for the country, other than Senator Sanders’ socialism, which was rejected by the Democrat Party as a deal-killer for winning the White House. Now, they think they have a godsend… a pandemic to blame on him and to destroy his unparalleled economy. They are not locking down COVID-19. They are locking down the economy. No concern for the working people for whom they claim to advocate. Democrat leadership advocates for itself, despite its propaganda and rhetoric. Their acts lead to no other possible conclusion.

You need not be “conspiratorial” in nature to see the facts before you. Nancy Pelosi’s unprecedented tearing up several copies of the State of the Union Address in a pre-planned, staged performance on camera, just behind the President, tells you all you need to know. Nothing but vile contempt for this duly elected President and resolve to take him down. Be clear, all the extreme and wrongful behavior is being done by progressive Leftists. The record speaks for itself.

Why does a physician comment on all this? Because there is a reality to this pandemic that is not an unparalleled horror, or even unique. Yes, there is death. There always is. It’s part of living. We need to minimize it. We will never eliminate it. Just like COVID-19. We don’t trivialize it. But, those like me who have devoted their lives to saving lives of others and minimizing suffering and death (walked the walk, not talked the talk), are appalled, no, enraged, at opportunistic politicians; self-absorbed, ego-inflated medical leaders; and extremist ideologues who are conspiring to create hysteria and conformity out of fear by propaganda and misinformation. It is perverse and dangerous. Moreover, the media are in on the fix. And, it is a lie.

I was for serious COVID-19 mitigation and lockdown when there was a paucity of information on the SARS-CoV-2 virus and the dynamics and direction of the outbreak. But, we are beyond that now. We can now re-open prudently and responsibly by,

1. Continued social distancing, masks, and personal cleansing until there is a consensus that SAR-CoV-2 activity is acceptable.

2. Opening schools and colleges.

3. Sequestering high-risk groups not in essential jobs if they wish and until disease activity is minimal. They have a right to put themselves at risk, at least the last time I looked.

4. All businesses continuing to follow distancing protocols and trying to segregate high-risk clients.

5. Where appropriate and practical, in the near future, working at home and using “tele” services (telemedicine).

6. Regular COVID-19 screening tests of healthcare workers, elderly care workers, workers in close quarters, etc.

7. Rapid response public health containment of new COVID-19 case hotspots.

Focus on the goals of “flattening the curve”, not eliminating COVID-19; minimizing death, but not “no deaths”; rescuing the economy and restoring our way of life and country.

Dr. Anthony Fauci’s testimony before the U.S. Senate is most revealing in how he crafts words, despite the facts of the epidemic, to adamantly push a point of view. Under questioning he said, “I don’t give advice about economic things. I don’t give advice about anything other than public health.” So, he demures on counseling on “things” outside his expertise, all the while posing before the media as the nation’s expert and authoritative voice on the pandemic. A federal employee at the highest levels of government for decades and he pulls back from any responsibility for the dire ramifications for our society and country for his recommendations and mistakes. Then, he insisted that schools and colleges likely need to remain closed in the Fall, employing language like acting with “extreme caution”, particularly when it comes to the children… If we don’t accept his position there will be “needless deaths and suffering.” “Needless” means that unless we do as he says, people will die who needn’t, but for we murderers. He further says, “I think we better be careful [that] we are not cavalier in thinking that children are completely immune to deleterious effects.”

So, after throwing out a litany of alarmist words…”extreme caution”, “cavalier”, “needless deaths” and “suffering”…he closes with the fail-safe emotional hot button, “the children.” To slam home his position, he used the safety of the children. This is what he tells the US Senate. Despite the solid stats showing healthy youth under 18yrs-old almost never die from COVID-19. No one asked him about that. Despite clear errors on his part over the past 2 months, reliance on pandemic models that were astoundingly off in their predictions by hundreds of percent, and his public reticence to accept any blame for any collateral damage to the society from his recommendations, he again asserts continued lockdown as his expert position. And, he now invokes the safety of the children as the ultimate weapon, with contradictory facts staring him in the face. Disingenuous, anyone?

Well, let’s look at COVID-19 and the kids. In the U.S., by April 2nd, there were 2,572 cases who were 18 years-old or younger (out of a total 150,000 cases). 5.7% were hospitalized, with only 3 deaths (I said “virtually” no deaths). China had the same type of pediatric stats. By May 2nd, in the U.S., there had been 174 pediatric deaths from seasonal influenza. And, note, this is 174 deaths when most children have received flu vaccine. So, do we conclude that COVID-19 as a risk for children (when there have been near no deaths from it unless a child is inherently unhealthy) is due cause to make ominous pronouncements before Congress and upon which to base another year of school closures? Talk about “cavalier”! To that, I would add, flamboyant and histrionic language doubling down on his alarmist, myopic position. There is another aspect to all this. The best defense is offense. Instead of finding himself painted into a corner of acknowledging and owning his mistakes and their results, he doubles down his position more resolutely, while covering his back saying he’s only a doctor and public health expert, certainly not a political leader and policy maker; so not accountable for policy results. Whatever happens bad, he didn’t make policy; above his pay rate.

Finally, he created more room for excuses for any further errors by saying the COVID-19 deaths total is “almost certainly higher” because in the first months we didn’t have enough tests to diagnose it. Of course, not having enough testing for the 80% of all COVID-19 patients that have minor or no symptoms, we cannot know the true risk of death because we don’t know how many tens of thousands were infected that did not die. It is estimated that there 12X the COVID-19 infections than those actually diagnosed. The virus may be far less fearsome, because its prevalence is much more extensive, and so the percentage of deaths much less. Statistics can always be manipulated to a purpose. “There are three kinds of lies. Lies, damn lies, and statistics.” (Mark Twain)

He also acknowledged there could be some “flare-ups….because it’s a highly transmissible virus. It is likely there will be virus somewhere on this planet that will likely get back to us.” So, Dr. Fauci is saying more outbreak flares will occur, just based on the biology of novel virus pandemics, the fault of no one. But, I thought he said we need to be extremely cautious and keep pretty locked down, like the schools… for the children. But now, it’s coming back anyway. What?

We cannot stay locked down indefinitely. This flies in the face of the serious policy errors of interminable lockdowns happening mostly in “blue” states, and justifying their continued lockdown based on the cautionary language of the national medical experts.

Why is all this important to examine in detail? Because Dr. Fauci has positioned himself as the medical face of COVID-19 Pandemic leadership and the media and political Left take every word of his that suits their agenda to criticize and undermine undermine the President’s and his Administration’s performance and pandemic policies. Remember, election year. Dr. Fauci wants it both ways—authority and celebrity, but no culpability. And, he is the Left’s justification for their draconian measures. I think the word is “demagoguery”. By the way, so desperate are the Democrats to get President Trump out that 90% agree with continued lockdowns irrespective of the risk to the economy and the country. But, what about all those “working folks” on Main Street they always fight for? Well, they just need to fend for themselves until they are back in power as political leaders with their privileged, entitled lives. After that… ah, the workers, yes.

The proper words that should be used regarding the outbreak are what is and is not reasonably probable and what is extremely low risk, rather than possible. Those are the words that define how we usually consider risk/benefit in every other aspect of our lives. Whether to drive or walk. Whether to go to a public event. Whether to pass through a dangerous neighborhood. Whether to undergo a medical procedure or to agree to a treatment. We do not require a guarantee of safety and no possible harm. Yet, the Left has concocted a narrative, no, a standard, of “no deaths acceptable.”

So, we need to ask how there can be such a divergence in approach to an infectious disease outbreak…along political party lines? I have only seen Democrat judges and governors threatening or imposing jail for anyone exercising civil disobedience in defying unlawful lockdown mandates. A biological process should, based on scientific facts and principles, lead to a fairly uniform and inarguable policy consensus, except for pockets of exceptional disease activity. The only way to explain this divergence is one side seeing the virus as an opportunity to disrupt the country, create “crisis”, foment panic/fear, impose authority, and emergently drain money (taxpayers’) from the U.S. Treasury. Can this all be off the rails “conspiracy” delusions, or, maybe, the truth? Too oft-quoted Democrat Chicago Mayor and President Obama’s first Chief of Staff, Rahm Emmanuel: “Never allow a good crisis to go to waste. It’s an opportunity to do the thing you once thought impossible”. Says it all. He thought this was funny, but he was sincere. What do these things below that Democrat Party Leadership have solely promoted or enacted tell you?

• Release of prisoners (mainly racial minority Democrat voters)

• Devastating the rampantly ascendant Trump economy of January, 2020, in a presidential election year; an economy that would have guaranteed President Trump’s re-election

• Create uncertainty about the future

• Grab power and limit rights to accustom the people to a new “normal” of centralized governing authority

• Ruin the middle class; having lost homes, jobs, careers, and savings, a mandate for a socialist model to support the masses with nowhere to turn but to the federal government

• Use the risk of COVID-19 infection to stop voting at polls; to justify mail-in ballots, more subject to voter fraud

• Diminish political adversaries’ funding support base—by ruining small business owners

• Amnesty for all illegal immigrants and taxpayer dollars to support those families, hardwiring a majority Leftist electorate for the indefinite future

And, all of the above is occurring while the U.S. House of Representatives is held in adjournment by Speaker Nancy Pelosi. But, while others have no pay, no jobs, no prospects, the House Democrats have their protected world,

• Continued full-pay

• Guaranteed retirement pay

• Private healthcare (not Obamacare)

Sort of reminds you of the Soviet Union Politburo or China’s Central Communist Party.

But, they are truly concerned about “the people” and “even one death is unacceptable”, at least so they say. Now, what’s for lunch? They are ecstatic.

In a word, the ends justify the means, even if countless lives are ruined. But, throughout history crises have been used to push radical societal change—the Russian Bolshevik Revolution, the collapse of the Weimar Republic making a way for Adolf Hitler, and “911” creating the currently dangerous Deep State Intelligence operations and the intrusive Transportation Safety Administration that disrupts and impedes our travel. A new permanent imposed “normal” from a temporary crisis.

Democrats are seeing their opportunity to get done what would never have happened in our pre-pandemic, normal country. In fact, they were losing their grip as racial minorities were going middle-class and unions getting disempowered. They were losing their “victim” base, so had to go shopping South of the Border and in the prisons. Next was going to be 16 yr-old voters. You think they’d exploit a major epidemic? They have exaggerated a public health crisis (this is no 1918 Spanish Flu Pandemic; with 675,000 American and 50 million worldwide deaths, mostly between 20-45 yrs-old) to attempt social engineering and permanent political power. No other conclusion can be reached if all the facts are carefully considered. By the way, anyone see the American Civil Liberties Union (ACLU)? Are they on strict lockdown?

In closing, at 70 yrs-old, if someone said to me I needed to die or have the lives of my children and grandchildren ruined, I would get my papers in order and kiss my family goodbye. I cannot imagine a person in their latter years with a heart and any sense of values and virtue who would do otherwise. Older people get it. They know what’s right.

We are not in a unique moment. We have been here before. The question is how many lives are we willing to concede to save our country and our way of life? To preserve our rights and freedoms? It is simply a matter of acceptable losses. We have the facts. It is a risk/benefit decision we make when we drive a car (or take our kids as passengers), drink alcohol, smoke a cigarette, walk the streets, go shopping, attend work or school during flu season, have a medical procedure or treatment, or go to war.

Let’s not make this more than it is. Let’s consider it carefully, then live with our decisions and take responsibility for them. They should be re-evaluated as new information develops and conditions change. This is a marathon, not a sprint. It is our decision, not that of elected public servants. Remember, they serve the will of the people, after providing their counsel. Remember, the goal was “flattening the curve” of case growth to spread out the illness burden over time to match our healthcare system capability. It was not to eradicate the virus. We do not move the goal-posts to suit a political agenda, absent legitimate reasons for the overall good of the country. We stay on mission.

The decision to do a controlled re-open, managing problems as they occur, is a life and way of life affirming decision. It is the pragmatic and right decision.

Edward R. Rensimer, MD

Infectious Diseases

International Medicine Center

Houston, TX

Copyright, 2020, E. R. Rensimer, MD, All Rights Reserved

COVID-19 Update 9

Why Should I Do It If “Essential” Workers Don’t?

We are pounded on incessantly by medical experts, by government leaders, by media, from every video screen we stare at, from notices on doors, from the radio… exercise The Golden Rule and be part of something bigger than yourself… stay apart! The more SARS-CoV-2 spreads, the more it kills. Yes, the old people. Yes, medical workers and first-responders who put themselves at risk. And, at times, even someone in middle age. Someone’s wife, husband, brother, sister, father, mother, grandparent… a best friend. It gets real when it isn’t just a number. It’s that person 2 months ago with whom you were planning a dream trip. Or, grandpa whose only remaining life’s desire was to see your child, his coming grandchild, be born next Thanksgiving. Or, just your buddy you meet every Tuesday for some coffee, and a sandwich, and a piece of chocolate pie, to make sense of what your life was and is, now that you’re both retired. Plans, dreams, memories, hopes… lives.
So, for the most part, many are making a reasonable effort to keep to themselves, to be part of the solution.

Yet, Sunday, I stop by Kroger’s Supermarket to load up the fridge for the week. I’m 70 and I’m wearing a mask and using hand cleanser on the way out of and into the car. As I stroll toward the entrance, the majority of people entering and exiting this human funnel have no masks. Haven’t they TVs, radios, mobile phones? Have they not heard the message? Worse, as I get my cart inside, I see a few supermarket workers with masks, many askew, but clearly not more than 50%.
Geez, the aisles don’t allow 6-feet separation of shoppers passing each other. At checkout, you are maybe 4-feet from the cash register guy. Maybe 3-feet from the bagger.

Then it comes to me. I get it. Because this is an essential service (food delivery) COVID-19 knows this and doesn’t come in here. That’s why, when I suggest to the register guy that he needs to shave off his goatee and tight-fit a mask, he has a “caught-in-the-headlights” frozen stare.

I can see the white-space bubble over his head, like in the comics, “What the hell is that your business?” I pull my trump card, “I am an Infectious Diseases expert. You look like you’re about 70 and are probably exposing yourself to 100 people a shift. You are at serious risk to die if you catch this virus. If you don’t care about yourself, care about somebody else, like us,” I assert through my muffling mask. He stares an annoyed stare and hands me my receipt. See you.

Just considering, is the supermarket putting USDA failed, spoiled food out on the shelves? Might as well seeing how they run their show in a pandemic. We all need food, so, the one place you would want to have the highest infection control measure would be where the close-in traffic is. How about putting signs up to dissuade those 65 and older or with medical conditions to not come in; have a surrogate pick up the milk? Or, at least supply them with a mask if they must shop for themselves. How about one-way traffic down each aisle, enforced by monitoring staff? Hand cleansers at the entry-way.

I mean, these essential businesses get to stay open and rake in the cash while other businesses don’t know if they’ll ever reopen and people are buying groceries off savings or debt. Yet, market management is so arrogant as to ignore what everyone else is doing for the greater good.
Where else? Hospitals. Walk the halls of a hospital floor and you’ll see their staff chatting, unmasked, several feet from each other. No social-distancing here. We’re special. We’re healthcare professionals. When we enter this special building, we are exempt from the biological reality all those schlemeels out there follow. Well, we actually do it at home, but not here. We have uniforms, we’re different. Well, it is different, we think, because the hospital Administration doesn’t require us to be tested every 2 weeks to prove work-fitness, so we don’t pass SARS-CoV-2 to the patients. Oh, the patients- – forgot about them, because we do work under special rules. Let’s see. A hospital is a place where such people go. Really sick people. Old, serious medical conditions, weakened immune systems- with their bodies physically handled hourly by nurses, therapists, blood drawers, physicians. I mean, is this COVID-19 heaven or what? Masks for everyone? Are you kidding? Nurses have been fired and doctors threatened for insisting on such measures since it might upset patients and families that there is a contagion afoot. What’s more important, infection control or public relations?

However, hospitals got serious a couple weeks ago when they limited visitation to one person a day per patient. I’m still trying to figure out how they were sure which patients were COVID-19 clean? Oh, that’s it. They set up a table with several staff at the single entry point allowed. Taking your temperature with an unreliable forehead thermometer got it done. Except, what if I had a fever an hour before or an hour after they spot-checked me? You must know that no infection causes continuous temperature elevation. I asked the hospital nurses manning the screening workstation. Blank stares. Just doing what they’re told. Others must know what’s right or we wouldn’t be doing this. After all, they’re doing it at the airport with international travelers. Most usually, infections cycle fevers up 2-4 times in 24 hours. All of them… malaria, TB, typhoid, AIDS, pneumonia, COVID-19.
But, at least it “looks” like they’re serious. This is what “leadership” hands down as policy. This is written as if this is comical. You have to do that to avoid being preachy and to compel the reader to stick with it. But, far from humorous or entertaining, this is a criminal disgrace. And, I never thought I could join a hospital and a grocery store into the same class.

The point? How do you get the regular guy in the street who half suspects a lot of this is just an exercise in wielding power to create hysteria to comply with public health policy?
He looks at these societal “essential” services and what their take is on the true threat of the situation. He sees no consistent or serious measures taken. He sees these as places where bodies are concentrated, yet they’re sure not distancing and masking. Ah, it’s just a bunch of malarkey. I’ll go my own way, carve my own path through this, he thinks.
And that, my friends, is how you fill graveyards.

You have more time on your hands now than you have ever had. Contact management at the essential services centers and raise their awareness that you are watching and that you will not patronize them if they don’t get with the program, don’t join the team. If you don’t sense intent to change, call the media and see if you can get a reporter to put it on air. Post it on social media.
Where our lives and those or our loved ones are at stake, there are no exemptions, especially for the essential services.

Ironically, they should be held at the highest standard by the community.

Graveyards.

Ed Rensimer, MD

Michael Berry Show Clip

Please listen to this segment on the Michael Berry Show, KTRH 740 radio, 4/3/2020. Michael thought so much of my discussion of COVID-19 that he replayed the entire piece on his second show of the day to a national audience. I am sure you will benefit from the content.

Ed Rensimer, MD

CLICK HERE FOR THE RADIO CLIP

COVID-19 Update 8: What’s THE Critical Next Step In Return to Normalcy?

Answer: A SARS-CoV-2 Serology Test

What is that? A single test? Are you kidding? Let’s first discuss what such a test is. Once you understand it, you will see it is a game-changer.

Serology is the area of medical laboratory science that refers to the markers in our serum (the liquid fraction of our blood) from reactions of our immune system cells. After an infection such a footprint is an antibody (like an “anti-missile”); a protein in the serum that our immune system cells made to attach or neutralize the invader, to kill it and/or clear it from our body- like a sticky glue made to inhibit further replication of the pathogen invader until other weapons and support troops (cells) can arrive as part of the overall immune response.
Once the infection is resolved, most often these protein antibodies stay around for a long time, often times for life. The antibodies are entirely specific to the invader. So, having had measles or chickenpox, there would be measurable antibodies in the serum that could show that you had had that viral infection decades ago.

Wow, lots of basic medical science. Where is this going? What’s it got to do with my currently miserable life and this COVID-19 mess? We already have a test for the SARS-CoV-2 agent, why are we talking about this?

The current COVID-19 screening test is for the genetic material of the virus itself. It is positive when an individual is infested with the virus or clinically ill from it, and shedding the virus. But, you’ve heard that up to 80% of COVID-19 infections may have no or minimal symptoms. So, a huge number of infections will not be diagnosed – they are below the radar screen. Are they important if no one is sick and no one harmed? Yes, it is critically important to identify these people. Once you do that you understand the true nature and extent of the pandemic; where the virus has been, and is headed.
The data we have now are on actively ill cases. So, if 5 of 100 ill people die, the fatality rate is 5%. But, if 80% of COVID-19 infections are minimally ill or without symptoms, then the group the 5 deaths came from was 500, and the death rate is 1%. These real numbers can be found out once COVID-19 serological testing is applied to the entire population. 1% (usual flu is 0.1%) or lower fatality rate makes it much more acceptable for people to return to work (especially when we continue to shelter high-risk people until widespread infection abates) when comparing the true risk of death to losing your livelihood, your home, your retirement savings, your business or your country. We do not close down the country for a severe seasonal flu epidemic, which can kill 40,000-60,000 per year. We make a decision to concede that. Just like we conceded 406,000 mostly young lives to World War II to save our way of life.

If a large number of patients are not counted because they are barely or not ill, then the fatality rate would be much higher, which would increase the sense of pervasive anxiety and dread and reluctance to approve rejoining society, a by-product of incomplete information.
The value of such accurate information is undisputed, but where is the impact right now of serological test results of the population showing all who have been infected? What’s the practical benefit?

1. If you know who has and has not been infected and, in keeping with most viral respiratory infections, cards could be issued to those who are “post-COVID-19” and who would likely be partially or completely protected from infection, or at least severe disease, allowing them to go to work, go to school, congregate in public places like restaurants, visit hospitals, proceed with pregnancies, and on and on.

2. Personal protection equipment, like masks, would be conserved and directed to the highest need- -medical professionals and first-responders exposed at work.

3. A pool of people able to donate plasma with COVID-19 antibodies for treatment of extreme illness cases would be identified.

4. Medical workers with positive antibodies could attend their duties with impunity, allowing antibody negative individuals to stay on work-leave until the intense phase of the epidemic waned.

5. If and when a vaccine became available, surely in limited supply at first, it could be targeted to those not yet infected as indicated by a negative serology test.

6. Should there be resurgent waves of infection over the next 1-2 years, usual with novel virus pandemics, those identified as never yet infected could be advised against social contact and to continue quarantine, without mass evacuation of schools and businesses. The suppressive-mitigation infection control measures would be applied to a well-defined much smaller population, without the profound social and economic disruption.

Yes, this one type test, currently under development, applied broadly would change every aspect of dealing with this pandemic, minimizing loss of life (by concentrating resources on those at true risk) while restoring our societal order and economy. This, of course, assumes that COVID-19 confers significant protection against re-infection and endures past the 1-2 years of usual infection resurgence. This is an important detail, but it is reasonably probable that COVID-19 antibody gives some, if not complete protection. SARS virus, the brother of SARS-CoV-2/ COVID-19 produced protective antibody that lasted at least 2 years, long enough for COVID-19 to no longer be “novel” to the human race, just another virus, like flu.
Let’s keep our eye on this and hold it as reasonable position of hopeful optimism. We’re due.

Ed Rensimer, MD

Infectious Diseases

COVID-19 Update 7: Infectious Diseases Specialty Overview

FRONTLINE CONCEPTS

SARS-CoV-2 vs. Influenza 3/17/2020

Statements have been made that Coronavirus-19 (SARS-CoV-2) is just like the flu- that too much is being made of it. To compare them,

1. COVID-19 and influenza are both respiratory illnesses caused by viruses.
2. Virus Shedding,
a. Patients ill from flu shed virus (and so may infect others) for 24H prior to onset of symptoms and for 5-10 days after.
b. COVID-19 virus shedding has been seen 2-3 weeks before onset of illness (persons who are not sick, asymptomatic), and then for possibly 2-3 weeks after illness onset.
c. COVID-19 death rates are anywhere from 10-50X that of influenza (numbers subject to change as virus detection testing is more available and the extent of infection across the entire population is defined).

So, these are very different viruses, probably mostly because SARS-CoV-2 is “novel” – crossed over from the animal kingdom to humans with no immunity, whereas many people have at least partial immunity from prior flu infections or vaccinations. In years ahead, once SARS-CoV-2 has passage through millions of humans and there is broad immunity across populations, this virus will likely resemble other respiratory viruses in its behavior.

The Pandemic

The biology of SARS-CoV-2 and its behavior in interacting with humans will not be known for months, maybe a year or more. However, looking at the experiences of individual epidemics within the pandemic provides valuable information, useful for dealing with the US outbreak as it is accelerating at exponential speed.

1. There are dozens of countries with exponential growth; all of Western Europe, Scandinavia, SE Asia/ Malaysia, Africa, and S. America.
Italy: A model for us, as a western society. 3 ½ weeks ago, there were only 3 cases; now has the highest number of cases outside China- 15,000 cases and 1,000 dead by 3/13/20. 25,000 by 3/16.
By 2/20/20, all healthcare workers were on continuous work shifts.
By 2/23, there were 76 cases.
By 2/25, there were 229 cases. Officials were behind in testing 7-10 days.
By 3/3/20, 10% of medical workers in Lombardy were infected.
From 3/1-3/11, between 9-11% of hospitalized patients went to the ICU.
On 3/8, the extraordinary measure of mandating quarantine of 60 million citizens was imposed. On 3/16, the decision to not offer ventilator support to anyone 65 yrs-old or older was implemented.
In Italy, COVID-19 cases have been doubling each week.

Asia: China’s extreme societal lockdown stopped exponential growth by the end of January. Japan, Singapore, Thailand, Taiwan, and Hong Kong were hit by SARS in 2003, and so learned about exponential growth; so they did lockdown earlier with COVID-19, holding the epidemic below exponential growth.
Note, when Wuhan, China thought it had 444 cases, it had 12,000 (27X more).
With COVID-19, the case numbers are always far under-estimated because of asymptomatic incubation pre-illness onset.
80% of COVID-19 cases are mild. 20% will be hospitalized and 5% of cases will go to the ICU.
Average doubling time for SARS-CoV-2 is about 6-7d; meaning after 11 doubling times (about 2 months), 500 cases would become 1 million. We must appreciate the explosive nature of this virus over a short time.
With the average time from illness onset to death being 17 days, and if there is a 1% mortality rate, then when 1 person dies, he probably was infected 3-4 weeks before- during that time there were 99 other cases (as he is the 1%). With a COVID-19 case doubling rate of 6 days, the numbers compound and that one person’s death suggests there are 500-1000 cases along with him.

Containment/Mitigation

Containment is impossible. COVID-19 now is endemic to America- “community-based” cases, unrelated to travel or exposure to travelers. With the entire country involved and the Italian COVID-19 track-record, we can only POSSIBLY SLOW the inevitable progression through our populace.
Slowing the pace of the outbreak is the strategy of “mitigation”. It is described as “flattening the curve”- the graph of new cases emerging. An analogy would be taking a 50-ft high tsunami and breaking it up into five 10-ft waves, hitting the shore in spaced apart succession. The idea is to allow an orderly processing though our healthcare system within the staffing, hospital bed. and medical equipment limits of our medical system. Should the illness load hit over a short period, say a month, as in Italy, rationing would be the dreaded necessity- deciding who gets admitted to the hospital, access to an ICU bed, or placed on a ventilator… or dies. That has been happening in Italy.
This is why what seems like overreaction and drastic measures across our society are being put into action. The tsunami is visible on the horizon and the near beach water is being sucked out to sea. Leadership realizes to hesitate or equivocate is likely an incomprehensible disaster.
If people are separated (“social distancing”), infections will occur, but at a much more controlled rate as they return to their normal lives, spreading out the case load over 2-3 months. There is hope that SARS-CoV-2 will be harmed by higher ultraviolet light levels and warmth as we head toward April, as is the case with some other respiratory viruses. Also, some such viruses that spread by airborne aerosol droplets (coughs, sneezing) do not spread as easily with high humidity that carries the droplets to the ground in a shorter distance (6 feet for SARS-CoV-2). We can expect such humid Gulf of Mexico air to move into Houston by April.
If the transmission rate decreases by 25% by social distancing, the case curve would flatten and delay the epidemic peak by 14 weeks; decrease by 50%, and the peak delays by 3 months and is much smaller.
Social distancing used too late with the 1918 Spanish Flu in Philadelphia caused 260 deaths/100,000; used early on in St. Louis, 50 deaths/100,000.

Healthcare System

We have about 160,000 ventilator machines in the U.S. As a novel virus, if SARS-CoV-2 paralleled the 1918 Spanish (Novel) Flu Pandemic, about 740,000 would need ventilators to have a chance to survive the illness.
The U.S. has 2.8 hospital beds/ 1000 people-less than Italy (3.2), China (4.3), and S. Korea (12.3.) … all of which struggled with SARS-CoV-2.
The U.S. has about 45,000 ICU beds. A moderate epidemic, would require about 200,000 beds; a more severe outbreak, it could be 3 million. US influenza deaths avg 12-60 thousand per year. But pandemic flu in 1957-1958 killed 116,000 and in 1968 killed 100,000. Both of these epidemics would have needed 65,000 ventilators to rescue people from likely death.
And, with COVID-19 cases taking up all these beds and ventilators, there would be collateral loss of life (not counted directly in the epidemic mortality statistics)- others who need the ICU management and/or ventilator: evolving strokes, heart attacks, severe bacterial infections, vehicular trauma, etc.
As we all know, because of the economics of the medical business, our healthcare system is streamlined with only a bit of extra capacity; hospitals are often at full occupancy in normal times. You can see where a crisis across the society could require rationing of care as the existential reality. It is no different than medical professionals choosing who will live or die based on medical futility and best chance of survival on a battlefield.
Currently the U.S. has an estimated 1% of the respiratory masks needed to cover all healthcare workers. And, remember, 10% of Italy’s medical workers have become infected (some fatally) partly due to insufficient protective equipment supplies.
I think you now get it. We are not prepared and cannot make up for it in time to contain this outbreak- only spread out the contagion over time to more closely match medical need to resources–mitigation. Social distancing can show positive effects in 2 weeks.

Conclusions

We must realize what we face. Actions that make sense now (and for continuous review as circumstances change),
1. Serious Social Distancing
a. Schools out
b. Public entertainment and other large group gatherings delayed
c. Stay at home, except for life essential activities.
d. Minimize human contact with those at or above 65yrs-old and/or with serious underlying medical problems.
e. Minimize visitors to elderly care facilities and hospitals.
f. Minimize visits to any medical facilities-physician offices, labs, imaging centers, etc; only appointments out of critical medical necessity for the next 1-3 months.
g. Pharmacies should provide extended medication supplies and consider home delivery.
h. Only essential services open: grocery stores, transportation, pharmacies, medical offices.
i. All medical care providers to adjust workflow communications and operations to achieve rapid access and egress for patients- the goal little or no waiting time in common areas with other patients.
Ignorance and risk uncertainty are the parents of panic and anarchy, primed by unrelenting media exaggeration and, at times, misinformation.
What are the elements of coming through all this with the best possible outcome?

Concern: Yes
Attention/Focus: Yes
Compliance: Yes
Flexibility (course corrections): Yes
Information: Yes
Action: Yes

I am confident that this country can manage its way through this. But, it will be with credible leadership; information transparency; timely, targeted action; trust and resolve; and always, always focus on those for whom we are responsible, while also seeing ourselves and our families as part of and stakeholders in something bigger than ourselves. The Golden Rule always works.

Ed Rensimer, MD
Director
International Medicine Center

To Dine or Not to Dine? What to Consider Amid Coronavirus Concerns

Take a look at this article for which I was interviewed on aspects of eating out during a pandemic,

Ed Rensimer, MD

https://houstonfoodfinder.com/news/to-dine-or-not-to-dine-what-to-consider-amid-coronavirus-fears/

CORONAVIRUS UPDATE 6: FOR THE PROFESSION

Re: Medical Facility Procedures/COVID-19 Containment 3/11/2020

Colleagues,

There appears to be no commentary or direction for those of us on the front-lines of what is a US epidemic within a novel virus pandemic. Aside from my office’s protocol for my staff (attached), I suggest that it therefore is on us to think this through.

Operative word: proaction. Your patients and their families will see you taking measures to protect them as well as your practice’s viability while this outbreak runs its course, and they will be grateful. It is time for the profession to engage.

So, consider the following,

1. Limit all appointments to only those that are time-critical from a medical point of view, i.e. standard of care required and unavoidable in the interests of the patient.

2. Workflow Change: Though this will impact the business, consider the impact if a number of your staff require quarantine. At the intake of a call for an appointment, tell the patient to call your office on arrival so your staff can approve entry to your facility such that there is little or no waiting time in your lobby, shown quickly into an individual exam room. If they are not in acute medical distress, have them wait in the building common areas or their vehicle.

3. Upon entry to your facility, provide a respiratory mask and require hand cleansing with soap and water or hand cleanser with over 60% alcohol.

4. As much as medically advisable, try to keep those 65 yrs and older away from your facility; elective appointments to be put off until we see if the COVID-19 pace and pattern of spread diminishes with warmer weather.

5. Wipe with appropriate cleaning solutions surfaces of likely patient contact after each visit: arm rests on chairs, exam table edges, door knobs, stethoscope diaphragms, BP cuff, etc.

6. Staff to cleanse their hands after each patient encounter.

7. Check-Out: Staff to cleanse their hands, pens and counter areas after each check-out financial transaction and appointment re-scheduling encounter.

8. Staff to wear masks.

9. Advise patients to avoid crowded elevators, or to cover their nose and mouth (?handkerchief) when in one with others, on their way to see you.

Previously, the focus for isolation/distancing measures was on anyone with respiratory symptoms and/or fever. Now, knowing the incubation period from time of virus acquisition is up to 14 days, and that many will not be ill but shedding virus (as well as post-illness shedding of virus for another 10 days, or more), everyone is an exposure risk. Now that there have been “community-based” cases, travel history is irrelevant with respect to COVID-19.

The basis of these ideas are the facts on the biology of COVID-19 as they are emerging as well as the nature of our practices and how they interact with the community. From an epidemiological view, physician offices and other medical facilities (diagnostic laboratories, hospitals, surgery centers, elderly living facilities), congregate and concentrate the most at risk protoplasm in the society and those at most jeopardy for serious illness and death—those 65 yrs-old and up. How much and what you decide to do will be customized to your practice environment and services.

We need to be thinking this way and we need to look at our patient populations, our services, and our physical plants, and then be the professionals and leaders our patients and communities expect and rely on us to be. We treat patients, but, cumulatively, we treat society. Inarguably, measures taken by the medical community to diminish spread within their workplaces will be the most impactful on this epidemic because our clinics are where the rubber meets the road on contagion. We do not want to become Italy.

Feel free to share this and anything else I have written with your friends and colleagues and even patients (who might bring these ideas before their other healthcare professionals). My email list is limited,and I hope this information is disseminated. It is all posted on my websites:

traveldoc.com

rensimer. com

Call me anytime with questions or ideas that I would be glad to consider as part of future bulletins.
I hope this has been useful in getting all of us thinking about our personal professional circumstances. Cliché though it may be, we are all in this together.

Ed Rensimer, MD
Infectious Diseases
Director, International Medicine Center
Houston, TX

Coronavirus (COVID-19) Update 5: 3/11/2020

The epidemic is accelerating, as expected, and it will do so over the next 1-2 months, at least. We will find hospitals over-burdened, even possibly without enough equipment and other resources to treat the deluge of seriously ill patients if community-based containment measures fail.

The only thing that will after this trajectory (note what is happening in Italy), will be investment by each citizen and every medical professional in conscious awareness of and action on containment efforts.

Things for you to do,

1. Every family member cleansing hands (soap and water for at least 20 seconds of all hand surfaces, or a hand cleanser with at least 60% alcohol) every hour if possible when outside the home.

Even without human-to-human contact (within 6 feet of a coughing individual or direct physical contact), COVID-19 can be picked up from contaminated surfaces—elevator buttons, phones, credit cards, chair arm-rests, steering wheels, you name it.

So, we should all be carrying hand cleanser with us.

2. Avoid touching your eyes, nose, or mouth with your hands.

3. Avoid visiting elderly people or those with serious pre-existing medical problems or on immune system-compromising treatments.

4. Medical Appointments: See my piece on “Medical Facility Procedures/COVID-19 Containment”, 3/11/2020. Take action, as a patient, to follow the “Workflow Change” principles with your physicians’ offices.

In fact, copy and share this commentary with your medical professionals, or direct them to these updates on our websites, traveldoc.com or rensimer.com. Disseminating this information as widely and quickly as possible and putting the recommendations into action are critical to containment, the only game in town for the foreseeable future.

5. Respiratory Masks: Consider any mask you can get, optimally an N-95 mask, for any closed-ventilation spaces, when gathering with others is unavoidable, such as airline flights, business meetings, school classes, etc; certainly if anyone in your group exhibits respiratory symptoms (cough, runny nose, sore throat) and/or fever.

Note: Children, by the Chinese experience, comprised only 2.4% of all the COVID-19 cases, so they appear naturally resistant to infection. However, as with hepatitis A, they very well may not be usually clinically ill when infected, but may be an exposure risk for adults from their asymptomatic virus-shedding. With respect to hand cleansing, children need to be included.

Edward R. Rensimer, MD
Infectious Diseases
Director, International Medicine Center
Houston, TX

COVID-19 Update 4: 3/9/2020

Prudent Personal Actions

Well, as had been apparent, coronavirus (COVID-19) is here, in most US states, soon to be in all. The experience in other countries indicates we will see exponential spread and many who are not clinically ill are shedding and spreading the virus now.
So, what should you do? Listen to all your personal “wish-system” that it is really nothing? Listen to political leaders who always and in every country, including ours, withhold communicable outbreak information or spin it to soften the impact in order to keep public order and economic stability?
What is known?

1. COVID-19 is highly transmissible, both before and up to 2 weeks after clinical illness.
2. Risk for a deadly outcome is mostly in those over 65 yrs-old, especially with pre-existing medical problems.
3. Transmission is by aerosol (coughing) up to about 6 feet and acquiring the virus off contaminated surfaces with self-inoculation of the nose, mouth, or eyes.
4. It is unclear what is COVID-19’s ability to mutate—into worse or less worse form—but, as with all viruses, the more passages through humans, the more chance for mutation.
5. It is unknown whether seasonal warming will diminish COVID-19 activity and so its spread.

So, our goals should be to avoid the virus and to be part of killing this outbreak.
Common sense measures,

1. Become a homebody for at least the next month.
2. Wash your hands with any public exposure or activity at least several times a day, if not every hour—soap and water, thoroughly, or with a cleanser with 60% or more alcohol content.
3. Spend no time with anyone with respiratory symptoms and/or fever—runny nose, sore throat, cough.
4. Try to have business or other meetings by phone or other “distancing” methods.
5. Medical Appointments/Procedures:
Avoid them. Re-schedule unless an appointment is absolutely medically necessary. There should be no “wellness” exams.

Medical facilities, particularly physicians’ waiting rooms, are shared ventilation spaces where ill people congregate, sometimes for long periods. Obviously, the elderly are disproportionately present, often moving from doctor office to doctor office, through emergency rooms, through medical testing facilities—they are an intensely medicalized subculture. All of this, when you think of it, magnifies the risk of cross-pollination with COVID-19.

Our office has patients don respiratory masks and clean hands upon entry. Patients with respiratory symptoms or fever are shown directly to an exam room, not to sit in a public area.
a. If elderly, call your doctor’s office ahead so that you can go directly to an exam room on arrival (wait outside until they call you on your mobile phone).
b. Wash your hands on entry and at departure from the office.
6. Avoid visiting elderly people. Call them or see them through FaceTime. If it is necessary to physically visit, avoid physical contact, and wash your hands on entering their physical space.
7. Respiratory masks are probably overkill, except in medical facilities or in prolonged, close quarters in close-ventilated spaces, such as an airliner.

There is no reason to panic. But, that is not permission to disregard what is happening before our eyes around the world and which is about to rapidly escalate here. Denigrating concern, anxiety, and responsible action in an evolving, widespread epidemic is just a form of condescending arrogance, willful ignorance, and blowhard bravado in a situation about which there are serious gaps in important information. If we all take part in pro-action to thwart the spread of COVID-19 and it turns out to have minor impact on the US, then we acted responsibly for our community, our loved ones, and ourselves. For that, we should be commended, not criticized.

Edward R. Rensimer, MD

Director

International Medicine Center

Coronavirus (COV-19) Overview/ Update 3: 2/28/20

It’s Here. What Do I Do?

Yes, COV-19 is now in the U.S. Do I deal with the information, or just duck it and go about my life, obliviously? The immediate answer is based on your life’s pragmatic philosophy on how you choose to deal with the inevitable “rough water.” For me, information is everything. It allows me some sense of control and to assume my natural optimism – that I have always and will always get the best possible outcome for the circumstances. Maybe not what I had wished, but the best that could be had.
So, what’s the overview and the bullet-point facts?

1. In a totalitarian society (China), where people can be forcibly locked into quarantine, beaten and imprisoned for not wearing face-masks, and entirely restricted from public assemblage and getting around, COV-19 has spread at breakneck speed. So, it is highly and casually (no intimate contact) transmissible.

2. Though we think the time of exposure to onset of illness is about 2 weeks, we don’t know, because we are basing our conclusions on Chinese data, subject to the propaganda filters of that regime.

3. COV-19 infected individuals who are not overtly ill can spread it.

4. We have no idea how long people shed the virus after the illness subsides. Ebola virus has been found in survivors’ tissues months to a year after being well.

5. We yet have no idea whether having had COV-19 immunizes a person against future infection.

6. Again, we have no idea of the real death-rate from COV-19, because there have not been enough cases outside China to compile statistics on deaths vs. the total number of diagnosed cases that are reliable.

7. We do not know if COV-19 mutates or changes to weaker or stronger ability to cause disease (virulence) as it passes through more and more human hosts (as does flu).

Think about it. We are an open, free society where we take for granted our mobility and rights to congregate. However, in an highly controlled and restrictive Chinese societal model, COV-19 could not be contained.
Some are saying it is not inevitable that we will have a widespread outbreak, a U.S. epidemic inside a worldwide epidemic, i.e. a pandemic. With all the facts to date, this seems implausible, though I hope to be wrong. At least, if COV-19 is heat-labile, perhaps it, like influenza, will wane as we get to mid-April and warmer days. However, that is yet unknown. A rational person should count on at least an abbreviated, but serious, epidemic over several months.
So far, those at most risk for death are 65 yrs and older, usually with serious, pre-exisiting medical problems. Not so comforting for those of us up there.
Alright, I’ve given my overview. It should be apparent that, now that there has been one U.S. case not directly associated with or imported from an affected country, the cat is out of the bag. There must be a number of unsuspecting U.S. citizens incubating the virus, and then more and more. There is no public health measure that can effectively stop propagation through the populace when you cannot always know who is carrying and shedding the virus. And, without entirely closing entry to the U.S., COV-19 will be imported from France, Italy, Brazil, Russia… from everywhere and anywhere.

But, though we cannot prevent it, we can minimize it.
What, right now, should you do?

1. Keep up on announcements on COV-19 based on developing information from western societies (from which we will develop factual information on transmissibility, virulence, and mortality rate); but always be aware that public officials (regardless of political party) are prone to censorship in war and other national crises, to allay panic and societal disruption.(cdc.gov)

2. Minimize exposure to large groups of people.

3. Avoid anyone, family, friends, neighbors, co-workers, classmates with a respiratory illness.

4. Have no contact with anyone who has traveled overseas, for at least 14 days.

5. Wash hands frequently and thoroughly.

6. Avoid casual physical contact with others (handshakes, etc.)

7. Do not send your child to school or other group settings if they have a respiratory illness.

8. If you develop a respiratory illness, warn your healthcare providers that you wish to be seen, but tell them you wonder if you should and/ or their staff should be “masked” at the outset of the encounter, before entering their facility; that includes urgent care and emergency facilities- protect the healthcare professionals by “The Golden Rule”. We’re going to need them alive and working.

9. Focus on activities away from others- be more a homebody the next couple months.

10. Emphasize exposure avoidance, awaiting the possibility of anti-viral medication treatment possibilities and potential vaccine development.

11. I have been asked whether public venues, such as fitness clubs, should be screening arrivals for fever. It can’t hurt, but the COV-19 problem is all those walking among us shedding the virus for days or weeks before they become ill, if they become ill at all.

The government alone cannot achieve control in a country like ours. We need to take personal responsibility to keep level-heads, to be informed, and to adjust behaviors until we get through this. And, hope for an early, warm Spring.

Ed Rensimer, MD

CORONAVIRUS UPDATE 2: SEEKING EVALUATION FOR CORONAVIRUS (COVID-19) 2/12/2020

You’ve recently traveled to a place where coronavirus cases have been diagnosed. Now, you have developed fever, cough, shortness of breath, and/or diarrhea. From your reading, you know coronavirus is a consideration.

What do you do?

1. Call your local hospital Emergency Department and ask if their lab is equipped to send specimens for COVID-19 testing.

The point of this is your doctor’s office cannot collect and process specimens since there are complex rules for safely packaging and shipping such infectious samples, and they must go at least to the state health dept. lab, or interstate to the Centers for Disease Control in Atlanta, GA. Individual practices are not set up to do this until local labs are able to do the testing; at which point specimens need not be shipped.

2. Tell the ER staff you need evaluation for COVID-19 and ask what is their procedure for seeing you while minimizing risk of exposing others (their staff and other patients) to you.
a. Likely, they will tell you to call on your mobile phone when you arrive outside their facility, so they can meet you with a respiratory mask before you enter.
b. Such a procedure is necessary to not expose unaware medical staff or other patients to COVID-19. And, a facility not handling this with a rigorous, clear procedure might find itself shut-down by public health officials, should a COVID-19 case be diagnosed after-the-fact. Your doctor does not want this, nor does a hospital Emergency Department.

3. Until you are seen by a physician, separate yourself from others-
a. Do not go to public gatherings: shopping areas, schools, church, etc.
b. If you can procure an N-95 respiratory mask (medical supply stores, Home Depot, etc… Google it), do so.
c. Wash your hands frequently, but optimally have no physical contact with anyone.
d. Cough into your bent arm if you haven’t a kerchief.
e. Drive yourself- no passangers.

4. Alternatively, you can call your county or state health department to get directions on where best to go for evaluation and testing. Your primary care doctor will not be able to handle this situation at this time, as testing is not available through his/her routine laboratories.

Finally, realize that influenza is much more likely to account for such illness in the U.S., at least until about the end of April.

Edward R. Rensimer, MD

Director, International Medicine Center

Houston, TX

Copyright, E. Rensimer, MD, 2020, All Rights Reserved

CORONAVIRUS UPDATED 1: 2019 NOVEL CORONAVIRUS (COVID-19)
China Origin 1/30/2020
FACTS TO KNOW/ PERSPECTIVE

COVID-19 is an apparently “novel” respiratory virus that emerged in Wuhan, China and spread from animals (?bats) recently to cross-over to cause disease in humans for the first time. That is what makes it “novel”, and so more dangerous as there is no broad-based immunity in the human herd from infection in prior years (such as exists with influenza viruses from past vaccines and infections). As such, the conditions exist for rapid spread widely, across large populations. How deadly it might be is not clear as of yet and relates to the COVID-19’s “virulence”, or ability to cause destruction in tissues and to invoke an immune response, which can destroy tissue (see the “Spanish Flu” of 1918). As the virus passes through humans, it can mutate such that virulence and transmissibility can increase or decrease, strengthening or weakening the ability to cause serious disease or death. It is a slot-machine model on which way that goes. If everything lines up, you have a worldwide pandemic. This is why you are seeing urgent public health bulletins from the CDC, the main goal containment to minimize passage through human bodies and so the risk of mutation and evolution to a more ominous disease agent. The news media, on the other hand, hype everything for market share. Realize that paying attention to this is being responsible, without assuming a position of emotional distress or outright panic. Maintain rational balance as information develops to inform your actions.
The other relevant facts are that there has been a COVID-19 case with dramatic inflammatory lung infiltrates in a person who was exposed (and so presumed contagious), but with no symptoms of disease or illness. Additionally, it appears that COVID-19 has an incubation period (virus acquired but the victim not yet showing signs of illness) of several to 14 days. Both situations mean you could be exposed and at risk for illness and not know it.
So, what are reasonable conclusions at this time?

1. Travel: If planning travel to or through areas where there has been widespread COVID-19 illness, it would be prudent to delay such travel.

Public health and political officials often craft propaganda during outbreaks to stabilize social and economic volatility over the specter of widespread, communicable illness. So, you must weigh the information at hand as possibly the tip of the iceberg. Officials tend to bleed bad information out gradually, in small doses, to calm the populace. As such, you could find yourself on a trip and,

2. Your itinerary is totally disrupted because of barriers to transportation and public health prohibitions.
3. Large public gatherings are prohibited (quarantined), such as at tourist spots, restaurants, retail centers, etc.
4. Healthcare resources are overwhelmed (just as you become ill).
5. Airports are shut down or travel directed to chosen airports (out of your way).
6. Quarantines are imposed on travelers attempting to return to the U.S. until a 14-day incubation period has expired without evidence of illness.
7. You become ill and must engage a foreign healthcare system, with all that that implies. Be aware, most people who can afford travel to exotic places are probably over 50, usually over 60. The majority of deaths from COVID-19 have been in those over 65. Not a good set of facts.

What to do if you must go?
1. Take an N-95 respiratory mask.
2. Take hand cleansers (60%, or more, alcohol concentration); soap and water.
3. Avoid close contact with anyone with respiratory symptoms or fever (6 feet or more distance).
4. Avoid spending prolonged periods of time in closed, shared air-spaces with others, especially groups.
5. Take a thermometer and medication for fever, body aches, nausea/vomiting, and diarrhea; possibly a respiratory tract infection antibiotic for bacterial infection secondary to the preceding viral infection.
6. Review your health insurance and obtain a temporary supplement for international travel. Medicare does not cover overseas medical care. Hate to say it, but if you are over 50, consider a medical air-evacuation policy and policy for repatriation of remains (death).

Finally, if you return from a country with COVID-19 activity and develop a fever-associated or respiratory system illness (fever, cough, sore throat, and/or shortness of breath), seek prompt medical evaluation, but wear an N-95 respiratory mask (can obtain at a pharmacy or medical supply store) and warn your doctor, the urgent care center, or emergency department staff that there may be a concern for COVID-19 so they can take measures to protect themselves and their facility (from Public Health closure). Also, put yourself on quarantine from family, friends, and co-workers.

Edward R. Rensimer, MD

Director, International Medicine Center

Houston, TX

Copyright, E. Rensimer, MD, 2020