Monthly Archives: March 2020

Shrink and Separate for the Greater Good

Posted on by
5

DSC_0461

For every person you contact, you are indirectly contacting every other person they contact.

This is what I’m calling your ‘exposure circle.’ The more people you contact, the more your circle grows–exponentially.

The fundamental goal of social distancing is to
1) shrink each of our exposure circles and
2) minimize overlap of different exposure circles (and unless we only see people who only see us, every circle is different).

At this point we should assume community spread of SARS-CoV-2, the virus that causes COVID-19 illness. Travel to and from ‘hotbed’ areas is likely no longer the main source of new infections.

Each infected person is thought to infect, on average, 2 additional people (the basic reproduction number, or R0=2), so spread is exponential.

If you have a hard time picturing what this looks like, go to the last page of One Grain of Rice A Mathematical Folktake by Demi.  You can see the grid on Amazon by clicking the “Look Inside” icon.  Doubling one grain of rice every day yields over 536 million grains of rice on day 30, and over 1 billion total grains accumulated over all 30 days.

Because we have not been able to test widely in the United States, we cannot know who is infected and who is not. So targeted isolation is not feasible.

It may very well be that young healthy people are infected and don’t show symptoms, so they spread to many others out in community without knowing.

This is why school closures should NOT be seen as vacation, license to go shopping, eating out, seeing movies, partying, etc.

THIS is why we need to keep our distance from one another–all of us.

I know it sucks. I know it’s incredibly disruptive and feels like overkill. If it works, nothing will be that bad and we will think, why did we do all of that?

And that is, of course, the goal.

If we succeed, we may never know how bad it could have been.

If we fail, we will see all too soon and it will be too late to regret.

Why the Drastic Measures?

Posted on by
8

IMG_3736

On COVID-19 (Coronavirus Disease 2019), caused by the SARS-CoV-2 virus.

For up to date information:  https://www.cdc.gov/coronavirus/2019-ncov/summary.html

 

My friends, it’s been such a strange and surreal week.

I’m feeling so much more tense and agitated than I ever would have expected.

What keeps me really hopeful, though, is connection.

My colleagues and I have dug deep, cancelled our own spring break plans, and stood up in solidarity, ready to do what is needed to help one another take care of all of our patients.

Patients express empathy and patience for us their docs, which is so heartwarming.

They listen to my explanations for decisions to cancel gatherings and close schools. They understand when I describe what’s happening in Italy, and the difference between St. Louis and Philly during the 1918 Spanish flu pandemic.

Many are living the economic consequences of these decisions much more concretely and acutely than I, and their perspectives moderate my own.

I think the best thing we can all remember in the next several weeks is that we are all doing the best we can.  We are all in it together.

It’s stressful and scary for everybody, and sometimes we will lose our cool.

Now is the perfect time to call forth our best efforts at calm, compassion, empathy, and forgiveness.

And then wash our hands.

I share below a compilation of the media pieces that have helped me most in my communication with patients, with the most salient quotes below each respective link.  Maybe they will help you, too.

Onward.

 

https://www.wbur.org/news/2020/03/10/coronavirus-covid-19-massachusetts-hospital-capacity-ashish-jha?fbclid=IwAR3I0HXO028IGmJeyXV2ZhvEmUW56WO_EvE5ToOcjSsaeHkEGZxlS1vZQMg

“Some of the best epidemiologists in the world are estimating that between 40 and 70% of adults will end up getting an infection. Even if we begin with that low end of 40% of adults in Massachusetts, that’s 2 million people getting infected. If we take data from China that says 20% of people needed hospitalizations, that’s 400,000 hospitalizations. Even if we said ‘No, that’s too many, we can cut that in half,’ that’s 200,000 hospitalizations. At any given time in Massachusetts, we think there are [3,000 to] 4,000 hospital beds open at most … And so, if you start doing the numbers, you very quickly realize we do not have anywhere near capacity to take care of tens of thousands of people with [COVID-19] who might need hospitalization … But if we can spread that out over many, many, many months — ideally a year — then I think we have a shot of being able to take care of everybody who will need the care.”

How how does that happen, that it becomes spread out?

“So, what we know is that this idea that people talk about social distancing — this is why Harvard University today just canceled classes. In-person classes; we’re going online. In our offices, were now encouraging everybody to work remotely … Certainly all large gatherings should close.”

 

https://www.theatlantic.com/ideas/archive/2020/03/coronavirus-cancel-everything/607675/

When the influenza epidemic of 1918 infected a quarter of the U.S. population, killing hundreds of thousands nationally and millions across the globe, seemingly small choices made the difference between life and death.

As the disease was spreading, Wilmer Krusen, Philadelphia’s health commissioner, allowed a huge parade to take place on September 28; some 200,000 people marched. In the following days and weeks, the bodies piled up in the city’s morgues. By the end of the season, 12,000 residents had died.

In St. Louis, a public-health commissioner named Max Starkloff decided to shut the city down. Ignoring the objections of influential businessmen, he closed the city’s schools, bars, cinemas, and sporting events. Thanks to his bold and unpopular actions, the per capita fatality rate in St. Louis was half that of Philadelphia. (In total, roughly 1,700 people died from influenza in St Louis.)

In the coming days, thousands of people across the country will face the choice between becoming a Wilmer Krusen or a Max Starkloff.

In the moment, it will seem easier to follow Krusen’s example. For a few days, while none of your peers are taking the same steps, moving classes online or canceling campaign events will seem profoundly odd. People are going to get angry. You will be ridiculed as an extremist or an alarmist. But it is still the right thing to do.

 

https://www.sciencemag.org/news/2020/03/does-closing-schools-slow-spread-novel-coronavirus?fbclid=IwAR0DZmornmQrYZJdgnz6ELAIl4cNocAl1nC6UExyZ4dIGByhaXrYV4PEcwo

When we engage in social distancing, it’s not so much that you don’t get infected yourself. The real advantage is that by removing yourself from circulation, you stop all the paths of this virus through you. You are doing a social service, you are helping the community. Employees who want to work from home [and are able to] can work from home.

 

Italy’s experience:

https://www.theatlantic.com/ideas/archive/2020/03/who-gets-hospital-bed/607807/

Two weeks ago, Italy had 322 confirmed cases of the coronavirus. At that point, doctors in the country’s hospitals could lavish significant attention on each stricken patient.

One week ago, Italy had 2,502 cases of the virus, which causes the disease known as COVID-19. At that point, doctors in the country’s hospitals could still perform the most lifesaving functions by artificially ventilating patients who experienced acute breathing difficulties.

Today, Italy has 10,149 cases of the coronavirus. There are now simply too many patients for each one of them to receive adequate care. Doctors and nurses are unable to tend to everybody. They lack machines to ventilate all those gasping for air.

Now the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has published guidelines for the criteria that doctors and nurses should follow in these extraordinary circumstances. The document begins by likening the moral choices facing Italian doctors to the forms of wartime triage that are required in the field of “catastrophe medicine.” Instead of providing intensive care to all patients who need it, its authors suggest, it may become necessary to follow “the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources.”

The principle they settle upon is utilitarian. “Informed by the principle of maximizing benefits for the largest number,” they suggest that “the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care.”

 

On taking the larger, community-centered view:

https://grownandflown.com/finest-hour-covid-19/?fbclid=IwAR34zisTQM3zb6JzF3u3obqL9EfkNEOwo7-x8R4QOciwJ36c8QA1ibCNeVY

Your losses are real. Your disappointments are real. Your hardships are real. I don’t mean to make light or to minimize the difficulty ahead for you, your family or community.

But this isn’t like other illnesses and we don’t get to act like it is. It’s more contagious, it’s more fatal—and most importantly, even if it can be managed. It can’t be managed at a massive scale—anywhere. We need this thing to move slowly enough for our collective national and worldwide medical systems to hold the very ill so that all of the very ill can get taken care of.

So what is our work? Yes, you need to wash your hands and stay home if you are sick. But the biggest work you can do is expand your heart and your mind to see yourself and see your family as part of a much bigger community that can have a massive—hugely massive—impact on the lives of other people.

You can help by canceling anything that requires a group gathering. You can help by not using the medical system unless it is urgent. You can help by staying home if you are sick. You can help by cooking or shopping or doing errands for a friend who needs to stay home. You can help by watching someone’s kid if they need to cover for someone else at work. You can help by ordering take-out from your local restaurants. Eat the food yourself or find someone who needs it. You can help by offering to help bring someone’s college student home or house out-of-town students if you have extra rooms. You can help by asking yourself, “What can I and my family do to help?” “What can we offer?” You can help by seeing yourself as part of something bigger than yourself.

 

Dr. Anthony Fauci on how to counsel patients, 13 min New England Journal of  Medicine podcast with transcript:

https://podcasts.jwatch.org/index.php/podcast-256-anthony-fauci-talking-with-patients-about-covid-19/2020/03/10/?query=RPF&fbclid=IwAR0gIzU7M5WOyC4964CbKnglcNw_wlSODvT6-KAYodWdKCMyrQWou2jyAK0

 

 

Sexism and Apologies 2020

Posted on by
9

IMG_3811

“If you say, ‘Yeah, there was sexism in this race,’ everyone says, ‘Whiner!’ If you say, ‘No, there was no sexism,’ about a bazillion women think, ‘What planet do you live on?’”

That is how Senator Elizabeth Warren answered a reporter when asked whether she thought gender played a role in her suspending her presidential campaign.  I recommend watching the whole video clip.  In case anyone wonders: if the question even needs to be asked, then yes, gender played a role.  But Senator Warren rightly called out the question for what it is: a trap for any woman running for high elected office.  Her statement summarizes it succinctly; she knows what’s what, and she names it without apology.

I was more upset than I expected when Aunt Eliz Crusader ended her campaign.   Megan Garber expressed the story of my profound disappointment eloquently in her piece for The Atlantic:  “America Punished Elizabeth Warren for her Competence”.  Basically she elaborates the apparently inevitable social equation for women:

Competent  +  Vocal  +  Unapologetic   =   “Strident”  +  “Shrill” +  “Condescending”

The past two weeks I have had a series of encounters wherein I find myself voicing opinions and positions more firmly than I might have in the past.  I feel confident and grounded in my knowledge and expertise.  I am professional and respectful.  I apologized for writing a long email, even though the words were necessary and clear.  My strong woman mentor reminded me to save apologies for when I actually commit a transgression.

What I have learned (perhaps again) in this time, however, is that relationship discord, even just the possibility of it, is what distresses me the most.  How will I be perceived for voicing my concerns, for advocating for my peers and teams?  How will a negative perception undermine my effectiveness?  Will it cost me my seat at this table or others?

Does any man ask himself these questions?

Given that I was already knee deep in vulnerability and self-doubt around these encounters, the Atlantic piece poked my fears and prodded them to the surface.  It shook me.  It also made me angry that here we still are, in 2020, unable to accept, let alone embrace, competent, vocal, and unapologetic women in leadership.  And it’s not just men; countless women also disavow their sisters.

I vented my disappointment on Facebook (of course):

“So it is down to three Old White Men.  Very disappointing.”

A friend tried to make light of the situation, pointing out that Donald Trump is the youngest of the three.  This attempt at levity (from the Right) felt like a nemesis rubbing salt in my fresh wound.  Twice I rebuffed; twice he persisted.  Finally I (voiced):  “I feel ignored and dismissed when I express distress and you make light of it.  Perhaps my distress is not clear to you, because you only know me through social media [we were friendly acquaintances in high school]; you may not know how upset I am.  But after two replies by me rejecting your attempt at humor, to have you schooling me [that humor is a ‘primary’ way] of dealing with [politics] just makes me more angry.”

Turns out he had mistyped; he’d meant to write that humor is one of his primary ways of coping with the absurdity of politics.  He apologized to me.  It felt sincere.  I was consoled, and I thanked him.

Competent and vocal.  Confident and unapologetic.  Respectful and humble.

We need all of these qualities and more to be true leaders.  Women, arguably, must work harder than our male counterparts to prove that we possess all of them.  Then we get punished when the proof proves irrefutable.  How sadly ironic.  The truth is we need many more of our leaders, men and women alike, to own, exude, and model these virtues.  The last two are not weak, though they may feel profoundly vulnerable, which is not the same thing.

I feel urgent impatience at the state of sexism in America.  But I know how to soothe and manage myself; I can reclaim the patient urgency of fierce optimism at my core.

I will persist.

Aunt Eliz has shown me how.