In the news             July 15, 2020

A few days ago I wrote about herd immunity, pointing out that if it comes about naturally it requires a very long time and it is temporary, whereas if it can be accomplished by a continual immunization program it is likely to occur relatively quickly and become permanent. For example, when immunization against the pneumococcus bacterium, a cause of minor infections such as ear infections and major ones such as meningitis and bacteremia (invasion of the bloodstream) became routine in children the incidence of pneumococcal pneumonia caused by vaccine strains among adults diminished significantly.

In the case of COVID-19 we need to think about children for another reason: they seldom become seriously ill from this new coronavirus unless they too have an underlying condition such as heart or lung disease. If we compare COVID-19 with chickenpox it reveals why opening the schools now will have significant value long-term.

Until the chickenpox (varicella) vaccine was developed in 1995 it was rare for anyone to reach adulthood without having experienced the disease. The illness is generally so mild in children that parents often staged “chickenpox parties” in the neighborhood to “get it over with.” Unfortunately about 150 children in the United States succumbed to the disease or to secondary infection every year. The story was quite different in adult victims, about twenty percent of whom developed chickenpox pneumonia and whose risk of dying was far greater. In some years prior to release of the vaccine an adult was 25 times more likely to die from chickenpox than a preschool child. Now that the virus has almost disappeared there have been almost no deaths due to chickenpox in this country in recent years.

How does this relate to COVID-19? Fatality rates begin to increase after the age of twenty; there is a dramatic rise beyond age sixty. Those beyond the age of eighty have the highest risk. In each of these age groups there is a progressively increasing incidence of type 2 diabetes. In the past few days there has been a cluster of medical journal articles (that I will discuss in next Saturday’s Pandemic Perspective blog) indicating that elevations of blood sugar even in persons who have not been diagnosed with diabetes increase the risk of severe disease and death. Obesity rates increase with age and it is a high-risk factor that often leads to the dreaded cytokine storm.

We should not fear the exposure of children to SARS-CoV-2. They have an innate resistance to severe disease, just as they do against chickenpox and they do not have the risk factors that are present in the vast majority of older adults. Further, as we have seen in other viral infections, the natural disease is likely to result in longer and stronger immunity than the vaccine-induced stimulus. A clear example is mumps, whose vaccine-induced immunity wanes dramatically during adolescence but in which natural infection produces lifelong immunity. By protecting children from COVID-19 infection we may be setting them up for a greater risk of disease when they become adults, whether or not they receive the COVID-19 vaccine.

Lifestyle

            Memory loss. Is this the worst annoyance of aging?

We dread it more than death, fearful that having difficulty in remembering names is a prelude to dementia. The prospect of becoming unable to recognize loved ones and to be incapable of managing the day-to-day routines of living is terrible to imagine. The good news is that we can do something to ward off memory loss and postpone the onset of Alzheimer’s disease and vascular dementia. Although Alzheimer’s disease has a strong genetic component, vascular dementia has little to do with aging; it is the product of the modern lifestyle and comprises about one-half of dementia cases.

Contrary to what I was taught in medical school, we can form new brain cells throughout life by engaging in physical exercise and we can increase connections between brain cells many-fold by engaging in taxing mental activity.

Exercise is important in maintaining normal body weight. Overweight and obesity lead to a loss of brain volume; excess body fat increases the risk of type 2 diabetes by a factor of eighteen (!) which leads to blood vessel damage within the brain. That in turn leads to starvation of brain cells and increased brain cell death.

In other words, regular, moderate physical activity – 4 or 5 times a week for at least one hour at an intensity that works up a sweat – not only reduces obesity but grows new brain cells and supports the health of old ones.

Good nutrition is also critical, especially omega-3 fats, abundant in fish (or a supplement if you just don’t like fish!)

Stimulate brain health by learning a new language, how to play a new musical instrument, reading, puzzles and games.

Okinawa has the highest percentage of centenarians on the planet, people who live beyond 100 years. They can take care of themselves and they can remember the names of their great-great-grandchildren. What do they have in common? Few labor-saving devices; they carry out most chores by hand or with simple tools. They eat almost no red meat and no refined grains or sugar; most of their calories come from plant foods.

A pretty simple lifestyle, and it works.

Pandemic Perspective #17   July 11, 2020

Is herd immunity a false hope?

Almost since COVID-19 became the leading story of 2020 there has been the hope that herd immunity would bring the pandemic to an end. Not likely. Authorities have flip-flopped on issues such as transmissibility, susceptibility, mask effectiveness, the efficacy of old and new drugs and ventilator therapy. We shouldn’t be surprised if the concept of herd immunity will be tested.

When a new microbe invades a population it sickens some, kills some and infects some who show no apparent symptoms. At a given point there are too few potential victims remaining or they are too widely dispersed so that the infectious agent seems to vanish. It might circulate quietly without causing much notice but can resurface when a new population of susceptible persons arises. The surviving herd is now relatively immune but danger always lurks.

That is not the ideal type of herd immunity because it is only temporary. A more desirable form of herd immunity is based on vaccines. When most of a population has been vaccinated – measles is a good example – a virus that arrives from the outside has no place to go. As long as immunization rates remain high, ideally above ninety percent, herd immunity is permanent and can remain so for generations, unlike that which occurs in natural infections.

Because measles vaccination was so effective by the end of the 20th century the United Sates was declared to be measles-free, a state that quickly changed when increasing numbers of parents refused to allow their children to receive routine childhood vaccinations, including MMR (Measles-Mumps-Rubella). In the past two decades there have been several outbreaks of measles when persons from outside the United States introduced the virus to a population not all of whom had vaccine-induced immunity.

How will the herd react to the coronavirus? The honest answer is that no one knows. In a world without a vaccine it will take years, perhaps decades, before most of the population has been infected, leaving behind so few susceptibles that the virus becomes an annoyance and not a threat, at least temporarily as noted above. As of mid-July there have been fewer than 15 million cases worldwide. Some epidemiologists believe that there are at least ten times that many persons who have encountered the virus but who have been misdiagnosed or missed entirely because they have had few or no symptoms, a total of perhaps 150 million. Among a global population of 7.5 billion that represents only 2 percent who have experienced the virus thus far. The likelihood of a naturally-occurring herd immunity is vanishingly small, especially when government officials are madly scrambling to prevent the development of herd immunity by limiting exposure.

Enter an effective, i.e., fully protective and long-lasting vaccine. Even if some of the more than 150 companies now racing toward this goal are successful, what will it take to provide herd immunity? Again, no one knows. Some vaccine candidates require two doses; some, like the influenza vaccine, may require annual doses. Protecting most of the world’s population with even a single lifetime dose will require a logistical effort unlike any that the world has ever accomplished.

Unless there is an immediate breakthrough with a highly effective drug against the SARS-CoV-2 virus it’s likely that a quarter-million Americans will have died of this disease by the end of 2021. Roughly half will have had conditions such as diseases of the heart, lungs or kidneys; most of those will be the elderly; being overweight and having type 2 diabetes are major risk factors. Perhaps a COVID-19 vaccine will protect individuals in these groups. I certainly hope so.

Unfortunately, herd immunity will not be a factor.

Pandemic Perspective #16   July 4, 2020

Happy Independence Day!

COVID-19: It’s time to think long-term

          A couple of months into the current pandemic there was wishful thinking that it would run its course before the end of the year, that there might only be a few flare-ups in some parts of the world, that mortality rates would improve as hydroxychloroquine, remdesivir and other medications stopped the virus in its tracks and that a vaccine would put an end to it once and for all. All these speculations have been quashed or at least their timelines drastically altered.

The COVID-19 pandemic is going to be a part of everyone’s life for a long time. It will not burn itself out; it will smolder for years as it penetrates into more remote areas not yet affected.

There are two great unknowns: what percentage of the population will have to have been infected to reach herd immunity and how effective a vaccine will be. The SARS-CoV-2 virus is not just another coronavirus. Although it is much less likely to kill its victims than its predecessors, SARS and MERS, it is more transmissible and certainly more unpredictable. It is deadly for seniors and produces a pattern of symptoms in very young children that pediatricians have never seen before.

Development of a vaccine will occur with historically breathtaking speed but there’s more to it than that. Although I feel that it will be more protective than some pessimists have predicted it may require more than one dose, adding to the already obvious challenge of rapid worldwide distribution. Lurking beneath is the matter of politics. The countries in which the vaccine is being manufactured claim first dibs; developing countries have expressed fears that they will be at the end of the line.

Our personal and public habits are in a tizzy. Dr. Fauci claims that handshaking will be taboo forevermore. Try wrapping your head around that one! Will older, i.e. persons over the age of fifty, no longer hug their grandchildren? The medical establishment warns us about fomites, things like doorknobs, railings and light switches that can seed the populace with live virus particles for days. So how about cash? Financial experts have been pushing us toward a cashless society for a couple of decades. Is this their chance to get it done? After all, think of how many hands have touched the change that the store clerk hands you if you have paid in cash. It will be another boon for Apple and Samsung, whose smart phones allow us to pay for anything by letting the device hover over the item we’re purchasing. Just like in the Amazon store.

Here’s another ugly thought: no more card games, e.g. blackjack, poker and canasta, in which playing cards pass from hand to hand for a couple of hours. Will the country’s casinos require than every craps player bring his or her (properly disinfected) dice. How will those casinos reconfigure slot machines to deliver winnings without a handle or a pushbutton? Hmmm! Maybe a smartphone can do that too.

The restaurant scene has already changed and they will all now become “intimate” – quiet, uncrowded. The menu is printed anew every day and you’ll place your order with that ever-more-important smartphone.

As one wag put it, “So in retrospect, in 2015, not a single person got the answer right to ‘Where do you see yourself 5 years from now?’”

In the news             July 1, 2020

The coronavirus pandemic reminds me of the game called pick-up-sticks that kids have been playing for centuries. It may have originated in China (how’s that for irony?) but Native Americans have also been credited for its invention. It’s difficult to move a single stick without moving others, a situation that seems to be playing out in the many facets of COVID-19.

The big news this week is the surge in new cases, especially in California where the numbers are increasing by as much as 5,500 daily. But maybe those numbers reflect conditions that were not apparent or even present a month or so ago.

Perhaps the greatest tragedy of this pandemic is the high mortality rate among the elderly who have underlying diseases of the heart, lungs, kidneys and immune system. Depending on the area of the country they account for as much as ninety percent of deaths. The good news is that around the world healthcare systems are doing a better job of protecting them. That might help to explain why the global fatality rate has dropped from 7.0 percent on April 28th (from the Johns Hopkins Coronavirus Resource Center) to 6.2 percent on May 28th and 4.9 percent on June 28th.

Epidemiologists predicted early on that there would be a decrease in cases and then a new wave would arrive. China is a good example, a country that has locked down some major cities after having reported a dramatic decline in new cases. That is not a peculiar feature of the current pandemic; we know from past plagues that there could be several waves over months or years.

The mushrooming accessibility of testing also plays a role although it does not explain the rise by itself. Some states are reporting hospitalization figures that again threaten the capacity of hospitals to provide ICU beds. But there is some good news: overall, the percentage of infected patients requiring hospitalization is decreasing and so is the mortality rate among them as treatment methods improve.

Then there are “the invincibles” — young persons who don’t fear the virus, who congregate freely in bars, on beaches and various venues. Pardon the politics, but when tens of thousands of protesters disdain distancing and face masks while shouting and chanting it shouldn’t come as a great surprise that the age of infected – and hospitalized – persons is dropping. This week’s report by the San Diego Health Department noted that the greatest surge at the moment is among persons between the age of twenty and forty. To the great dismay of this younger crowd, bars, nightclubs and restaurants have again been ordered to shut down.

When we celebrate Independence Day this weekend let’s be grateful that the United States of America is not only a beacon of freedom but that it leads the world in innovation, compassion and generosity. For all those reasons we’ll emerge from the pandemic, the riots and the hurt economy like an injured bone that is stronger at the broken places.

Lifestyle

          Decreased mobility – another annoyance of aging.

As we age we become less mobile for many reasons. Weakness of muscles, stiffness of joints, diminished flexibility, carrying extra weight and neurological diseases add up to quite a mix. When you’re at the fitness center, watching those twenty-somethings bounce around, jump three feet onto a platform from a standing start and run for what seems like hours on the treadmill is really rubbing it in. The bright side is that those of us who move more slowly and deliberately are less likely to injure ourselves. Yeah! Right!

The truth however is that we can maintain strength, flexibility and speed (Well, not so much speed.) far longer than the average person if we work at it.

Why do old people shuffle? The answer is that they don’t have enough strength in their legs to raise their feet. The sedentary lifestyle not only weakens muscles, it diminishes blood circulation to those muscles. That means less oxygenation, less removal of waste products and less ability of muscle groups to stretch.

You might have noticed after reading these blogs that several of the so-called diseases of aging can be postponed with exercise. So simple, yet so true. If you can lose a few pounds through exercise it’s like taking off a heavy backpack. And less weight relieves pressure on the hip and knee joints.

And there’s another benefit of exercise. When your legs become stronger they provide a braking effect that prevents a hard landing with every step and less of an impact on your hips, knees, ankles and feet.

The unsteadiness that results from poor balance also affects our mobility and exercise helps there too by maintaining the health of spindle cells. These are attached to healthy muscle cells and explain why we can navigate or reach for objects with our eyes closed. Spindle cells provide position sense, the loss of which has nothing to do with aging. When muscle cells shrivel from lack of activity they take spindle cells with them.

There are lots of annoyances of aging that we can’t avoid but losing our mobility isn’t one of them until we hit the century mark. Just ask Don Pellman, the 100-year-old pole vaulter who also set records in the long jump, high jump and discus throw at the San Diego Senior Olympics in 2015.

Pandemic Perspective #15      June 27, 2020

Will wine kill the coronavirus?

Well, alcohol kills the coronavirus, so maybe this is one more health benefit of wine. If only!

As the pandemic rolls on, medical workers are getting more innovative and desperate to find some way to stop it. To date there have been more than 100 studies designed to evaluate the possibility that rinsing the mouth with various chemicals, alone or in combination, might reduce the number of virus particles. These include hydrogen peroxide, povidone-iodine, chlorhexidine and cetylpyridinium chloride – and ethyl alcohol, a component of many of our favorite adult beverages.

If you have visited your dentist recently you probably were given a mouthwash that includes hydrogen peroxide, fortunately in a low concentration that doesn’t cause gagging. Healthcare workers such as dentists, their assistants and ear, nose and throat surgeons who spend long periods only inches away from virus particles that might be escaping from their patients’ mouths are properly concerned about becoming victims of the new coronavirus. If you visit one of these practitioners you’ll be given a slug of mouthwash before anything gets done.

Of the scores of studies done so far there is no clear consensus that any of the preparations will work. Some studies have only been done in vitro (the Latin term means in glass, not in a human or animal body) so that the results are very preliminary.

What researchers have found so far in studies with real people is that an oral rinse (mouthwash) does seem to have some beneficial effect but it’s not ready for prime time. It’s somewhat like the situation that I have described in earlier blogs regarding face masks: it depends. Wearing a mask does prevent some spread of virus particles from the wearer and does offer some protection to an exposed person but the devil is in the details. (Sorry for the cliché.) An infected person sheds some virus from the lungs, not just the mouth or throat. Sometimes the virus is present in the salivary glands so that using a mouthwash has only a temporary effect. We don’t know how often a rinse is necessary. Is a minute of swishing the stuff around enough or does the user have to gargle? Some of these chemicals cause allergic reactions and hydrogen peroxide can cause tissue damage in concentrations of more than 5 percent. (For reference, the hydrogen peroxide on the drugstore shelf has a concentration of 3 percent.)

But getting back to wine – it does have an alcohol content of between 5 and 20 percent. Better yet, the alcohol percentage in scotch ranges from 40 to 63 percent! Research studies – yes, they do pay scientists to study these things – show that mouthwashes containing 21 to 27 percent ethanol (as in wine and one-third as much as in Johnny Walker) combined with essential oils, reduced levels of influenza virus by a whopping 99.99 percent!

The next goal of the scientists: is red wine better than white wine? Salud! I hope that this helps you to get over the COVID-19 blues!

Pandemic Perspective #14    June 20

Face masks forever?

The confusion and contradictory advice regarding face masks is never-ending and the varying rules among several state governors about wearing them might go on forever too! How long are you willing to wear a mask whenever you are outside your own home or vehicle? Are you thinking about having your mask-defying neighbors over for dinner anytime soon? That last idea might get you arrested, or at least cited. Dr. Wilma Wooten, San Diego County’s public health officer, says that getting together with someone not in your own household would likely be banned until we have achieved herd immunity.

That last point is crucial. In order for herd immunity to effectively slow down the spread of the coronavirus it would probably require that at least half – and perhaps as many as 70 or 80 or 90 percent! – of persons in the major population centers of the world would have to have recovered from the virus or to have received a proven vaccine.  Fewer than 10 million cases have been identified so far out of a global population of more than 7 billion! Like so many issues involving this new coronavirus, no infectious disease or public health expert has any idea of what herd immunity means for COVID-19.

But wait a minute! The more we succeed at limiting spread of the virus by shutting down the world’s economy the longer it will take to achieve herd immunity. Even if the most optimistic estimates pan out it will be a least a year before an effective vaccine will reach most of the industrial world.

And here’s another fly in the face mask ointment. On June 16th Greek researchers reported that coughing through a face mask could propel virus-carrying droplets as far as four feet. As one of the study’s authors noted, “The use of a mask will not provide complete protection.” That has been tragically obvious among healthcare workers who spend days on end within inches of the faces of infected patients, wearing masks that are nearly 100 percent effective. Some virus particles are eventually going to get through and long exposure to high concentrations of a virus can be deadly.

And here’s something that is hardly ever mentioned: there is an enormous difference between a properly fitted medical grade N95 mask and a cloth mask.

A headline in the San Diego Union-Tribune (June 19, 2020) reflects the confusion: Muddled mask messaging may be haunting coronavirus re-openings.” The article describes the masks being recommended: “…cloth coverings – homemade masks, bandanas, gaiters, scarves” and that medical-grade masks commonly known as N95, “should be saved for healthcare workers.” It’s very clear, however, that simple cloth masks are not very effective. Bandanas? Scarves?

The Keystone Kops (yes, that’s the way they spelled it in the early 1900s) had nothing on the coronavirus experts of 2020.

In regard to the term “forever” in the title of this blog, here’s a cheery note. In a survey by the New York Times more than half of more than 500 epidemiologists and infectious diseases experts said that it will be at least a year before they stop routinely wearing a mask.

My suggestions – at least for the moment:

Follow the rules and wear a good mask; stay away from anyone who is coughing.

Come out of isolation whenever you can to preserve your sanity, especially if that involves being outdoors where the risk is close to zero.

Accept that you might become infected with the coronavirus. It’s part of being human and you are adding to herd immunity.

In the news

When epidemics form a perfect storm

The climatologists who coined the term “perfect storm” probably never imagined that it would be applied to epidemics. Yet here we are, as the global community is experiencing a collision of three epidemics: obesity, type 2 diabetes and the SARS-CoV-2 coronavirus. The last one struck swiftly; the first two have been gnawing away at humanity for more than a half-century but health authorities classify them as epidemics. As they collide we are experiencing a perfect storm.

Almost any group photo from the era around World War Two seldom includes an obviously obese person and even fewer show more than one. In 1950 the rate of obesity — somewhat arbitrarily defined as thirty pounds over normal weight for height – was only ten percent. According to the Centers for Disease Control and Prevention (CDC) the rate of obesity – now defined as a Body Mass Index (BMI) of thirty or greater — in the United States is forty-two percent! It is even higher in some southern states. More than seventy-five percent of our population is either overweight or obese but both groups are affected by what I will discuss below.

The rise in type 2 diabetes began later but in 1950 it was diagnosed in only one percent of the population. It was called adult onset diabetes in order to differentiate it from type 1 diabetes, known as juvenile diabetes. Both terms are obsolete as the type 2 form is now common in adolescents; the current incidence in the U.S. population is an astonishing twelve percent. In persons over the age of sixty it is nearly three times as high.

Most persons with type 2 diabetes are overweight or obese. A few not so classified have excess body fat, which has similar consequences. They all have dysfunctional immune systems that put them at high risk from various types of infectious diseases, especially influenza and COVID-19. Soon after health authorities became aware of the scope of this new coronavirus they recognized that obese persons had a higher risk of dying than those of normal weight. This was exaggerated among the elderly, who not only tended to be overweight or obese as well as diabetic, but suffered from the complications caused by excessive weight, diseases of the heart, lungs and kidneys. Those who suffered greatly from these chronic diseases lived in senior facilities. It is no surprise that so many deaths from COVID-19 occurred among this group.

A fat-laden body carries more than engorged fat cells. That tissue harbors cells of the immune system that produce inflammatory chemicals known as cytokines. Inflammation is part of the normal response to infection but during a viral infection in some obese persons, inflammation goes out of control, producing cytokine storm. The flood of cytokines wreaks havoc among normal organs, causing them to fail and resulting in death.

What if today’s Americans had the very low levels of obesity and type 2 diabetes of 1950? There would be fewer persons at risk. There would be no economic paralysis. COVID-19 will eventually fade away as a result of herd immunity, vaccines, new antiviral agents and more sensible public health measures. But obesity and type 2 diabetes are here to stay. And the next pandemic, likely to occur before the end of this century, will terrorize the world again.

Lifestyle

Depression – it’s more than just an annoyance of aging.

Depression often accompanies the aging process for several reasons: loss of a spouse, the onset of chronic or life-threatening disease, financial difficulties and loneliness. It is often unrecognized by the patient and by health professionals who miss some of its signs such as poor appetite, disordered sleep or loss of interest in previously enjoyed activities.

The current COVID-19 pandemic and the resultant shutdown of the economy can only exacerbate the problem, even as it extends to younger persons.

As I have pointed out in several of these annoyances of aging, depression may be a symptom of some other illness or even a side effect of a prescription medication. It can be a sign of thyroid disease, a neurological problem such as Parkinson’s disease or multiple sclerosis or even chronic infection such as Lyme disease. Each of these conditions is notorious for being missed by health professionals, sometimes for years. The range of prescription drugs that are linked to depression is remarkably diverse. It includes sedatives, anticonvulsants, heart medications and many more.

A sad element of depression is that the victim is often in denial. Treatment is a challenge; anti-depressants often have serious side effects.

What appears to be depression should always prompt a search for an underlying cause even if there appear to be life-related issues.

Pandemic Perspective #13      June 13

          This Saturday’s blog is part of a sort-of-regular newsletter that I provide to persons in our church congregation who have taken our CPR course – more than 700 since the program began in 2001 – or who have expressed a desire to take a class. Learning basic CPR is one of the most valuable things that you will ever experience. The fear, anxiety and paralysis that affect most untrained persons when a loved one collapses will no longer affect you after a mere three hours of training.

          I’m sure that many of you have been concerned, as I have been, about the risk that we might be taking these days if we provide CPR for a person whose COVID-19 status we don’t know. Some authorities tell us that many persons with the infection are asymptomatic although that is conjecture with mixed opinions from scientists. The conflicting statements from the W.H.O. are clear evidence of that. A seemingly similar conjecture appeared in a http://www.medscape.com article this week.

An analysis from Seattle concluded that providing CPR during the pandemic carries little risk. I want to emphasize – as the analysts themselves honestly do – there is no real evidence for the numbers that they provide. However, it is somewhat reassuring, although it is based on “compressions only” (known as “hands only”) in which there are NO rescue breaths (mouth-to-mouth) given. The assumption is that ten percent of victims are infected and the assumed risk for acquiring infection is ten percent by rescuers NOT wearing masks (PPE – Personal Protective Equipment). In other words, your risk of getting infected is one out of a hundred.

If the risk of dying is one percent (or 0.01 percent in the opinion of some epidemiologists), your risk of dying if you give someone compressions-only CPR is one out of ten thousand!

I’d like to offer a couple of points:

You can’t give rescue breaths through a mask. But the analysts suggest wearing one if you only provide compressions.

The victim might need rescue breathing!! Not all unconscious, non-breathing victims have a heart problem. A person might have a heartbeat but no breathing if they have had a stroke, were electrocuted or have had a drug overdose.

If more than about four minutes have elapsed since the victim stopped breathing, they will require oxygen via rescue breathing. If professional responders have not arrived by then, what will you do?

Do you have a barrier mask with you at all times? The smallest packets with a simple plastic mask are a little bigger than your thumb and are easy to carry in your pocket, purse, car glove compartment or console, or on a key ring. They cost about $1.00 on Amazon. You might not find them at your local CVS or Walgreens.

Finally, if you are under the age of 60 and don’t have any heart, lung, kidney or immune system disorders, your risk of serious disease in doing a FULL resuscitation are vanishingly small but immensely rewarding.

Pandemic Perspective #12      June 6

Today is a very special day, the 76th anniversary of the Normandy invasion. Let’s take a moment to remember and to thank all those who died, and those who carried the physical and mental scars for the rest of their lives.

COVID-19 Lemonade for the Workplace

Yesterday’s good employment news made the likelihood of a V-shaped economic recovery look better than it did just a few days ago after the widespread and violent protests that followed the tragic death of George Floyd in Minneapolis. Still, businesses that had expected to be closed temporarily may never recover from the looting and destruction. The untouched shops and restaurants around them might not survive either.

Closely-packed, maskless, shouting demonstrators are sure to spread the virus. It seems that the bug can travel a long way from the throats of loud talkers and singers – note the extreme spread among two choir groups a couple of months ago – it’s one reason that we are going to have limited singing at our church services. Even though the protests have been out in the open we can expect more cases among those enthusiastic participants.

I’ve been tracking the case numbers in New York City, Los Angeles and Minneapolis since May 31st; by mid-June we should know if those cities and their suburbs will experience an even worse rebound than some health authorities warned us about because of premature reopenings.

Businesses are already revamping their workplaces on a massive scale. I know of at least two that have told nearly all their employees that they will be working from home until the end of the year. It will probably be a couple of years before things become stabilized but there will be some advantages to these changes.

The main reason for working from home is obviously the reduced risk of SARS-CoV-2 infection from co-workers but it goes beyond that. The influenza virus spreads through office spaces nearly as rapidly as this new coronavirus and so do the many different cold viruses. (Mild forms of the coronavirus cause about one-quarter of common colds.) That adds up to less absenteeism and higher productivity during the next cold and flu season that begins in just a few months. Keeping preschoolers at home makes getting things done more complicated but the kids won’t be bringing germs home from daycare and infecting their parents and older siblings. During my practice years I often had to explain to parents that the average preschooler acquires a respiratory or intestinal infection about once every five weeks; if they are in day care the infection rate nearly doubles. Keeping them at home will also improve the family’s cash flow considerably.

Americans eat nearly half their meals outside the home and much of that is fast food. For the homebound worker that’s probably healthier and it’s certainly less expensive. You’ve seen the cartoons and jokes about quarantine weight gain, such as Batman and Mona Lisa who now each check in at about 300 pounds. Expect to see a lot more TV ads for weight loss programs.

Every part of the auto industry is taking a hit, from manufacturing to sales to repairs but the upside is cleaner air and less traffic-associated stress. One tankful of gas lasts a month. I have an all-electric vehicle and I don’t expect to recharge it until July! We have already received two credits from our auto insurance company because their claims have fallen. And we welcome the drop in motor vehicle-related deaths and injuries.

Next week I’ll discuss facts and foibles regarding how to prepare for the next pandemic, including what steps to take if the current one has a severe and extended surge. It goes beyond toilet paper, rice and peanut butter!

In the news

 Will the fat lady ever sing?                

   “It ain’t over ‘til the fat lady sings,’ attributed to sportswriter Dan Cook, 1976.

            If this well-worn saying refers to the coronavirus pandemic we may never hear her final aria. SARS-CoV-2 is here to stay. It differs from the SARS coronavirus that surfaced in 2002 and MERS (Middle East Respiratory Syndrome) that was first identified in 2012. Unlike those two versions it has a low mortality rate except for elderly persons with underlying medical conditions. This strain is much more contagious and has rapidly infected more than one-half billion people around the globe in a little more than six months. In that brief period it has forever changed the world’s economy, challenged healthcare systems and profoundly altered how humans interact and communicate with each other. It will be a long time before the pandemic subsides and we can feel that life has settled into the next version of normal.

The good news is that the proverbial silver lining is already evident. Vaccine technology, accelerated by advances in genetics, may yield a SARS-CoV-2 vaccine in months, not years. Anticipating success, some manufacturers have already prepared millions of doses that can be distributed immediately as soon as their candidate is found to be safe and effective. Nothing like this has happened since Dr. Edward Jenner developed the first safe and successful smallpox vaccine late in the 18th century.

Social distancing has accelerated the move toward digital communications. There could be a reversal of the steep upward trajectory of college costs as online presentations replace lecture halls and classrooms. Zoom conferences don’t require business travel. Some healthcare providers already report that ninety percent of routine patient visits no longer take place in the office but via the telephone or computer. Devices that transmit vital signs such as blood pressure, temperature and oxygen levels are no longer Star Trek imaginings and they will proliferate.

How long will the fear of crowds affect our behavior? What will happen to events that by their nature draw large numbers of people? Will sports teams and entertainers be able to fill stadiums and arenas? Will movie theaters be able to survive when even the least tech-savvy among us have finally learned how to navigate our smart TVs to find the latest releases on Hulu, Apple TV or scores of other streaming services?

Almost no government, business, institution or individual was prepared for COVID-19. A few national leaders did foresee a pandemic scenario – Bill Gates and Marco Rubio come to mind – but no one heeded their warnings. Worse, federal and state administrations allowed stockpiles of medical supplies to dwindle. This time people and governments will listen to the prophets among us. The “prepper” movement will gain new adherents; to the mantra of “beans, bullets and band-aids” they will add “toilet paper”. Financial advisors who have warned us for decades that having one year’s income in savings was prudent no matter how difficult, will see that many families are following their advice. Fifty governors will ensure that their citizens will have ventilators, medical supplies and other essential items before the next pandemic arrives.

We might see the eventual reversal of the twin epidemics of obesity and type 2 diabetes. Early in the pandemic it became clear that the elderly were those at highest risk. It was not because of their years, it was because they had comorbidities that included overweight and diabetes and other conditions that included lung disease, high blood pressure and chronic kidney disease, all of which are almost entirely the result of lifestyle and are thus avoidable.

Physicians will develop new insights into viral diseases, how to treat them and how the human body reacts to them. They are learning how to use mechanical ventilators more effectively and how to prevent or treat the aberrant immunological response to infection known as cytokine storm.

The pandemic has accelerated research into dozens of antiviral drugs, novel applications of drugs that were developed more than a half-century ago and innovative diagnostic methods. Since the Renaissance era, wartime diseases and injuries have accelerated medical progress. This new war will do the same.

The fallout from the coronavirus pandemic will shadow us for years, possibly decades. If that view is correct, the fat lady will be waiting in the wings for a very long time.

Lifestyle

We’re all concentrating on avoiding the coronavirus and in keeping our sanity in this prolonged loss of social contacts. Routine doctor visits are being postponed but sometimes urgent problems override caution. One of the annoyances of aging, (the 17th in our series) kidney stones, is one of those. The severity of the pain that they cause is almost never life-threatening; it just feels like it.

Most kidney stones are composed of calcium oxalate and thus we can avoid them with minor changes in our lifestyle. Some are caused by a genetic biochemical defect and a few accompany gout, a painful condition of the joints.

The single most important factor in the development of kidney stones is dehydration, a condition that is common among older persons but that is almost always avoidable. When we get behind in our fluid intake the body responds by conserving water, thus making the urine more concentrated. Some of the solid materials that have been filtered through the kidneys also become more concentrated. As they coalesce they form itty-bitty (a scientific term) particles within the kidney that grow larger as dehydration persists, eventually forming stones. The tiniest leave the kidney and depart harmlessly when we empty our bladder. When larger stones exit the kidney via the ureter they encounter a couple of narrow sections and cause severe pain as they squeeze through. That’s not the end of the story. If they make it to the bladder they make the voiding process similarly painful.

The rough surface of a kidney stone that causes severe pain often scratches the walls of the ureter enough to cause bleeding. Sometimes blood in the urine is the first sign of a stone and is always an indication for a visit to the doctor.

Once upon a time doctors told patients who had suffered from kidney stones to reduce their calcium intake in order to prevent a recurrence. Just the opposite is true; taking too little calcium will encourage stone formation. The culprit is not calcium but oxalate. Oxalate is a constituent of many plant foods, especially rhubarb, spinach, strawberries and chocolate. (Sigh!)  Calcium in our food binds oxalate so that too little calcium allows excess oxalate to be absorbed into the bloodstream where there is plenty of calcium. When the calcium oxalate complex is filtered through the kidney it will precipitate out to begin stone formation if the urine is not dilute enough.

Dietary calcium is rarely a problem but persons who take large doses (more than 1,000 milligrams) of calcium, especially with vitamin D are at increased risk of stone formation. The guidelines to follow: never take more than 500 mg. of a calcium supplement at a time, never exceed 1,000 mg. per day and never take it at bedtime.

Water intake is critical but there is no magic formula. You will avoid dehydration and kidney stones if you drink enough water so that your urine is always light yellow with only a mild odor.