Endemic ≠ Benign

 

“There is a widespread, rosy misconception that viruses evolve over time to become more benign. This is not the case: there is no predestined evolutionary outcome for a virus to become more benign, especially ones, such as SARS-CoV-2, in which most transmission happens before the virus causes severe disease…”

Aris Katzourakis
Professor of Evolution and Genomics
University of Oxford

 

I typically don’t like to post on a non-psychiatric topic immediately after posting one.  But the current level of misinformation on the pandemic necessitates this. That is obviously not because I am a big influencer with widespread readership – but I like responding to the sea of right wing misinformation on Twitter. And today it was all about how the response to the pandemic was an overreaction with far reaching effects. Nothing about how the virus has killed 1.1 million Americans, the impact of that mortality on families and businesses, the impact on the healthcare system and its workers, and the enduring disability of millions with long COVID.  The evidence is clear that the pandemic was mishandled early on as the Trump administration denied the degree of the problem and then falsely reassured the public that everything was under control. The only way the right wing can rewrite that history is to push a false narrative that there was a conspiracy theory to prevent any investigation of the lab leak theory, that face masks and public health measures don’t work, that school children are irrevocably damaged from online learning, and that all of these unnecessary measures were really an unnecessary infringement on freedom. Unfortunately, pandemic viruses don’t work that way. They do not really care about your political affiliation or what you read on Twitter.

One of the popular myths during the early to mid-pandemic was the idea of herd immunity and how by ignoring all of the public health suggestions up to and including the immunizations (or “jabs” as they are referred to by the right wing) the entire population would build up immunity and the pandemic would fade away. The way that argument was typically presented minimized any death or disability along the way.  Herd immunity would happen and it would happen quickly to resolve the problem.  It also implicitly assumed that writing off the elderly and the 10% of the population that is immunocompromised was morally acceptable.  Not much discussion of how herd immunity would happen without immunizations – since many of the proponents were ideologically sympathetic to the idea that public health measures and immunization were unnecessary.

An associated concept of endemic disease cropped up at one point. The popular usage was  to say: “This is no longer a pandemic, there are no more large outbreaks, therefore we can declare it is an endemic like the common cold viruses.”  Since this was also an ideological rather than scientific argument – it was also a rationale for stopping all of the suggested public health measures and getting things back to normal as soon as possible,

That brings me to a brief essay on endemics written by evolutionary virologist Aris Koutzourakis in Nature (1).  The title speaks for itself.  His definition of endemic is straightforward -  endemic infections mean that the infection rate is static – not rising or falling. The best intuitive example is common cold viruses – there are predictable seasonal fluctuations but the number of viruses and the composition of the pool of common respiratory viruses stays about the same and no one outcompetes the others. Nobody is too worried about common cold viruses because they are not too deadly and don’t commonly overwhelm the healthcare system.  Influenza viruses are somewhat different.  Whether and epidemic or pandemic occurs depends on an elaborate system of guessing the correct components for the influenza vaccine and measures taken to prevent zoonotic transmission of potentially more lethal influenzas viruses – like avian influenza. That backdrop of common cold versus influenza viruses seems like a way to understand endemicity.  It leaves out one important point and that is endemic pathogens can also be lethal and create disability.

Dr. Koutzourakis lists several examples of endemic, but lethal pathogens including malaria, polio, and tuberculosis.  They are all significant causes of mortality and morbidity.  He successfully predicted that unless the pandemic was stopped quickly subsequent evolving variants could be more transmissible and difficult to treat.  That occurred with the subsequent 4 SARS-CoV-2 variants. Viral evolution has also been observed with other pandemic viruses and the occurrence of more dangerous variants. He analyzes the current behavioral situation correctly in the United States.  Even if people are not using the word endemic – they are generally stating that the pandemic is over and that it is time for a return to normal.  Normal typically means no public health measures like masking, social distancing, or even deciding to stay home if you are ill.  The only place that those measures are acceptable is in a medical or dental facility and even then they are no longer universal. To compound the problem, the anti-public health ideologues are either bragging that they were correct all along or actively spreading misinformation about masks, vaccines, or the origin of the virus.

The graphic at the top of this page (click to enlarge) is taken from the CDC web site today.  Even though the area in the red rectangle looks fairly static going back to May of 2022 – the actual number of cases per week ranges from 170 to 900K.  That corresponds with weekly deaths 1,795 to 3,697.   Dr. Katzourakis suggests that there is the potential to see additional spikes of infection and suggests that the direction this pandemic will take at this point depends a lot on continued public health measures, immunizations, antiviral medication, and individual behavior.  One of the critical aspects of science as I explained in my previous post is that scientists look at data supporting or refuting hypotheses in terms of probabilities and also speculate with probability statements. Viral epidemiologists and evolutionary virologists know how viruses work and evolve. Their predictions are much more likely to be accurate than someone with no expertise and no data.  The next time you hear politicians or news personalities talking like this pandemic is over take it as an unfounded opinion. Do the same thing when your neighbor tells you that you don’t need to get any more vaccinations or wear a mask in crowded places.

Don’t let ideology blind you to science.

 

George Dawson, MD, DFAPA

 

References:

1:  Katzourakis A. COVID-19: endemic doesn't mean harmless. Nature. 2022 Jan;601(7894):485. doi: 10.1038/d41586-022-00155-x. PMID: 35075305.

2:  Centers for Disease Control and Prevention. COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2023, March 12. https://covid.cdc.gov/covid-data-tracker  accessed on 03/12/2023

3:  Callaway E. Beyond Omicron: what's next for COVID's viral evolution. Nature. 2021 Dec;600(7888):204-207. doi: 10.1038/d41586-021-03619-8. PMID: 34876665.

This Is How Civilization Ends...

I had that thought immediately after seeing the above graph on the CDC web site. Over a million new cases.  An all-time high by far.  At that point, the news had been heavy with discussions about the Omicron virus for about 3 weeks. The trail though Africa and Europe was described.  In the United States we had plenty of warning and plenty of time to adjust.  It wasn’t like that first peak in the fall and winter of 2020-2021.  Back then there were no vaccinations.  My wife an I finally got vaccinated in March of 2021 and then only by an extraordinary stroke of luck.  Before Omicron we were flush with vaccinations.  Two different retail pharmacy chains were scheduling appointments and they were free. When the booster came out that was also free and much easier to get. The overwhelming scientific evidence was that the immunizations were safe and effective.

The public health measures seemed less effective. That could be confirmed by a walk around Target or Walmart. At the absolute peak of mask wearing in Minnesota, my estimates were up to 30% of shoppers were masked. Half of those masks were loose fitting cloth masks and probably not very effective. Today, at the height of the Omicron spike 10% of the people in my coffee shop were masked and I was the only guy wearing an N95.  Despite an increasingly vocal group of aerosol scientists most people remain shockingly ignorant or willfully ignoring the airborne route of transmission. The most easily observed scenario is restaurant dining where the customers wear a mask to the table and then take it off to eat and talk for the next two hours. There is no magical protection from airborne virus in that scenario. Forget about the 6 feet safe distance rule at the start of the pandemic. Looking for restaurants that have improved their HVAC systems to improve airflow and air exchanges over time was also disappointing. So far in the Twin Cities Metro area I have found 1 restaurant. No restaurant or business as far as I know is posting their air exchanges per hour or carbon dioxide measurements to describe the potential risk of their environment. They are posting that they adhere to social distancing and all of the surfaces are wiped clean between diners.

Despite all of that inertia, the restaurants are packed.  Typically, shutdown occurs when a significant number of staff are ill with coronavirus and they cannot stay open. I dodged a bullet at Christmas just as infections were increasing. My wife and I were supposed to meet another couple at a restaurant. My suggestion to get take out and eat it at either of our homes was met with resistance. I was saved by a call from that restaurant that significant numbers of their staff were ill and they would be closing until things improved.   

The general cultural landscape has been even more grim. I follow all of the experts in the media on a regular basis – Drs. Fauci, Hotez, Jha, and Walensky.  On an average day they are awash in a sea of misinformation.  That sea contains the entrepreneurs who see the pandemic as a money-making scheme as well as the purely irrational who find that conspiracy theories about the virus, vaccine, and public health measures are easier to understand and believe than the science. Political opportunists are in the mix and as recently as today were suggesting that “white people” were being discriminated against and were less likely to get the vaccine as a result. The Florida Governor made this statement:

“We reject the biomedical security state that curtails liberty, ruins livelihoods and divides society.”

Biomedical security state? The politicization of this pandemic knows no bounds. It obscures both the science and goodwill toward the scientific and medical communities.  But it doesn’t stop there.  In some large health care organizations 10% of the workforce has been fired for not complying with workplace mandates on COVID-19 immunizations.  Some of these workers are physicians who should have been taught basic epidemiological concepts – the most basic being that vaccinations are a rare medical miracle that have saved the lives of tens of millions of people.  Disease have been eradicated, prevented, and the course of infectious diseases has been altered.  And even if you are not a physician, everyone has the experience of taking all of the mandatory vaccinations required to attend school.  Most of these vaccinations had a significantly worse side effect profile than the currently available COVID-19 vaccinations.

Apart from reducing rates of infection, hospitalization, and death these modern vaccinations also reduce the risk of chronicity. Chronic or “long COVID” symptoms might occur in as many as 70% of patients after the infection. Remission rates and rates of disability are still being determined at this time.  Given the risk/benefit considerations of the vaccinations it is difficult to see how any rational person would refuse it.  It is even more difficult to understand how a rational person would not take basic measures to protect themselves and their families from airborne virus or justify ignoring the pandemic on the basis of a completely implausible conspiracy theory. In some cases, the motivations are very clear.  Politicians would rather use various forms of rhetoric to attack the idea of a pandemic and what it takes to resolve it for political gain rather than taking positive steps recommended by experts. It is a standard political tactic.  That rhetoric has been advanced to extreme levels and to the point where scientists and their families are being threatened.  Today the suggestion that “white people” were being discriminated against struck me as white nationalist rhetoric.  It was viewed just as another “falsehood” in the media.  Certainly, blind partisan acceptance of these statements is not very likely to exhibit flexibility in thinking about the pandemic, the virus, or possible solutions.

The press has stepped in and commented on the process as a “mass delusion” or “mass psychosis” as if the use of psychiatric jargon by a journalist would add credibility to the criticism of many people thinking and acting irrationally. Many of them are agitated, visibly angry, and can become aggressive typically when confronted about pandemic precautions in schools and businesses.  Hardly a day goes by without seeing an airline passenger or town hall meeting participant screaming until they are red in the face and carted away by security. None of these people has a psychiatric disorder.  They can cool off somewhere, suppress their irrational thoughts and the associated anger, and get up and go to work the next morning.  During the run up to the 2020 Presidential election there was heated commentary about President Trump’s mental health and fitness for office. There was some debate in the psychiatric community if it was appropriate to discuss that issue based on Trump’s observed behavior rather than a psychiatric assessment. This essay looks at the other side of that debate. Why do so many people follow leaders who make repeatedly false statements that in some cases are viewed as potentially inciting people to do the wrong thing? And conversely – how do so many people accept the more obvious rational path and reject all of the paranoia and conspiracy theories?

There are of course numerous theories about how this comes about.  The theories generally depend on the same theories that have been used to describe normal development, psychopathology, and normal learning processes.  In some cases the theories have a philosophical basis – that seem to be fashionable these days. And despite many of these theorists incorporating a neurobiological model – very little explanation about how that is relevant.

The relevance is obvious to me starting with the relationship between emotion and cognition specifically decision making. In order for it to be obvious, the relationship between emotions and normal decision making needs a brief exploration. Human decision making typically occurs as an integrated process in the frontal cortex. I won’t digress into any subdivisions or tracks in this post. The key word here is integrated. That means the frontal cortex takes a large number of inputs and uses them to varying degrees in the ultimate decision. That includes a lot of memory input, specific types or learning, emotional input, and real time sensory and perceptual data.  The amount of input is large and much of it occurs at an unconscious level. How it occurs is largely unknown at this point but with our limiting inputs have been determined.  One of those inputs is emotion. We know for example from lesion studies that emotional input is absolutely critical for normal day to day decision making. Of the vast number of potential decisions we all have a subset that are associated with emotional valences that can affect our preferences. Without access to those valences decision making slows and grinds to a halt.

Restricting our consideration of the decision space to all of the possible decisions about the pandemic and how to proceed – all of the medical, scientific, personal, political, manipulative, and conspiracy theories the possibilities are very large. If we have 300 million decision makers and they all have unique conscious states and personal capacities for decision making the potential outcomes are large. It is also a more complex scenario than all of the typical explanations for pandemic denial.  Each one of our 300 million decision makers has unique experience affecting the emotional valences of their decisions. The overt decisions may seem to coalesce at some points but for many different reasons. For example, believing what a politician says despite the clear documentation that they are lying can occur as the result of identification with similar people in the past, identification with a general class attitude or ethos that it represents, or it simply could be activated by the angry emotion that politician effects. Those are just a few possibilities.

The pandemic vaccination vs. anti-pandemic antivaxx is by definition a binary polarized debate – the reality based on what we know about how the brain works it is far from that simple.  Even on what appears to be the rational side there is no Spock-like analysis.  The public health experts are all accessing emotion when making their decisions. Rational thought is reward-based learning and associated to one degree or another with a “Eureka” moment.    

The key question going forward is what can be done to address the degrees of freedom associated with the possible decisions of this brain process.  What can be done to improve the process and by improve, I mean assure that civilization survives the current and potentially more lethal pandemics. To that end, there are numerous cinematic depictions of apocalyptic pandemics. Based on the depictions prior to this pandemic they are probably fairly accurate. Once a lethal pandemic takes hold, the decision space for survival collapses as fewer and fewer decisions are possible. An intuitive writer or film maker knows that at some level.  Time to make it general knowledge.

 

George Dawson, MD, DFAPA

Happy Labor Day 2021

 

This is my annual Labor Day greeting to my physician colleagues. I had to go back and look at last year’s greeting to see if I had factored in the pandemic or not.  It appears at the time that I was fairly enthusiastic about telepsychiatry and its applications during the pandemic. Ironically, I will be giving a presentation on telepsychiatry later this year and in reviewing a fairly massive amount of information my initial enthusiasm has been tempered. Although it appears to have had a semi-permanent effect on the regulatory environment there are still unanswered questions about its optimal applications. How it will be used by the business community is also unknown at this point.

One of the articles I reviewed in New York Magazine - outlined a pattern of questionable business practices at least as it was applied to therapists. Direct interviews with therapists suggested that they were being exploited by being paid much less than their going rate with the expectation that they would be more available after hours and by texting. Preliminary surveys indicate that there are psychiatric clinics popping up looking for psychiatrists to staff telepsychiatry visits. There are many unknowns about their practice. In another article, some employers were asking therapists to see people outside of the state they were licensed and hope that the regulatory environment would catch up with the employment practice. Those are not good signs for the labor environment.

I noticed in my 2020 post that I had an initial drawing of how the practice environment had changed and now that drawing has been expanded and includes many more details. It captures most of what I have endured as employed psychiatrist. I include a graphic below and hope that as physicians we can reverse the trend at some point.

The pandemic has clearly been demoralizing for physicians in general but much more for frontline acute care physicians responsible for COVID-19 patients and their frontline colleagues in nursing and hospital support. There has been a shortage of personal protective equipment (PPE), beds, adequate ventilation, and supportive services. There have been deaths and resignations compounding the personnel problem. As the staffing ratios worsen - the emotional stress is at an all-time high. Local disasters compound the COVID crises in many areas.  All the descriptions I see indicated that the healthcare system will end up permanently altered by this pandemic and probably not in a positive way. There seems to be no effort to incorporate a public health approach into the current subsidized business rationing approach that dominates American healthcare. That is not only detrimental to physicians and their coworkers but also the public health infrastructure in general.

A new dimension to the demoralization has been the misinformation industry associated with the pandemic. Physicians trying to provide information in good faith have been attacked and even threatened by some of the zealots associated with or affected by that misinformation. That includes some of the top experts in the world who have been active in research and teaching immunology, epidemiology, virology, and vaccine production. Physicians are given the message that is up to them to communicate to the zealots and convince them that the pandemic is real, it is a really a virus, and that immunizations are the best approach. There appears to be no convincing a large group of people that wearing masks may reduce viral transmission even though that practice was widespread in the 1918 epidemic in the US and is currently widespread in many parts of the world. Physicians are getting the message that they have to magically find a way to communicate with this group of people who have rejected all of the usual channels.

It seems obvious to me that physicians are the only group that are excluded from empathic communication. The expectation is that physicians will be all-knowing, all understanding, and that somehow will correct most of the anti-vaccine, anti-science, anti-expert, and anti-COVID sentiment out there. I think that is a fairly naïve approach and what physicians need is concrete help from politicians, community leaders, and regulators.  Social media is gradually coming around but has responded at a glacial rate. 

I also notice in my greeting from last year that I commented on an APA Presidential Task Force on Assessment of Psychiatric Bed Needs in the US.  I saw no further action and that and was not able to find it in a search. That potential bright spot maybe on hold due to the pandemic, a lot also depends on the conclusions if they are available.

Progress against the burnout industry has been maintained but it is clearly a war of attrition. Physicians in general reject the idea that burnout is due to some inherent personal deficiency and are more likely to see it as the real product of an unrealistic work environment. In many cases that unrealistic work environment has increased many-fold due to the pandemic and all of the associated problems. I hear from physicians every day who are able to exercise minimal self-care due to overwork and limited time away from work. Weight gain is common due to unhealthy diet and no time for exercise. A solution for some has been to leave those work setting behind even if it means early retirement or taking an undetermined period of time off. Many physicians who could easily have worked into their early to mid-70s are retiring at age 65.

Employers seem to be doubling down in this adverse environment. I quit my last job in January 2021. Since then, I have been actively looking for new positions. There has been a recurrent pattern of highly leveraged job descriptions, that I would accept only if I really needed employment. By highly leveraged I mean that the job description contains anywhere from 20 to 30 bullet points, the majority of which have nothing to do with being a clinical psychiatrist. To cite one example, many of the applications describe a “leadership role” where the really is none. No organization that I am aware of wants a frontline clinical psychiatrist to attempt to correct their obvious administrative problems. I received a cold call one day from a recruiter who asked me if I was interested in a “very good” inpatient position. I asked him what the productivity expectations were and he said I have the options of seeing 18 or 22 patients per day. He quoted a disproportionately greater premium for seeing 22 patients a day. He seemed convinced that I would accept the position until I asked him “When am I supposed to live or sleep?” I had the thankless job of covering inpatient unit of 20 patients for an entire year with the help of an excellent physician assistant and that almost killed me.

The unrealistic expectations being placed on physicians are still out there and they are as bad as they ever have been. It is why I used a heavy lifting graphic for this post again. Despite the pandemic the business leverage against physicians is not letting up and that is not a good sign. To make matters worse, there always seems to be room for it in the medical literature. The latest example I can think of is a recent essay in the New England Journal of Medicine claiming that digital healthcare fee-for-service payments are unsustainable and there must be a capitated system. That seems to be part of the master plan to continue a rationed-for-profit system that guarantees over-employment of bureaucrats and business managers as well as corporate profits at the cost of treating physicians like highly paid laborers as depicted in the above diagram.

I don’t think physicians will have any reason to celebrate Labor Day, until that rationed- for-profit system is dismantled.  Until then do what you need to do to take care of yourself and survive. Help from professional organizations would be useful, but there are too many conflicts of interest for that to be realized.  I am still hopeful that we can get back to the stimulating clinical environment of the 1980s, but I will be the first to admit - there is no obvious path back in the face of a trillion dollar healthcare rationing business - largely invented by Congress.

 George Dawson, MD, DFAPA

 

Graphic Credit:

Robert Yarnall Richie, No restrictions, via Wikimedia Commons. "Workers Adjusting Tracks, Texas Gulf Sulfur Company."

How To Survive Social Distancing If You Are An Exercise Fanatic

This is an interesting topic from a personal, practical, and consciousness level. I came by some of this knowledge the hard way and hope to pass that along to people who can benefit from it. I also hope to reach the people that are thinking right now “I can make the best of staying at home by only eating between 2 PM and 9 PM, increasing my resistance workouts, and doing more intervals or HIIT (high-intensity interval training)”.  You might be able to but there are some precautions along the way.

A couple of high points from my experience. About 10 years ago, I was out on the local speedskating track. I had just started warming up and noticed my heart rate monitor was at 160 bpm. I did not see that is being out of the ordinary and after another couple of laps my monitor started chirping away. The display read 240 bpm. There was also a warning light. I checked my carotid pulse and sure enough I was in atrial fibrillation. That began a 10-year saga of cardiac ultrasounds, stress tests, episodes of anticoagulation, cardioversion, and antiarrhythmic therapy. The ultimate diagnosis was lone atrial fibrillation. In other words, atrial fibrillation from no known structural cause. The likely cause was long periods of time of running my heart rate way beyond the maximum recommended heart rate for a guy my age.

Even before that I was out speedskating on the roads when I went down and ended up with a large abrasion over my left lateral thigh. My first thought was whether I should cover it with something. It was a clean abrasion that I had washed thoroughly and immediately and it looked good.  Over the next several days it no longer looked good and was clearly infected. In the emergency department was given an intramuscular injection of cephalexin with a number of capsules to take home.

Both of these scenarios highlight the fact that exercise related injury can lead to treatment in the ED (emergency department). During the time of a pandemic you do not want to end up in an emergency department. So the first lesson here is to avoid extremes and also high risk scenarios where you could end up with an abrasion, a cut, head trauma, fracture, a sprain, or any other sports injury that needs acute medical attention. I think there are practical ways around that but it also takes addressing the exercise fanatic mindset.

1.  Avoid the gym:

I can only speak for what happens in the men’s locker room but hygiene at the gyms I have been in is atrocious. It is the primary reason I stopped going to gyms even though my wife encourages me to go to her gym on a regular basis. There is also the problem of risky behavior. I got tired of seeing personal trainers trying to kill novices with some absurd exercise routine, the roid rage folks threatening one another, and having to intervene in order to prevent serious injury. You can only advise that teenager with a loaded barbell resting on his cervical spine that it is not a good idea so many times, before you get known as the old white guy who is a know-it-all.  Luckily many governors and mayors have shut these facilities down as a transmission risk.

2.  Maintenance not maxing out:

Most exercise fanatics collect a lot of data on their favorite exercise routines. You can certainly do it with smart phones and activity monitors these days but a lot of us also automatically keep track of reps, times, and maximums. For example on a day-to-day basis I can predict my maximum number of push-ups, pull-ups, back extensions, bicep curls, max power output on my ergometer, and max road speed on a bike. When you think like an exercise fanatic, you are always thinking about how to maximize those numbers. That also happens to be the periods of likely injury. I naturally hit a wall at about age 55. Up to that point I thought it was indestructible in terms of exercise tolerance. After that point, I questioned why I had been so foolish and not adhered to some basic rules like maximum heart rate.  First and foremost don’t push it like you are 20 when you are 40 or 50. Secondly, don’t push it to high age-appropriate levels when there emergency services are limited by a pandemic and you don't want to be an additional burden on that resource.

3. Avoid the typical Internet suggestions:

During this period of social isolation there are any number of exercise sites advising you on how to stay fit outside of the gym. They range from exercises that focus on specific body regions to replacing exercise equipment with everyday household items. Keep in mind that doing reps with a gallon of milk or a can of paint is not like using that Cybex machine at the gym. The biomechanics are completely different and even the grip can result in injury. Don’t take innovation too far when it comes to exercises that you are used to doing in a specific range of motion on well-designed equipment. Even mimicking that young aerobics instructor video and she does various leg extensions can be a problem. Start out with very few repetitions to make sure it is safe before you try the whole workout.  Even then there are exercise that are not appropriate for certain ages or injury patterns. Many athletes have learned this over a number of years from their physical therapist. Don't ever ignore the advice of a physical therapist. 

4. Stop immediately if you are hurt; don’t exercise until the pain is long gone.  If it doesn’t go you need an assessment.

Repetitive stress and overuse injuries are common with aging and you have to overcome the propaganda that you heard in high school or your early 20s that all you have to do is “shake it off” or that pain is somehow therapeutic. I first noticed significant knee pain when I had to carry a floor sander up three flights of stairs. It weighed about 250 pounds. I remember thinking as I went up that stairway: “It feels like my knees are going to blow out at any time”. I was about forty years old. By paying close attention to that feeling I have been able to preserve my knees for another 25 years. During that time they have served me well with thousands of miles of cycling and speedskating. I pay close attention to that joint stress perception when I am weightlifting or even doing push-ups or pull-ups. I plan to avoid any of those situations during the pandemic social isolation.

These are a few tips to avoid injury and needing medical care during a pandemic. To most people they are obvious. To exercise fanatics they may not be.  Being an exercise fanatic is an interesting conscious state. Reality testing is intact to a large extent. As an example I would never think that I could skate in the Olympics or cycle in the Tour de France. At the same time my personal goals were probably unrealistic for men my age and yet I reached many of them. The part of my reality testing that was not intact involved the basic denial of the aging human organism. For example, I recognized in a nick of time that my spine could probably not tolerate lifting large amounts of weight anymore. As we age, intervertebral discs degenerate and in many cases disappear. Osteophytes form. The old human spine is a lot less stable then the young human spine. That has implications for maximum load whether that load is a stack of weights or running.

I used to think that men were particularly prone to the exercise fanatic mindset but since then I have encountered many women with the same biases. A significant number of them continued to exercise when they were injured and ended up with permanent disabilities. Women may be more likely to be told that their exercise is “an addiction” because of the over exercising associated with an eating disorder diagnoses. They have that bias to live with that men generally do not.

Stay fit during this time by staying with what you know, taking it easy, and avoiding injury. If you are an exercise fanatic this is the wrong time to be pushing your limits - and you might ask yourself if there is ever a right time.  Even as a novice it is the wrong time to jump into a rigorous program because there is somebody selling it on the Internet and it looks good.

George Dawson, MD, DFAPA

The Pandemic Report From Beam Avenue

It was my day off yesterday but I have been looking at a “need maintenance” light for the past four days. I had to leave the house for car maintenance. Given the pandemic status this would be a whole new trip. Even though Minnesota does not have a lot of cases at this time, they are increasing and there is an identified COVID-19 case in a town 5 miles away and a neighbor four houses away with direct exposure to coronavirus in the workplace. My secondary goal during this trip was to take a look at social distancing and the other practical suggestions to contain the spread of this virus.

Beam Avenue is a busy thoroughfare that connects Highway 61 on the west and White Bear Avenue on the east. My Toyota dealer is on the west end of Beam Avenue and 1.5 miles away a popular shopping mall sits on the corner of Beam Avenue and White Bear Avenue. St. Johns Hospital is about half way down and the photo was shot from the sidewalk. Average vehicle traffic in this area is about 17 to 18,000 vehicles per day.

I don’t generally set up appointments for vehicle maintenance. I wait until the light goes off and then I typically drive in and wait. Even though the wait takes 1 to 2 hours, the accommodations for customers at this dealership are excellent. A comfortable waiting area, free cookies, and free coffee. This waiting area is generally very congested due to the high levels of work done at this dealership. It was going to be a challenge to see if social distancing was possible or not.

I pulled into the service area and was greeted by one of the service managers. He took me over to his desk and we started going through all the details. I told him I needed a new battery in my starter fob. He took it from me, pried open, installed the new battery, blew the dust out of both halves of the fob with his own breath, snapped it together, and handed it back to me. We talked about the purpose of this visit specifically oil change and tire rotation. He offered to sell me a new service plan but I told him I was thinking of trading in my current RAV4 for a new one. He asked me what my timeframe was and I told him:

“I want to see this coronavirus thing pans out.”  He smiled at that.

After deciding the course of action he told me it might take one to two hours and I headed into the customer waiting area. I have probably seen more customers there at other times but it was packed, everyone was eating cookies and drinking coffee, and there were few open seats. There are study carrels along one wall. That is where I typically sit and do computer work while I wait. I decided it was a bad idea because there is no expectation that these surfaces would be sanitized. The same would be true of the padded and more comfortable seating in the middle of the waiting area. Appropriate social distancing was not evident and in fact I counted 16 people in the service area that were probably within a 10 foot radius of me. I decided it was a good time for a walk.

Beam Avenue is not the ultimate walking course. There are numerous pedestrian crossings just to get to the main sidewalk on the north side. Several large businesses have entrances across that sidewalk. It was an opportunity to see how many motorists never stop or even slow down when making a right-hand turn at a red light or stop sign. Costco motorists seemed more prone to that maneuver. The problem with the walkway is the intensity of traffic and the associated noise and exhaust fumes. That might explain why during the entire 3 mile walk I did not encounter a single fellow pedestrian. The traffic at 3 o’clock on Friday afternoon was as intense as I have ever seen it.

I got to the mall and walked through the main entrance. All the entrances and exits to the mall had pneumatic sliding doors and that is clearly a plus in terms of virus transmission. As I walked further into the mall those benefits seem to diminish. I came across children who were swarming all over free plastic playground equipment. I also saw kids jammed into moving seats wearing some kind of virtual reality goggles that appeared to be simulating a Star Wars battle. I did not inspect all of this equipment but hand sanitizers were not apparent. The kids all looked like they were having fun - it is probably hard to think about social distancing when you are a parent of young children.

When I got to the food court I was surprised that the tables had been thinned out. It looked like there was about a 60% reduction in the total number. As a result there was roughly 10 to 12 feet between most of the tables-the suggested social distancing interval. The other notable change was that even with fewer tables, there was hardly anybody eating at the food court. There was one long line of what appeared to be high school students who had not been seated. There is also visible housekeeping staff with sanitation equipment and they appear to be interested primarily in the food court area.

The men’s room was disappointing. With all the emphasis on handwashing there should be an expectation that any facility will be adequate for that task. In the men’s room, 40% of the soap dispensers and 60% of the faucets were not working. One of the faucets was totally gone. There was a paper towel dispenser that was empty and two air hand dryers. I had time to discover that I needed to go from sink to sink but if there was any crowding - I am sure it would affect the number of people adequately washing their hands. I headed out the door and back to the Toyota dealer.

When I got back - social distancing remained a problem. The service manager met me in the cashier line and reviewed all of the billing. There are two cashiers with six people in two lines and we were all about 1 foot apart. Nobody was coughing or sneezing. I was able to pay and leave in about five minutes.

On the way home I had to pick up some milk and bread and stopped at one of the major grocery store chains in the Twin Cities. The parking lot was packed. I decided to shop without a cart and avoid any cart contamination. There were hundreds of people in the store many of them very old. The store was well-stocked and the only thing that was missing was the toilet paper and paper toweling. A woman in front of me laughed very loudly when she turned the corner and saw that there was about a 50-foot section of shelving completely empty where these paper items had been. I grabbed the milk and bread and headed to the self-checkout line. Six people in line again to get to the touchscreen checkout computer. I checked out got in my car and used a liberal amount of hand sanitizer. I had also used outdoor gloves to negotiate doorways at the car dealership.

On the final drive home, I was thinking about how social distancing was absent in most of the scenarios I encountered. Vehicle and foot traffic were heavy and there was plenty of congestion.  What will it take to get people to stay home and out of public spaces? Some commentators have said that inconsistent messaging is a big part of it. Declaring a pandemic a political hoax one day an actual public health emergency the next day doesn’t work. Today I read three different conspiracy theories on COVID-19 as a bio weapon that was either deliberately used by the United States or China or inadvertently escaped the Chinese bioweapons lab. None of those theories appears to be consistent with what really happened. I was watching a celebrity news program and saw a caller say that the only time he took the pandemic seriously was when he learned that Tom Hanks and Rita Wilson had contracted the virus.

I started to think about why I take it seriously. I worked on two different Avian Influenza Task Forces about 15 years ago. It was a significant effort. One of the main concerns was surge suppression or preventing emergency departments and other resources from being overwhelmed by people who thought they had the disease. There is actually a program called Psychological First Aid where mental health professionals train volunteers to counsel these people and direct them away from emergency departments. I was a trainer for this course. In our meetings there was always a vague discussion of what would actually happen in hospitals if they were overwhelmed by patients with avian influenza.  In some of those discussions we would see a PowerPoint slide of a pallet loaded with Tamiflu at some Air Force Base. We were reassured that in the event of a local epidemic- that medication would be made available. The specifics about negative pressure rooms, ventilators, workflow, and manpower requirements were never really discussed. The current strategy for coronavirus of slowing the infection rate by social distancing and quarantine was also not discussed. At some point it was apparent to me that if avian influenza pandemic occurred, we would be making it up as we went along. I had studied several of these epidemics and had concerns about surge suppression especially in a highly infectious situation.

There appear to be some common errors that are made along the way when considering that pandemics are not only possible but likely. The first one is analyzing the situation according to a particular political bias. This is a very common mistake these days even though it clearly doesn’t work. Contradictory information in addition to those political biases amplifies the problem. Independent of political bias, it takes the ability to imagine that a pandemic is possible. That approach can be historical, biological, medical or mathematical. Any one of those disciplines can provide the necessary knowledge base. There are concerns today that in the era of social media dynamics – every one is an expert at the rhetorical level. The signal of real expertise is lost in the noise of grabbing for celebrity and the associated benefits. Self-selection leads to all of the adherents of a common belief isolating themselves in one little area on the Internet. That leads to the expected cognitive biases but also the illusion that life can go on as a member of an isolated group with no role in greater society.  Pandemics directly confront that denial.

I did see some bright spots on Beam Avenue today, but not many.  Vehicle and foot traffic is heavy and social isolation is a problem in high congestion areas. If people are expected to wash their hands frequently – washrooms need frequent attention and repair. The focus on cancellation of mass sporting and entertainment events is useful, but day to day sources of possible contamination need attention – especially when there are clearly identified cases and exposures in the area.

People need to stay home unless travelling to congested areas is absolutely necessary.  It is the best way to prevent the severe measures being taken in some countries right now and get through this.

George Dawson, MD, DFAPA