Community Acquired Pneumonia - and How To Avoid it

 

Disclaimer:  Like all posts on this blog this is intended for educational and commentary purposes and is not medical advice in any form.  All medical decisions need to be made in collaboration with your personal physician who knows your history.  For reasons stated below - vaccination information and recommendations are also less clear than they have ever been due largely to political influences that can also affect physicians.

 

This a strategic post about pneumonia.  By strategic I mean I hope to clarify what it is and how to prevent it.  This is not about diagnosing and treating it.  Most people reading this blog either don’t need to know that or know a lot more than me about it. Instead, I hope to address three things – misinformation about it, barriers in the modern healthcare system to acute care, and how to prevent it.

My focus will be on community acquired pneumonia (CAP).  It is a term I am very familiar with dating back 40 years to med school and my medical internship. As an intern I carried around my copy of Sanford’s antimicrobial therapy and the relevant section of Phantom Notes which was basically an outline of the leading Internal Medicine text at the time.  Thirty percent of the people I admitted to the hospital had some kind of pulmonary problem.  Depending on who you read chronic obstructive pulmonary disease (COPD) is as high as the third leading cause of death worldwide.  Exacerbations of COPD were very common reasons for hospital and ICU admission. 

CAP by definition is acquired in the community and not in a hospital setting.  It can be cause by a range of microorganisms and host factors.  It can also develop in people with no known risk factors. Conventional wisdom used to be that the lung was sterile territory but now we know that it contains a low biomass microbiome consisting of bacterial, viral, and fungal elements that are there via microaspiration of mouth contents.  Local physiological changes can occur to change the microbiome, or pathogens can be inhaled that establish primary infections (1).   Certain lung diseases like COPD and asthma can also lead to selective proliferation of elements of the microbiome. 

The ability of the lung to repair itself after injury or infection is controversial. Some research suggested that the lung was permanently changed by infection.  One example would be the association of asthma with previous rhinovirus infection. More recent work suggests there is room for optimism if the regenerative capacity of the lung can be activated (2).  

My motivation for this post was a clinical trial I read in the New England Journal of Medicine.  It was about treating CAP in East Africa.  The research question was whether adding glucocorticoids to antibiotic treatment as usual would improve outcomes.  That study quotes the mortality of CAP as 25-30%. The study was conducted in Kenya.  2,180 study patients were randomized to standard care versus glucocorticoids.  All patients were admitted to a hospital and CAP was defined as “the presence of at least two of the following signs and symptoms for less than 14 days: cough, fever, dyspnea, hemoptysis, chest pain, or crackles on chest examination.”  Imaging was not a criterion for study entrance because it was not available in many settings.  They were started on the protocol within 48 hours of admission. Glucocorticoids were provided for free as one of five glucocorticoids in bioequivalent doses for a total of 10 days (including after discharge) in addition to standard care (6 mg of dexamethasone, 160 mg of hydrocortisone, 30 mg of methylprednisolone, 50 mg of prednisolone, or 50 mg of prednisone).  Standard care was antibiotic therapy per World Health Organization (WHO) guidelines (beta lactam and macrolide antibiotics). Exclusion criteria are available in the paper.

30-day mortality was the primary endpoint in an intent-to-treat analysis.  To get to the treatment population a total of 46,224 patients were screened.  Of the 2,180 patients mortality was 530 (24.3%) at 30 days.  246 of 1089 (22.6%) were in the glucocorticoid group and 284 of 1091 (26.0%) in the glucocorticoid group.  That translates to a hazard ratio of 0.84.  The authors explain the limitations (comorbid illnesses – HIV, hypertension) and advantages (large N, lower media age) of their study.  That seems like a slight reduction in mortality for the intervention, but the authors point out that several other studies had better results up to a 50% reduction in mortality with glucocorticoids and it is a low tech readily available intervention.

In looking at the side effects of glucocorticoids   Pulmonary tuberculosis and hyperglycemia were the most common adverse effects in the glucocorticoid treated group.  Pulmonary tuberculosis and acute kidney injury were the most common adverse effects in the standard care group. 

The striking part of this study for me are the mortality figures. Although the researchers emphasized throughout their study that this was a pragmatic trial in a healthcare system with fewer resources – the estimated mortality for community acquired pneumonia in the United States is 6% at 30 days for hospitalized patients but that increases to 34% at 30 days for patients who do not initially improve initially (4).  There are treatment guidelines for primary care physicians about who can or cannot be treated on an ambulatory basis.  Age is a risk factor for increased incidence of pneumonia with the rate increasing from 248 (all adults) to 634 (ages 65 to 79) to 16,430 per 100,000 after the age of 80 (5).  Pre-existing COPD increases the risk of hospitalization 9-fold.

There are characteristic patterns of pneumonia by pathogen based on the immune response.  Bacterial infections elicit an infiltration of neutrophils into the alveolar space in a pattern of lobar or bronchopneumonia that results in an exudate of dead cells and phagocytes in the alveolar space.  Viral infections cause an interstitial pattern of inflammation with lymphocytic cell infiltrates.  Identification of the pathogen is largely done on a clinical basis due to difficulty identifying the pathogens.  Indirect methods can be used like determining acute and convalescent phase antibodies to specific viruses. Both types of infection compromise normal physiology and can lead to hypoxia and in the case of bacteria secondary infections - like meningitis.      

Recent sporadic and annual viral pandemics have created a confluence of factors at the hospital that are best avoided.  The first is the use of broad-spectrum antibiotics.  Since a significant portion of people admitted with viral pneumonia develop hospital acquired secondary bacterial infections – antibiotics are given prophylactically to prevent that complication.  Increasing exposure to increasingly potent antibiotics leads to multiple drug-resistant bacteria.  The best pathway is to avoid getting the respiratory infection in the first place. 

The absolute best way to avoid is vaccinations.  Vaccinations are currently available for influenza, COVID-19 (Sars-CoV-2), respiratory syncytial virus (RSV), and Streptococcus pneumoniae (pneumococcal pneumonia and meningitis).  They have all been tested and offer relative protection (rather than absolute) against serious illness, hospitalization, and death, especially for adults 65+ years of age.  Vaccinations have become a mixed bag of accessibility.  On the one hand you can get them from pharmacies and that is a recent development.  On the other hand we have an elected government that has appointed a well known antivaccination promoter as the head of Health and Human Services – Robert F. Kennedy, Jr.  So far there have been restrictions on the COVID vaccination to people who are 65+ or have an underlying health condition.  Since the administration is apparently making health decision based on politics and ideology many states and professional organizations are publishing their own guidelines.  As an example here is a list of respiratory virus vaccination guidelines from the American Academy of Family Practice (AAFP).  The CDC still has pneumococcal vaccination recommendations for children less than the age of 5 and adults over the age of 50.

The University of Minnesota Center for Infectious Disease Research and Policy (CIDRAP) program has a good brief on the vaccine controversy and chaos introduced by the Trump administration and the lack of scientific origins at this link.

Apart from vaccinations risk factor modification should be considered.  If you were born and raised in American culture – it is important to realize that you have been socialized to expect to get sick in the wintertime.  I did not realize that until I was getting sick 2-3 times a year on the inpatient unit where I worked.  They were viral illnesses that took 2-3 weeks to recover from.  The building was made in an era where preservation of heat was the primary design goal.  There was minimal circulation of clean air or filtration.  My suggestions to improve the air quality were ignored.  The mini-epidemics were made worse by admitting people who were ill with respiratory viruses and not using any precautions to prevent the spread of those viruses.  The new personal time off (PTO) policies that make no distinction between vacation and sick days also lead to increased exposure to sick employees who would rather work sick than use PTO days for sick time.  Since the COVID pandemic even outpatient clinics ask questions every time they see you to minimize staff exposure to respiratory viruses.

Masks work.  They must be N95 masks and fit correctly but there is no doubt that they work.  These days it is common to see political arguments and in the extreme ridicule heaped on people who use them. Large scale uncontrolled studies are often cited as evidence that they are a weak intervention.  These studies are almost all self report with no measures of actual adherence to masking.  The best studies are done in a lab that look at filtering virus sized particles and there is no doubt they are equal to that test.  

Risk factor modification is probably important.  Cardiopulmonary diseases are significant risk factors for pneumonia – so maintaining the best possible treatment for those conditions is important.  Weight control and activity level are also important.  There is at least one study showing that 65+ year olds who maintain high activity levels have better immunity than those who do not.  The specific dose of exercise for that effect is unknown currently. 

Expert advice on vaccine allergies is an important point.  I have personal history of an anaphylactic reaction to anti-rabies duck embryo vaccine in 1975.  For the next 30 years I did not get a single vaccine against influenza because it was egg based.  I had innumerable episodes of viral illness that was probably influenza and decided to see an immunologist to see if I could be desensitized to eggs so I could get the flu vaccine.  When he confirmed that I could eat eggs without a problem he said that I would probably not have any problems with the vaccine.  He was correct and I have not missed an annual dose since.

Look for respiratory infection season onset and peaks.  They are typically available through your state public health department and the CDC. When I notice it – I change my routine to shop at nonpeak hours and wear a mask in stores.  In addition to protection from the airborne transmission route hand washing is also important.  Shopping carts, door handles, and other high traffic areas are unavoidable areas for direct contact transmission. That may include being in a public bathroom any time somebody flushes a toilet.  Keep in mind that there are number of circulating common cold viruses that include 4 coronaviruses that can make you very ill.

What about barriers to care in the current healthcare non-system in the US?  There are many since businesses have taken over health care in the past 40 years.  Healthcare is rationed by both businesses and governments with only a very grudging nod to quality. The most obvious example is avoidance of the emergency department if you need it.  Anyone with previous experience knows about waits in emergency departments and delays in care.  People avoid paramedics and ambulances out of fear they will be billed for that service.  If you expect that you are ill beyond a typical cold and have additional warning signs like shortness of breath – seek help immediately.  I have given that advice to many people and it is included in the final paragraph of this AMA information sheet.   Keep in mind that pneumococcal infection can also cause meningitis which is even a more significant emergency and those symptoms can include a severe headache and neck stiffness.  Maintain a low threshold for checking these symptoms out with your primary care physician’s office during working hours and their call line after hours. But if that is not available or able to give you an answer call 911 and get a paramedic there in person to advise you and advocate for you getting timely care.  Even in our fragmented healthcare system you do not have to go it alone.  

Finally – you must realize that the infectious disease space has been infiltrated by many people who do not belong there.  They have mixed agendas involving politics and health and wellness profits.  In some cases, they are just promoting themselves.  This varies from a kernel of truth rhetoric (eg. “most people who get this virus do not die”) to outright lies (eg. “this vaccine has never been adequately tested”).  There are many points in between such as “He died of pneumonia not COVID”.  In outrageous cases they have attacked and threatened public health officials.  It is important to recognize who these people are and why they must be ignored to preserve your interest and that is your personal health. 

I attached a list of the main respiratory pathogen vaccinations as a supplementary below. The indications are taken directly from the FDA approved package insert that is in turn based on clinical trials for efficacy and safety. There are significant differences between the FDA approved indications and eligibility as determined by various organizations. There are also links to those graphics in the appended material. Note that for the COVID vaccinations especially the eligibility can vary based on age, susceptibility status, and what has been referred to as mutual decision making. In my opinion this is basically slow walking vaccine denial in as eligibility. Essentially all medical decisions are based on informed consent as mutual decision making. I did not get a single influenza vaccine for 30 years because of mutual decision making that was based on inadequate information. I asked an Internist about what he would recommend in the cased of COVID-19 vaccinations and he said: “Definitely recommend for over 65. Recommend for patients with multiple comorbidities. Recommend for healthy young adults if they were healthcare workers, teachers or in an occupation with lots of exposure to the public.” Why are the eligibility criteria not that simple?  As far as I can tell the answer is politics.

That is my overall strategy to avoid pneumonia.  It is most important as you age into categories where your risk doubles (65+ yrs old) and increases 25-fold (80+ yrs old).  I use these strategies myself and have found them to be very effective.  And remember the overall strategy is to avoid the physical virus or bacteria if at all possible and failing that make sure your immune system is activated by a vaccination to attack it if you are infected.

 

George Dawson, MD, DFAPA

 

References:

1: Li, R., Li, J. & Zhou, X. Lung microbiome: new insights into the pathogenesis of respiratory diseases. Sig Transduct Target Ther 9, 19 (2024). https://doi.org/10.1038/s41392-023-01722-y 

2:  Ainsworth C. Lung, heal thyself. Nature. 2026 Jan 29;649:S9 – S11.

3:  Lucinde RK, Gathuri H, Mwaniki P, et al. A Pragmatic Trial of Glucocorticoids for Community-Acquired Pneumonia. N Engl J Med. 2025 Dec 4;393(22):2187-2197. doi: 10.1056/NEJMoa2507100. Epub 2025 Oct 29. PMID: 41159889; PMCID: PMC12659994.

4:  Peyrani P, Arnold FW, Bordon J, et al. Incidence and mortality of adults hospitalized with community-acquired pneumonia according to clinical course. Chest. 2020;157(1):34-41.    

5:  Jain S, Self WH, Wunderink RG, et al.; CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med. 2015;373(5):415-427.

Graphic:

Pages from my trusty copy of Phantom Notes that I used on wards as a medical student.  I went back to check to see if community acquired pneumonia was a thing back then and it was not.  If you can read it they do discuss where it was acquired under Classification (D3).   According to PubMed that term was used just twice in 1981 - but became progressively more popular in the 1990s.

Note also that we have an expanded list of viral pathogens compared with 1981.

Phantom Notes Medicine 79-80 edition copyright Joe D. Glickman, Jr, MD All Rights Reserved.  

A Shocking Anecdote about Pneumococcus:

When I was an intern on neurology (1983) I was called down to the emergency department to assess a 70 year old woman for "agitation".   That was all they could tell me aside from the fact that her labs and exam were normal.  She was unresponsive, groaning softly and rolling from side to side on the bed.  I proceeded with my examination and found that she had a stiff neck and pus draining out of her left ear.  I called my two senior neurology residents and they came sprinting to the ED.  A quick gram stain of the pus showed gram positive cocci and we gave her 1 gram of IV chloramphenicol, did a lumbar puncture and transferred her to the Neurology ICU.  She subsequently developed ARDS and required transfer to the medical ICU for ventilatory support.  She was discharged a month later and was completely deaf as a result of pneumococcal meningitis.

Vaccines for Respiratory Tract Infections: Indications versus Eligibility:

 

Vaccine	Indication (From Package Insert)	Eligibility (From CDC)
Influenza	FLUARIX is a vaccine indicated for active immunization for the prevention of disease caused by influenza A subtype viruses and type B virus contained in the vaccine. FLUARIX is approved for use in persons aged 6 months and older. (1)  - Fluzone High-Dose is a vaccine indicated for active immunization for the prevention of disease caused by influenza A subtype viruses and type B virus contained in the vaccine. (1) Fluzone High-Dose is approved for use in persons 65 years of age and older. (1)	Annual all adults CDC Guidance
COVID	Moderna - SPIKEVAX is a vaccine indicated for active immunization to prevent coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SPIKEVAX is approved for use in individuals who are: • 65 years of age and older, or • 6 months through 64 years of age with at least one underlying condition that puts them at risk of severe outcomes from COVID-19   Pfizer - COMIRNATY is a vaccine indicated for active immunization to prevent coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). (1) COMIRNATY is approved for use in individuals who are:  65 years of age and older, or  5 years through 64 years of age with at least one underlying condition that puts them at high risk for severe outcomes from COVID-19. (1)	Adults should discuss with their health care provider to see if this vaccine is right for them. CDC Guidance
RSV	-Active immunization of pregnant individuals at 32 through 36 weeks gestational age for the prevention of lower respiratory tract disease (LRTD) and severe LRTD caused by respiratory syncytial virus (RSV) in infants from birth through 6 months of age. (1.1) - Active immunization for the prevention of LRTD caused by RSV in individuals 60 years of age and older. (1.2) -Active immunization for the prevention of LRTD caused by RSV in individuals 18 through 59 years of age who are at increased risk for LRTD caused by RSV	Adults 75+ Adults 50-74 at increased risk CDC guidance
Pneumococcus	Pneumococcal Conjugate Vaccines (PCV)   PCV15 (Vaxneuvance): Protects against 15 types of pneumococcal bacteria.  is indicated for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F, and 33F in individuals 6 weeks of age and older.   PCV20 (Prevnar 20): Protects against 20 types of bacteria; it has largely replaced the older PCV13 (Prevnar 13). Prevnar 20 is a vaccine indicated for • active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 8, 9V, 10A, 11A, 12F, 14, 15B, 18C, 19A, 19F, 22F, 23F, and 33F in individuals 6 weeks of age and older. (1) • active immunization for the prevention of otitis media caused by S. pneumoniae serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F in individuals 6 weeks through 5 years of age. (1) • active immunization for the prevention of pneumonia caused by S. pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 8, 9V, 10A, 11A, 12F, 14, 15B, 18C, 19A, 19F, 22F, 23F, and 33F in individuals 18 years of age and older. (1) The indication for the prevention of pneumonia caused by S.pneumoniae serotypes 8, 10A, 11A, 12F, 15B, 22F, and 33F in individuals 18 years of age and older is approved under accelerated approval based on immune responses as measured by opsonophagocytic activity (OPA) assay.   PCV21 (Capvaxive): A newer vaccine approved in 2024 for adults, protecting against 21 types, including several strains not covered by other vaccines. CAPVAXIVE™ is a vaccine indicated for: • active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 3, 6A, 7F, 8, 9N, 10A, 11A, 12F, 15A, 15B, 15C, 16F, 17F, 19A, 20A, 22F, 23A, 23B, 24F, 31, 33F, and 35B in individuals 18 years of age and older. (1) • active immunization for the prevention of pneumonia caused by S. pneumoniae serotypes 3, 6A, 7F, 8, 9N, 10A, 11A, 12F, 15A,15C, 16F, 17F, 19A, 20A, 22F, 23A, 23B, 24F, 31, 33F, and 35B in individuals 18 years of age and older. (1) The indication for the prevention of pneumonia caused by S. pneumoniae serotypes 3, 6A, 7F, 8, 9N, 10A, 11A, 12F, 15A, 15C, 16F, 17F, 19A, 20A, 22F, 23A, 23B, 24F, 31, 33F, and 35B is approved under accelerated approval based on immune responses as measured by opsonophagocytic activity (OPA).Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial. (1) Pneumococcal Polysaccharide Vaccine (PPSV) PPSV23 (Pneumovax 23) PNEUMOVAX 23 is a vaccine indicated for active immunization for the prevention of pneumococcal disease caused by the 23 serotypes contained in the vaccine (1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F,14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F). (1.1) PNEUMOVAX 23 is approved for use in persons 50 years of age or older and persons aged ≥2 years who are at increased risk for pneumococcal disease. (1.1, 14.1)	Adults aged 50 or older according to CDC

 

 *High risk for severe outcomes:  For the comprehensive list of underlying medical conditions that place a person at risk for severe outcomes from COVID-19 see this CDC document: https://www.cdc.gov/covid/hcp/clinical-care/underlying-conditions.html

 FDA Vaccine, Blood, and Biologics Web Page:  https://www.fda.gov/vaccines-blood-biologics

 FDA Vaccines Licensed for Use in the United States:  https://www.fda.gov/vaccines-blood-biologics/vaccines/vaccines-licensed-use-united-states

CDC Vaccine Schedule with graphic:  https://www.cdc.gov/vaccines/imz-schedules/adult-easyread.html

COVID recommendation:  “Adults should talk to their health care provider to decide if this vaccine is right for them”.

 AAFP Adult Vaccination Schedule with graphic:  https://www.aafp.org/dam/AAFP/documents/patient_care/immunizations/2025%20adult%20Schedule_NOV.pdf

COVID recommendation:  “1 – 2 or more (age >65) does of the updated 2025-2026 vaccine”.

 Minnesota Department of Health Adult Vaccination Schedule with graphic: https://www.health.state.mn.us/people/immunize/resprecs.pdf

COVID recommendation:  “All adults especially 65+ (2 doses)”.

 

 

Threads and Why Post-Apocalyptic Art Is Not A Deterrent To An Apocalypse

 

I watch a lot of post-apocalyptic television series and movies.  In fact, I watch so much of it that Netflix categorizes my favorite genre as “Extreme Survival In Twisted Worlds”.  That is an actual category.  I have also read the survivalist literature and literature on extreme survival shelters. You can call a company and have one delivered that they will sink in your back yard.  Some include sophisticated features like cooling your shelter exhaust so it cannot be picked up by infrared detectors.  If you have several million dollars to spend you can get a deluxe survival condo located in an old missile silo.  That assumes that you have adequate warning of the impending apocalypse to travel there. The standard post-apocalyptic fiction seems to assume that there will be significant numbers of survivors, that they will be well prepared, and the only worries will be ruthless leaders and defending yourself and your resources from them. The only exception I can think of is the movie version of Cormac McCarthy’s The Road, that is focused on the grim post-apocalyptic existence of a man and his son. But even in that story there was a relatively happy ending.

A week ago, I was watching clips from Jason Pargin.  He is an author who offers insightful sociocultural commentary on various topics.  The one I saw was about this topic in general. He observed that most post-apocalyptic movies and television series are inhabited by attractive people who don’t seem to be in that much distress.  They all seem to have survival skills and are getting along famously.  The only exception seems to be when they need to use their survival skills in physical confrontations with roving hordes of zombies or rival camps trying to steal their food or personnel.  Even then they prevail.  He suggested the 1985 film Threads as a counterpoint.  The movie is about a nuclear attack on the United Kingdom.  His point was that this was probably a much more accurate depiction of post-apocalyptic survival and it is grim – even decades after the event.  

On that recommendation I was able to find the movie on a streaming service and watched it from beginning to end.  It starts off in a couple of cities in the UK, and we focus on a few familiar people and their routine.  There is background news that the US has started some kind of military operation in Iraq and Russia is starting to respond.  There are some antiwar protests about it in the UK.  Eventually it escalates to a single nuclear device attack from Russia responded to by a single nuclear weapon from the US.  Tensions increase and eventually a high-altitude nuclear weapon is exploded over the UK as an electromagnetic pulse (EMP) that knocks out communication. That is followed by nuclear attacks on major cities.  We witness the mushroom cloud, anxiety, and panic.  There are a massive number of deaths from the initial blast and burn injuries.  There are an equal number of people exposed to radiation and injuries that nobody can treat.  There are no medical systems left that can treat or triage the massive number of injured.  That should be intuitive for anyone who lived through the COVID epidemic because at one point the mass casualty systems in many countries were overwhelmed by that respiratory infection.  By comparison a nuclear attack in any major city would produce hundreds of thousands to millions of injuries.  Most of these people would die without care. 

Removal of dead bodies was another problem.  There was insufficient manpower and fuel left to bury or burn them. There were scenes of bodies everywhere.  They were burned from radiation and decomposing.  Sanitation was a problem with no clean water, sewage, or garbage disposal.  Rats and dogs were everywhere spreading contamination and disease.  People had to seek shelter in partially demolished buildings that could not protect them from radioactive dust.  In the days following the blast more people came down with and died from radiation poisoning.  At one point the public officials who were supposed to be managing the disaster just gave up.  The landscape was littered with survivors wearing dirty clothing, shivering in the cold, with nothing to eat or drink.  Diseases that has been gone for centuries due to improved sanitation were back and killing survivors.

The confrontations depicted in the usual post-apocalyptic movies were still there but on a much smaller scale.  It was no longer village versus village. It was two people against one and all three significantly debilitated.  As the nuclear winter set in from debris blown into the atmosphere – there was some cooperation manually harvesting crops that were still in the ground.  It was a slow process due to the poor physical health of the survivors, a lack of food, and the lack of operable farm equipment.  Once those sparse crops were harvested there was not much hope for a planting season.

Threads does highlights at several intervals after the nuclear attack. About 20 years after the attack, they estimate that there are about 1.0 - 1.5 million people left in the UK or about the number that were there in Medieval times.  In 1985, there were 56.6 million people in the UK.

Threads accurately depicts the catastrophic changes that are likely to occur after a nuclear war.  The imagery in the film is much grimmer than I am describing in this essay. I found the final scene so gruesome that I am not mentioning it here. I don’t think it is necessarily important to watch it all.  It does not take much imagination to think about what will happen if suddenly the power goes out, municipal safe water systems shut down, and you no longer have a safe food supply or medical care.  More importantly – you no longer have the hope that any of these systems will ever be restored.  One of my concerns has always been – what happens to the people who are taking life saving medication every day for chronic problems.  What happens to the millions on CPAP for sleep apnea? Most of them will encounter very serious problems in the next 1-3 months and that assumes they were able to save their current supply of medicine. 

How does Threads compare to other films in this genre?  The closest approximation is probably The Day After a 1983 American movie that depicts similar levels of mayhem and destruction but alludes to the severity of the destruction at the end saying an actual attack would be much worse than what is depicted.  There is apparently is a 2025 film called Nuclear Winter that I cannot find anywhere.  There are several films that leave the results of a nuclear attack up to the imagination of the viewer.  Fail Safe is a classic film demonstrating the catastrophic consequences of mistakes with nuclear weapons but the viewer only experiences the anxiety and fear of the government and military officials.  The recent Kathyrn Bigelow film A House of Dynamite uses a similar approach while pointing out the folly of anti-missile systems.  There are scores of survival manuals available from government web sites that describe is detail what happens during a nuclear attack and what you need to protect yourself.  None of them say anything about what it will be like when all the services and infrastructure that you need every day to live is permanently gone. There are certainly glimpses of this from conventional weapons.  The devastation in Palestine is a recent example.  But even the horror of what happened in Palestine seems to be minimized and sanitized on a daily basis as if it can be argued away.

The scariest prospect of living in the 21^st century is that there are no peace movements anymore.  The only realistic prevention strategy is to maintain the peace and international relationships and there are few people who talk realistically about that.  All the current world leaders seem poorly equipped for that task.  Many seem to adhere to the Athenian precedent from 415 BC when they ignored an appeal from the Island of Melos based on their neutrality.  Instead, they attacked and massacred all the men and enslaved the women and children.  In today’s world we see the dynamic of power over morality being played out on a regular basis.  A related issue is the people in power are old men with questionable values and motivations. They have no stake in the future and the immediate goals of many are self-enrichment and fictional legacies.  Many of them are convicted criminals or have been charged with war crimes.  Many clearly have no interest in averting a climate apocalypse that will amplify the power over morality dynamic that has been present since prehistoric times. That is hardly a group I would assemble to prevent nuclear war. It seems that modern man has very advanced destructive technology being managed by the same primitive brain.

A significant portion of the general populations of each country do not seem much better. Instead of recognizing the sanctity of the universal struggle for existence and all that involves they tolerate megalomaniacs and, in many cases, seem to worship them.  In the United States, billionaires and an impending trillionaire are all considered geniuses and given privileges (most notably lower taxation rates) that the average citizen does not have.  The media hangs on the predictions of this elite group as if they are accurate. While this group profits from taxpayer supported subsidies and contracts, many of the people paying the taxes can’t afford food, housing, child care, or healthcare. In the US, the people and the Congress representing them seem powerless to change the recent more malignant course of power over morality. Much of that powerlessness comes from new trends in negating reality and science by politics and rhetoric.  It is easier to listen to an antivaxxer rant than contemplate a burned-up world with nothing left to sustain human life.  It is as if the zombie apocalypse has already happened and the people have become a slow-moving herd of the undead, watching their little screens while the world burns.  

None of this makes me very hopeful about the future. If you can deny that vaccines have been the single most significant mortality reducing medical achievement in history you can deny a nuclear winter with tens of millions of dead bodies littering the landscape.   

And remember a nuclear war is not "winnable" or containable based on geography.  It is much more likely the end of civilization and probably our species.  

 

George Dawson, MD, DFAPA

Graphic Credit:

Palestinian News & Information Agency (Wafa) in contract with APAimages, Public domain, via Wikimedia Commons.

Description: Damage in Gaza Strip during the October 2023 - 29

 https://commons.wikimedia.org/wiki/File:Damage_in_Gaza_Strip_during_the_October_2023_-_29.jpg

Creative Commons License CC B-Y SA 3.0 Attribution-ShareAlike 3.0 Unported

Existential Threats....

 

Mapping Existential Threats in the Medical Literature

 

I heard President Trump and several right-wing politicians complaining about the term “existential threat” in the press the other day.  Some of the clips were a few months old but the overall message was first – “I didn’t know what it means”, second – the people using the term (in this case former President Biden discussing climate change) don’t know what it means, and third you are an elitist if you use the term because the average family in American does not use the term and you should learn to talk like them.  Like most statements uttered by the current President and his unquestioning party I found it rhetorical, not useful, and decided to see what the medical literature said.  This is what I found.

On PubMed, there are 248 references to the term dating back to 1979.  As seen in the table most of the scenarios listed like climate change, COVID and other pandemics (in this case HIV), diseases, antibiotic resistance, artificial intelligence, and other threats to life are the commonest threats listed in medical literature.  By definition, an existential threat puts the future of some group (humanity, specified individuals) or person at risk.  The worst-case scenario is an extinction event like the Cretaceous-Paleogene (K-Pg extinction) event that occurred 66 million years ago.  That was caused by an asteroid strike and it led to the extinction of non-avian dinosaurs and 75% of all plant and animal species. 

The tables contain existential threats to humanity, many subgroups including physicians and the afflicted, school and businesses, other animals, and plants, as well as ecosystems.  It also includes the psychological component where the perceived threat is experienced as a threat to existence, but more at a symbolic level.  Yalom’s text (1) on existential psychotherapy breaks those threats down to death anxiety, freedom, isolation, and meaninglessness.  Other psychoanalytical writers point out that existential crises are more likely to occur at various points in human development.  In psychiatric practice it is common to see people experiencing crises in these areas across all settings.  Existential crises can exist at the level of group or individual psychology depending on the nature and scope of the threat. Some scientists hypothesize that we are currently in the midst an extinction event.  They describe this as the sixth mass extinction event and verify it by estimating the number of vertebrate species that have gone extinct and compare it to previous mass extinctions (3).  Human culture is a critical factor in this extinction and the conclusion are a massive effort is needed to head off this event and much of that effort needs to be directed at reducing overconsumption, transitioning to environmentally friendly technologies, and an equitable path to those transitions (2).  These authors point out obstacles to these changes including most people being unaware of the changes required to prevent ecosystem damage by human culture, the scope of the problem, and the necessary solution of scaling back human impact – both the scale and processes.

The political use of the term “existential threat” has been applied to the Trump administration and this is probably why Trump himself is trying to spin the term in his favor. He is focused on blaming the opposition party, but at this point it goes far beyond the Democrats.  The non-partisan Bulletin of the Atomic Scientists has posted that the well know extreme budget cuts of the administration pose an existential threat to the next generation of scientists. Various publications around the world have written about Trump as an existential threat to democracy, the American economy, former American allies, Social Security, freedom, black Americans, American colleges and universities, public health, science, and critical international food and medical aid.  In many of these areas the facts are clear.  I can think of no better example than USAID and the PEPFAR program.  Just defunding those programs could lead to as many as 14 million deaths if none of these changes are reversed by the courts.  

Paranoid people do not do well with existential threats.  They lack the ability to assign probabilities. They cannot see a car on the street and just see it as another car.  They get the idea that all cars or all red cars are threats to them. The defined threat may be elaborated as surveillance by Homeland Security to being attacked by microwaves being transmitted from these cars.  In some cases, everything is seen as a threat.  The anxiety is real but the threat assessment is wrong.

If you do not know what an existential crisis is – you should.  Most students in the US start reading existential themed literature in middle school and early high school.  The average person needs to know at what level the threat exists (personal, group, civilization-wide) and what can be done about it.  That means that it makes sense to break down the specific threat, adequately assess it, and not leave it hanging there as ill-defined.  For example, nuclear war, a massive asteroid collision, and climate change threaten all human, animal, and plant life on the planet.  Not being able to get a job in an area where you were trained in college or losing your first significant relationship can be existential crises at an individual level.  That can be life changing at a personal level and the good news is most people find their way back on track with the help of family, friends, and the occasional therapist. 

The outcomes of existential threats can lead to unexpected action.  When I was in college, one of my jobs was working in the local public library.  It was a multi-county library and the main part of my work consisted of mailing out books and films to all the co-operating libraries. One day the chief librarian came in and told me it was now my job to dismantle the fall-out shelter in the basement.  The year was 1972 just 10 years after the Cuban Missile Crisis. The library had two Fallout Shelter signs like the one at the top of this post.  I went down into the basement and found about 100 steel drums.  They were all about 30-gallon capacity. According to the instructions on the side they were supposed to be used for water storage.  When empty they were supposed to be used as latrines.  None of them contained water.  I guess the planners thought there would be time after a nuclear attack to fill them all. When I asked my boss what I was supposed to do with the drums he said:” I don’t care just get them out of here.”  I took them back to my neighborhood and handed them out to anyone who wanted them.  Apart from the steel drums there was no food or medical supplies.  Just a very large room full of steel drums.

It took me a long time to figure out what happened to the fallout shelters and how they went from a national priority to complete disrepair and abandonment in a decade.  The only explanation is that the planners knew there would be no survivors. A few groups here and there would survive the blast and radiation but nobody would survive the nuclear winter.  Even a limited nuclear exchange kicks enough dust up into the atmosphere that makes food production impossible. That marks the end of humanity – the ultimate existential crisis.

Shouldn’t the man with the power to end civilization quickly or slowly know something about this?  Shouldn’t everyone know the real existential threats we are facing?  Shouldn't we all be facing these threats realistically instead of denying they exist or pretending that we can survive them?

 

George Dawson, MD, DFAPA

 

References:

1:  Yalom ID.  Existential Psychotherapy.  Basic Books.  New York, 1980.

2:  Dirzo R, Ceballos G, Ehrlich PR. Circling the drain: the extinction crisis and the future of humanity. Philos Trans R Soc Lond B Biol Sci. 2022 Aug 15;377(1857):20210378. doi: 10.1098/rstb.2021.0378. Epub 2022 Jun 27. PMID: 35757873; PMCID: PMC9237743.

3: G. Ceballos, P. R. Ehrlich, A. D. Barnosky, A. García, R. M. Pringle, T. M. Palmer.  Accelerated modern human–induced species losses: Entering the sixth mass extinction. Sci. Adv. 1, e1400253 (2015).

Supplementary:

I thought I would list a few references to existential crisis as they occur:

Ford L.  Seymour Hersh Issues Grave Warning in Venice: “Trump Wants to Be Commander of America — He Wants to Not Have Another Election”  The Hollywood Reporter.  August 29, 2025.

https://www.yahoo.com/news/articles/seymour-hersh-issues-grave-warning-111210675.html

“There’s still integrity in America right now but as somebody said recently, we’re in existential crisis right now. And the president is a man who wants to be here for life. He wants to be commander of America. My belief is that’s his absolute sole mission. He wants to not have another election, because under the Constitution he cannot…. That’s what he’s going to be doing for the next three years.”

Killing Us Slowly…..

 

I became aware today of a Brown University study that estimates the current Trump tax cut bill will close about 580 nursing homes. Since the average nursing home has about 109 beds that means 63,220 people will be out on the street or worse.  Where do politicians (more specifically the Republican party and their constituents) think these people will go?  And why don’t they seem to care?

Over the course of my career – I have probably been in at least 50 different nursing homes in Wisconsin and Minnesota.  The care I have observed in most of those places is managed to be adequate to barely adequate.  By that I mean like all businesses they are managed to make money.  Unless they are privately financed by a foundation or high paying patients, that typically means there is minimal staffing and the most qualified people are typically RNs who spend most of their shift managing medications and medical problems.  That can mean long waits for medicines or care.  It can also mean that behavioral problems like agitation or overt aggression are allowed to escalate to a dangerous point.

When I first started doing assessments in nursing homes it was 1986.  In those days, there were very few diagnoses of Alzheimer’s Disease (AD) or vascular dementia (VaD) since the NINCDS-ADRDA criteria were not widely known.  Most of the people I was seeing had diagnoses of arteriosclerotic dementia, arteriosclerosis, or hardening of the arteries. At some point very early in this timeline, there was an initiative to make sure that old people with psychiatric diagnoses did not get admitted to nursing homes.  But like all political initiatives it was not always an either-or situation.  I would frequently see people with schizophrenia and bipolar disorder who had developed AD, VaD, Parkinson’s plus syndromes, or tardive syndromes in addition to the primary psychiatric disorder.  In many of those situations a subsequent rule about tapering antipsychotic medications to prevent oversedation and associated morbidities became a problem because of the need for maintenance medication.

Psychiatric services are needed in nursing homes for all of those reasons but they are rare.  The reason they are rare is funding – specifically rationing psychiatric services by both Medicare and Medicaid. I ran a Geriatric Psychiatry and Memory Disorders Clinic for a decade and we eventually closed because we could not maintain an adequate work quality and get adequate reimbursement. For a time, my clinic nurse and I decided to go out into nursing homes and see patients there to make it more convenient for patients, families and staff and see if it made a difference. We were reimbursed at an even lower rate for those efforts.  My speculation is that most of the psychiatric care and treatment in nursing homes is done by nonpsychiatrists and probably nonphysicians.  This in part is an additional reason for low quality care in most nursing homes.

Let’s consider the impact of all of these nursing home closures. First, it will greatly add to the current burden of emergency department (ED) congestion.  There is always a steady influx of nursing home patients to the ED with new diagnoses (pneumonia, urinary tract infections, cellulitis, etc). With further reductions in staffing, it may be more difficult to get them back.  I can recall one of my social work colleagues calling 22 different nursing homes one day to discharge one of our stable patients.  None of them would accept that patient. We were under intense pressure from the hospital at the time to discharge that patient because we needed to admit patients from the ED.  That whole chain of events will get worse – not the least due to the fact that far fewer nursing homes will accept people who have been admitted to an acute care psychiatric unit. There will be backups all around – on inpatient units and in the ED.  The same chain of events will occur on medical and surgical units who often put pressure on psychiatry to take their “stable” nursing home patients who may have a psychiatric disorder.

There will also be a steady-state of patients bouncing in and out of the ED-inpatient psychiatry or medicine-discharge sequence.  This is a familiar pattern in many hospital subpopulations that usually occurs because of a lack of adequate housing.  Expect to see more elderly nursing patients captured by this cycle.

Will there be excessive mortality and morbidity?  Of course there will be.  In the course of my career, I had to discharge patient to nursing homes where I knew they could not get the level of care they got on my inpatient unit.   I worked with highly skilled RNs – 4 on the day shift, 3 on the evening shift, and one on nights with 3, 2, and 2 nursing assistants respectively covering 20 beds. We cared for patients with complex medical problems that required frequent monitoring and intervention.  I knew there was no nursing home that I could discharge them to where they would get the same level of care and that would be a problem for them.

I have also walked in to a nursing home and seen the results with my own eyes. I recall visiting a 92 yr old woman with congestive heart failure and hypertension.  She was obtunded, cyanotic, and barely responsive.  When I asked the staff to check her oximetry and start oxygen they produced a nursing supervisor instead for a discussion.  When the oximetry was finally done it was 60% and she regained a normal conscious state with oxygen.  The assessment I made only required knowing this patient’s baseline state and asking what had happened given her chronic conditions.  Is that too much to ask in the case of nursing home staff?

In another more recent case – a 92 yr old man had C. difficile colitis following extended antibiotic therapies for post COVID-19 pneumonia.   During that time his body weight went from 130 to 87 lbs (he was 5’11” tall).  He was weak and barely able to ambulate. Despite the C. difficile diagnosis there were no infection control precautions and he shared a bathroom with 3 roommates.  Despite his clinical status (barely able to walk unassisted, not able to eat, BMI of 12.1) the insurance company paying for his care insisted that he be discharged home under the care of his family where he died the next day.  

Both of these cases are examples of low-quality care.  Rationing care is the most likely reason.  In one case the rationing is implicit (low staffing based on the need for profits from reimbursement) and explicit (inappropriate utilization review decision).   It all comes back to reimbursement.

A final consideration is that the funding cuts go far beyond nursing home care.  The most conservative estimate I have found is that the cuts would increase the number of uninsured by 7.8 million people and reduce Medicaid enrollment for 10.3 million.  Hospitals are legally obligated to treat all people with acute care conditions whether they have insurance or not. That means that many of these people will be in the ED-inpatient-discharge steady state cycle taking up beds.  They will also more likely be acutely ill and spend more time in the hospital.  All of that care is unreimbursed.  That means higher health care costs and premiums for everyone.  One projection is a doubling of premiums.  This is essentially another tax on the average American who is just trying to break even.  All of that is to provide tax cuts for billionaires and businesses while still incurring a 3-5 trillion dollar deficient.

It also means less access to hospital beds when you need it.  I have illustrated on this blog what can happen when you don’t have timely hospital bed access for what is considered a routine condition.

In the final analysis, nursing home care in the United States is seriously rationed care. Although there are some high-end nursing homes that require additional reimbursement and provide more supportive environments - most are not operating at that level.  They provide the basic function of providing care on a 24/7 basis to a severely disabled person that the family cannot care for.  Even that is a recent concept in American society.  As an example, one of my elderly ancestors had a closed head injury as a result of blast injury. He lived at a time when there were no nursing homes in his area only a poor farm, that cared for the indigent and poor elderly.  He had a problem with severe aggression and would routinely wreck all of the furniture in the house. I never learned how they were able to contain this behavior, but the modern question is whether this is an acceptable standard for families.  Can family members be expected to contain severe aggression from a family member with dementia and keep everyone safe?  I don’t see how.      

Severe rationing of health care in the bill being debated hurts us all…

 

George Dawson, MD, DFAPA

Photo Credit:  Thanks to Rick Ziegler for the thunderstorm photo. 

The Demon Haunted World – A Survivalist Counterfactual

 

The Demon Haunted World – A Survivalist Counterfactual

 

I found myself watching survivalist videos last night.  I had just completed a blog post and was working on another (that is becoming a thesis rather than a blog) and decided to take a break.  I have dabbled in that literature on and off over the past 30 years and found that it does not add much. The end games are typically played out in popular movies and fiction. You either find yourself in an impregnable underground shelter or wandering semi-aimlessly over a barren and hostile landscape.  Both scenarios have their problems.

In the impregnable fortress there are the inevitable power struggles, equipment breakdowns, outside attacks, functional and dysfunctional alliances, and lack of planning.  Good recent examples include The Silo and Fallout.  In the wandering scenario there seem to be a plethora of hazards including violent psychopaths, cannibals, various zombies, diseases, natural disasters, and the ever-present lack of food and water.   Examples include The Road, The Walking Dead, and The Last of Us.

Survivalists are more realistically focused. The brief series that I watched emphasized escaping detection by any means.  The implication was that you were in a secure remote location with adequate food and water.  The assumption is that there are many people who were not prepared for when the shit hits the fan or WTSHTF for short.  Four days of starvation is enough to make most people desperate and at that point they cannot be trusted.  A corollary is that once they get skilled at taking what they need from others – you may be the next target.

The first video discussed the importance of smoke. A poorly constructed fire can lead to a smoke signal for people to see for miles.  That signal translates to shelter, warmth, food, and resources to any desperate person who sees it.  The author emphasized methods to minimize smoke production. Elaborate underground survival shelters not only minimize smoke but also heat signatures to avoid infrared detectors and missiles.

 The second avoidable signal to the post-apocalyptic miscreants is gunfire. You might be thinking hunting, but the emphasis was on interpersonal conflict rather than hunting.  There may be better ways to resolve a dispute and secondarily gunfire WTSHTF is not necessarily a red flag. It is a sign out there that somebody has food and resources they want to protect.   The zombie mindset is “even if you do not have a gun – you might be able to hang around in the darkness long enough to get what you want.”  No other ways were discussed about how to avoid gunfire.

The final avoidable signal was light.  Even as little as a candle represents somebody with enough resources that they can and want to see in the dark. It represents the last vestige of civilization.  For that reason, it must be blocked at all costs. Curtains were emphasized as a practical measure but black out screens were preferable.  It reminded me of the subtitle to Carl Sagan’s classic book The Demon Haunted World (TDHW).  That subtitle is: Science as a candle in the dark.  It seemed like a perfect metaphor for what is currently happening in the world. To anyone who has not read the book – the subtitle is from Thomas Ayd’s 1655 treatise on witchcraft A Candle In the Dark where he described witchhunts as a way to delude the people about what was otherwise unexplainable.  Sagan sums up the progress against witchmongering this way:

“Microbiology and meteorology now explain what only a few centuries ago was considered sufficient cause to burn women to death.” (p. 26).

The title is a metaphor for reason and truth in the context of dire superstition and this is captured by Sagan’s summation.

Many reviews of TDHW suggest that Sagan’s views are formulaic – a few rules about how to assess facts and be skeptical along with listing logical fallacies. That minimizes the context he provides about the founding fathers and how they were impacted by The Enlightenment and science. Sagan’s thesis is more complex. He is the first to acknowledge that science is not perfect but that the method of science encourages and produces self-correction. To capture reasoning that is strictly outside of formal science, Sagan suggests that all matter of human endeavor like politics, economics, and even specific policies can be subjected to scientific reasoning and scrutiny and it will result in better results and prevent primitive biases.    

Since the beginning of the COVID-19 pandemic there has been an almost continuous attack on science and scientific experts.  The first Trump administration attacked public health officials, physicians, scientists, and anyone affiliated with them.  They promoted ineffective and potentially harmful treatments for COVID, suggested vaccines were problematic, said that COVID-19 was no worse than the flu, and that case and death rates were overstated.  Several conspiracy theories were promoted suggesting that HIV was a planned bioweapon, that NIH officials were corrupt, and that the “planned” HIV epidemic was paralleled by the “planned” COVID epidemic.  If the COVID epidemic was not planned it was supposed to have originated from a lab leak in China despite all the evidence pointing against that.  The problem is not merely a lack of training in science and the scientific method.  The problem is that we have a large segment of the population that really does not care about their ignorance of science and a large segment who seem to happily take advantage of that on social media.

Sagan has a famous quote that is considered prophetic by many:

“…Science is more than a body of knowledge; it is a way of thinking.  I have a foreboding of an America in my children’s or grandchildren’s time – when the United States is a service and information economy; when nearly all the key manufacturing industries have slipped away to other countries; when awesome technological powers are in the hands of a few, and no one representing the public interest can even grasp the issues; when the people have lost the ability to set their own agendas or knowledgeably question those in authority; when, clutching our crystals and nervously consulting our horoscopes, our critical faculties in decline, unable to distinguish between what feels good and what’s true, we slide almost without noticing, back into darkness and superstition.”   (p. 25).   

Much has been made about manufacturing in the US and there is an active debate.  Specifically – is it a feasible solution for whatever economic problems you claim it will solve?  I have seen business experts interviewed who say it is not and others who have their own specialized supply chains within the country as being a solution. How will it be compounded by tariffs and an attempt to resuscitate the coal industry? The technological power is concentrated at the monopoly level according to several court decisions.  And what about artificial intelligence? There are daily predictions that AI will replace not only truck drivers and assembly line works but also doctors and teachers.  There are grandiose claims that AI will "cure all diseases" in less than the time I have been writing this blog.  Those aspects of Sagan’s prediction seem too uncertain to be useful.

The lack of knowledge in both the general population and at the highest levels of government is also on display.  Scientific knowledge and thinking is lacking and that it is not enough.  Any reasonable analysis of population wide policies needs to include a scientific dimension, a rational thinking dimension, and a moral/ethical dimension.  This is the real current failure.  As an example, the divisive rhetoric used around the COVID-19 issue.  There was a lot of uncertainty about the best way to stop the pandemic. As physicians and public health officials were learning about this and saving lives – the counter response was that no measures were necessary including vaccinations.  In the end public health officials were being blamed for lockdowns and school closings that could only have been done by local elected officials. That rapidly evolved to conspiracy theories that led to threats of physical harm and legal action against some of the top scientists.  The culmination of this rhetoric was recently evident when the Trump administration replaced a government webpage providing scientific information on COVID-19 with one that presents a combination of conspiracy theories and pseudoscience.  None of this sequence of activity included science, rationality, or ethics.

This is what Sagan is referring to in his quote. The current web page on COVID is emblematic of sliding into the modern version of darkness and superstition. Like the old version the new one is as out in the open and accepted by many. There is an army of celebrities, podcasters, media networks, social media bots, and writers supporting it. Some of the wealthiest people in the country claim they were “censored” because they opposed some suggested COVID measures or supported anti-science rhetoric – even though there was no formal censoring. The dark narrative is very present and it continues to take its toll in terms of cabinet appointees who promote it and some who seek vindication against scientists and officials who were making a good faith effort.

As far as science goes, whether that is hard science or the dismal science of economics – we have a choice to stay in darkness and superstition or move toward the light of science and facts.   Not caring about the smoke is the difference between surviving and living.

 

 

George Dawson, MD, DFAPA

 

 

Graphics Credit:

Campfire in the forest by Crusier, CC license BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0&gt https://commons.wikimedia.org/wiki/File:Campfire_in_forest.jpg

References:

1:  Sagan Carl.  The Demon-Haunted World – Science as a Candle In The Dark.  Ballantine Books 1997.

2:  Ayd Thomas.  A Candle in the Dark.  Smithfield, London. 1655.