Can They Be Resuscitated? Should They Be Resuscitated Or Made DNR ?
Needless to say the events of the past year have had a devastating effect on New York City as well as on other major cities across the country. Many of these great cities like Chicago, Los Angeles and Seattle are virtually on life support at this time. First, having been decimated by Covid-19, otherwise known as the “plague” or “China Virus,” these cities were next set upon by gangs of marauding vandals whose clear intent was to pillage and destroy the very cities that contributed so much to making this country great. Legitimate issues that initially provoked rightful protests and demonstrations were usurped by anarchists whose sole aim was not justice but rioting and destruction of the country. These anarchists used whatever tools they could to wreak havoc on everyone who failed to join them in their quest of destruction. They were organized and appeared to be well funded by sources who yet remain in the shadows. What they managed to accomplish in large part was the ruination of the businesses and residential areas upon which these cities depended for survival both economic and social. So our great cities sustained a “one-two” punch. The first being the Covid-19 itself and the second being the riots. Now those people who can are leaving the big cities in droves. Thanks to technology “telecommuting” has become a real thing. Many of us no longer have to go to a conventional office to work. We can work in a virtual office anywhere so why risk living and working in a city that is falling apart and dangerous? The leaders of these cities have really done nothing to help their fellow citizens who want to stay and work. These citizens are not protected, and they are not supported so they feel it is time to leave. Who can blame them? In actuality, it is time to leave if your leaders cannot or will not protect you because their priorities lie elsewhere. In this case these priorities seem to lie with the rioters and anarchists. So can our cities be resuscitated? Should we even try?
The situation with our cities really is like a critical illness. They were first attacked by a terrible virus. Many of our elected state and city leaders made bad treatment decisions which resulted in loss of life. These mistakes were unintentional, but they happened just like in real medicine. Weakened by a terrible virus our cities were next attacked by another necrotizing infection; namely, anarchy and rioting. Call it whatever you like, but this second wave of destruction caused by criminals was analogous to what is seen in medicine when a patient weakened by an infection is hit with a second infection causing even more severe damage. The third and final assault on theses patients, our cities, who were in the care of our political leaders is the exodus of the heart and soul of the city. The middle class upon whom these cities depended can no longer can afford to live in the city. Nor do they want to, and they certainly don’t have to. The wealthy are now joining the exodus. They can easily afford to live elsewhere. The only ones left, unless things drastically change, will be those who cannot afford to leave.
For decades the citizens of this country have been ripped off by the big pharmaceutical companies and their intermediary distributors. I’ve written about this previously (What’s Wrong With The U.S Health Care System?), but now with the stroke of a pen and by executive order President Trump has finally been able to do what preceding presidents and congresses have never been able to achieve. There will now be a system whereby the cost of drugs for citizens of the U.S. will be on a parity with other countries. This a great day for all of us whether Republican or Democrat. Let’s see how his works. Here are a few of the key points.
Health and Human Services (HHS) will end the “kick back” system that allowed middle men distributors to jack up the price of drugs that are sold at the pharmacy. Medicare patients will see these “kick backs” as discounts in their Medicare Part D plan instead of the money going to the middlemen.
There will be particular savings on insulin products dispensed through federally qualified health centers (FQHCs). This will be especially helpful to many uninsured or underinsured patients.
Through the Medicare program seniors in the U.S. will pay no more for Medicare Part B drugs than patients in other economically comparable countries.
A pathway will be created for safe, imported lower cost drugs.
This plan may not solve all of the problems regard the high cost of pharmaceuticals in the U.S., but it is certainly a step in the right direction. This is a step which previous presidents and congresses should have taken decades ago. No longer will U.S. citizens be the only ones paying for the innovative research which the pharmaceutical companies often use as an excuse for the exorbitant costs of their products.
According to the New York Times as of 7/23/2020 there were 414,405 cases of Covid-19 reported in New York State and 32,270 deaths.* According to the Florida Board of Health there have been a total of 389,868 coronavirus cases and 5,632 deaths. Though the populations of New York and Florida are similar (Florida has about 2 million more residents) and the number of overall cases reported by each state thus far are similar, there is close to a 6 fold difference in mortality. Hopefully Florida will not catch up to New York in regard to the death toll, but why we have this difference is not yet completely clear. It may never be completely understood, but there are some logical reasons as to why Florida has had so many fewer deaths than New York so far in spite of the fact that Florida has the larger population and a greater percentage of elderly patients. One likely reason for this is that Governor Desantis took a more aggressive approach in protecting this vulnerable, elderly population. For example, unlike in New York elderly Covid-19 patients were not sent into nursing homes where they could easily infect other residents and staff. In early March, Governor DeSantis put out a strong preventive message to his elder population, advising them to stay at home in order to avoid potential exposure. He made sure that nursing home personnel had the protective personal equipment (PPE) that they needed to help prevent acquisition and spread of the virus. He deployed the National Guard to help institute testing in the state’s nursing homes where older COVID-19 patients were not sent. These actions and others helped to give Florida a much better survival rate for patients in long term care facilities compared to New York. On the other hand in New York, Governor Cuomo had patients with Covid -19 go back to nursing homes that were not prepared to care for them. In spite of the fact that there were other alternatives such as the hospital set up at the Javits Center, the Hospital Ship Comfort that was sent to New York Harbor by President Trump and the Samaritan’s Purse field hospital that was set up in Central Park. There was inadequate protective personal equipment (PPE) for the staff in these nursing home facilities in New York and inadequate isolation procedures which led to promulgation of the virus and increased death tolls among staff and patients. In late April, the New York State Health department finally clarified that nursing homes should not take any new residents if they are unable to meet their needs. In May Governor Cuomo finally reversed his directive, and tried to shift the blame for the nursing home fiasco on to President Trump though President Trump had no role in determining Governor Cuomo’s response to the pandemic on a statewide basis. Governor Cuomo also said that nursing homes could have refused to comply, but he did not specify how they could do so without incurring any penalties.
Some Other Reasons Why New York Infections Skyrocketed
Another probable reason as to why New York became an epicenter of this virus is that early on in the pandemic, New York’s Governor Cuomo and the New York City’s Mayor de Blasio, tended to downplay the significance of the virus telling people to continue their normal activities including socializing. This lead New York City with its great population density to become an epicentre of the pandemic in the U.S. in such a rapid fashion that New York’s hospital system was overwhelmed. Their response as political leaders was marked by missed warning signs and health care policies that many health-care workers say put residents at greater risk and led to unnecessary deaths. For example, in the first few days of March, Governor Andrew Cuomo and Mayor Bill de Blasio assured New Yorkers things were under control. On March 2, Mayor de Blasio tweeted that people should “go see a movie”. Only after the disease was running rampant in the New York City’s low-income neighborhoods later in March did Governor Cuomo and Mayor de Blasio mobilize public and private hospitals to create more beds and intensive-care units.
Some Good News
The good news is that the death rate from the virus seems to be decreasing nationwide even though the incidence of infection may be surging in some areas like Florida and Texas right now. The reasons for this decrease in death rate are again not completely clear, but some of this may be due to the fact that we have learned how to better manage this infection. We know more about the sequelae of the infection and how to treat them. We have better contact tracing and management. We have some therapeutic modalities that seem to be helpful. Whatever the means, driving down Covid-19 deaths is becoming a major breakthrough. If treatments for Covid 19 eventually result in a mortality rate of only 0.1% similar to influenza than the Covid-19 would no longer be a major health problem even though it might persist in the population for long time to come.
More Testing Means More Numbers But Accuracy and Interpretation of Data Are Key
It should also be remembered that it may also be possible that the virus itself is changing and mutating to a less virulent and less infectious form. As far as the incidence of new cases is concerned some of these numbers have to be interpreted in light of the fact that more and more people are being tested. Moreover, as we get further and further away from this pandemic as time goes on, we may find that there have been irregularities in the data reporting and problems with the various screening tests that have been brought to market in terms of their reliability and accuracy. For example, the number of false positives and false negatives will need to be better scrutinized especially since there are a number of companies marketing tests that may not have been fully validated. So the total numbers of patients who have been exposed to coronavirus may be greater or lesser than what we now appreciate. Mortality issues will also need to be reevaluated. Many patients who have been cited as having died from coronavirus may actually have died from other illnesses, but they were listed as Covid-19 deaths because they were found to be positive for the virus when they were tested in the hospital. It’s well know that many patients who have the virus are asymptomatic or relatively asymptomatic so having a positive test in someone who ultimately died of something unrelated to Covid-19, but reported as a Covid-19 death, would obviously skew the data regarding total Covid-19 deaths.
Importance of “Herd Immunity” Cannot Be Overemphasized
Given the increased numbers of individuals who have been exposed to and presumably have antibodies against the virus should lead to greater “herd immunity” as time goes on. Overall, even though we are seeing some peaks of infection nationwide, the pandemic seems to be decreasing. “Flattening the curve” does not necessarily mean eliminating the virus all at once. What is really means is that the incidence of infection is flattening so that we are not overwhelmed by large number of cases. Things should only get better as time goes on and we get vaccines along with better therapeutics in the months to come. Also, as time goes on “herd immunity” will become greater and greater. Ultimately the virus that causes Covid-19 virus should, if not disappear completely, become much more manageable much like our conventional influenza virus. We may need annual vaccines like we do for influenza, and we may need to rely on different antiviral agents to treat sick patients. However, Covid-19 will likely become much much more manageable as time goes on similar to influenza. There is also the possibility that this coronavirus (Sars-Cov-2) will mutate to a less infectious and aggressive form as these viruses sometimes do although the alternative is also possible.
*This was data collated by the New York Times from several sources.
This phrase has a long history dating back to biblical times in one form or the other. Though the origin of this saying cannot be pinned down, it seems particularly pertinent to what we are experiencing as a nation today. It is a reminder that regardless of our troubles today with coronavirus and the overwhelming impact it often has on our daily lives, it will indeed ultimately pass. We have been damaged physically, emotionally, socially and economically. Thousands of lives have been lost, but we and the rest of the world will get over this sooner or later. Hopefully, we will all be smarter and stronger having gone through this so that we are better prepared for the next pandemic which is sure to come at some point.
So now one wonders what is next with outbreaks of the virus occurring in different parts of the country when it just began to look like we might have had things under control. Keep in mind that this should not have been unexpected. The virus is here to stay until one of two things happens. First, the virus may mutate itself out of existence meaning that it changes in such a way that it becomes less capable of attaching to and invading human cells. However, there is a caveat to this first scenario since the virus could also mutate in such a fashion as to make itself more likely to attach to a human cell and replicate. The second thing that could happens, which we should hope for, is that so-called “herd immunity” develops. This occurs when a large portion of the population either asquires the illness, survives and produces antibodies to the virus; or, a vaccine is given which also creates immunity. When immunity develops in either fashion, the virus is less likely to enter a host to replicate, cause illness and spread to other susceptible people. Those who were either sick and have recovered and those who have had the vaccine can no longer harbor the virus and thereby prevent it from replicating and invading the remaining susceptible individuals. In those who have been vaccinated and developed antibodies, the virus is not longer able to attach to the host cell and enter it to cause damage to the cell and replicate itself. In those who have acquired the immunity by having had the illness, antibodies likewise develop which prevent attachment of the virus to the susceptible cell so the virus once again cannot replicate and spread. Either way, the chain of transmission is thereby blocked and the incidence of viral infection decreases in a population. However, there is a caveat here also in terms of those who have naturally acquired immunity through infection; namely, that some individuals who have had the illness and recovered may theoretically become carriers of the virus. Not enough is yet known about this virus to make any comments about a carrier state. Remember that our objective here is “flatten the curve.” That does not mean that we have eliminated the virus. What is means is that we have reached a point where the rate of new cases occurring has slowed and reached a plateau making it much easier to control the pandemic. Hopefully at some point the virus will have disappeared, but that may never completely occur. Instead, what we may see is a situation similar to the influenza virus where we have to deal with a new strain or strains every year. In the meantime while we await the development of vaccines and antiviral medications, we try to identify and isolate infected people as quickly as we can, maintain social distancing in a reasonable way in order to minimize exposure, and we try to resume our lives as close to normal as possible.
How And When Will The Pandemic End?
We do not know yet how and when the pandemic will end, but it will will end. This does not mean that the virus itself will completely disappear though it may. Instead, we may see this coronavirus or other similar coronaviruses popping up periodically in different places for years to come.
Lessons To Be Learned
This Sars CoV -2 coronavirus is “novel.” Its combination of easy transmissibility and its wide range of symptoms makes it somewhat unique, but there are lessons that can be learned from previous pandemics like the SpanishFlu of 1918. This pandemic lasted over two years and came in three waves that killed 50 million and 100 million people. Exactly why the virus became extinguished remains unclear. There were no vaccines for it and no effective treatments. It has been estimated that over a period of two years 500 million people worldwide were infected and somewhere between 50 and 100 million people may have died. Several theories for its disappearance have been postulated, but it seems likely that this was due to a combination of factors. One of these might have been that the virus mutated to a less pathogenic form which often happens with viruses. Social distancing once it was used more aggressively likely decreased the rate of transmission. Also, as time went on more and more people got exposed to the virus and became immune leading to so called “herd immunity.” When enough people in a population are immune either through naturally occurring infection or immunization, the likelihood of transmitting the virus to the remaining others in the population who are not immune decreases dramatically. This is where we are hopefully heading now.
What happens next and how soon this pandemic ends depends on a combination of factors in addition to the development of herd immunity. This includes the natural history of the virus itself, in other words, will the virus mutate to a less aggressive form; how effective the vaccines are; how good we get at discovering new antiviral medications; and how good we get at treating the inflammatory effects of the viral infection such as the so called “cytokine storm.”
Through all of this turmoil just remember that “this too shall pass.”
We in the U.S. are currently battling two major illnesses that may change the social fabric, customs and morality of our country for years to come if not forever. Both are very different but certainly intertwined. Together they will test our strength as a nation.
The first of these is Covid-19. While as a whole the country seems to be doing better handling this pandemic, we are by no means out of danger. More illness and death is yet to come. However, keep in mind that as time goes on and more and more people are exposed to the virus more herd immunity will occur, and that is really what we need in order to overcome the threat of pandemic. We achieve that “herd immunity” in two ways (see The Dilemma of Immunity). One way is by immunization. The second way is through naturally occuring infection. This means that as more and more people are exposed to the virus naturally in the environment and recover, then fewer and fewer people are left susceptible to the virus. The corollary to this concept is that people who have had the disease and recovered would be unlikely to spread the disease to the remaining others who might still be susceptible. Hence there will be less communicability as time goes on. This may seem obvious, but it is an important concept and probably as important as immunization if not more so. However, there are some caveats to be considered here. For example, we are assuming with good reason that having had the infection confirms immunity. While this is likely it has not yet been completely validated at this point. Neither has it been validated that the immunity will be lifelong.. Another issue which remains open yet is whether the virus will mutate to such a degree that prior immunity will no longer be effective as often happens with the influenza virus for which new vaccines are required on a yearly basis. Of course the alternative is also possible; namely, that the virus will mutate and become in and of itself less infectious as time goes on. We will likely have a vaccine (or vaccines) for Covid-19 early next year and newer antiviral medications will likely be developed in the months ahead as well. Also, very importantly, other medications to treat the lethal inflammatory sequelae of the virus will soon be developed thanks to our robust pharmaceutical industry. All of this should save lives. However, other new viruses and infectious agents will also likely come to our shores in time to come, and we will need to be better prepared for this future possibility. Please see my previous blog about what we have learned from this pandemic (seeWhat Have We Learned From Covid-19). In the meantime our experience with Covid-19 has had dramatic effects on how we live our lives and conduct our business. There is no more hand shaking. Social gatherings are limited. People walk around in fear of getting a dreaded illness, which by the way, has a mortality rate far lower that initially projected. People are wearing face masks in situations where there is no rational reason to do so (see Pandemic). Uncertainty about our economic future and security is causing fear and panic in the population leading to unreasonable doubts about our survival as a nation. We will survive the Covid-19 pandemic and other infectious disease threats that may follow. Not only will we survive these threats, but will will do well once we learn how to cope with them.
The greater threat to our health, both individually and as a nation, is the emergence of various anarchist groups threatening to overthrow our government and the rule of law without which no society can survive. The widespread violence and destruction that we are now seeing and the inability of local governments, particularly those in left wing democratic cities, to control this is a greater risk to the health and wellbeing of the nation as a whole compared to any viral pandemic. We can face pandemics together as one nation and do what is necessary to overcome them if we put petty politics aside and use good judgement. Instead, what we see happening is our politicians using this pandemic as a political tool to destroy the opposition putting power before country. Beyond this we see some of our elected leaders, principally socialist democrats, on a state and local basis permitting, condoning and even encouraging rioting and destruction. There is absolutely no doubt that we have social problems that need to be urgently addressed, but destroying the country is not the healthy way to do so. The wanton destruction of private property, the desecration of monuments, the attacks on law abiding citizens does nothing but create more fear and hostility at a time when what we need is unity. The health of the nation and its citizens depends on it. To destroy our government and our institutions, as the leftists and particularly the anarchists want to do, is like seeing a sick patient in the hospital who has an excellent chance of recovery and saying he has to be euthanized because he is not worth saving.