Black Health Matters Too: The Role of Race in Life-and-Death Medical Decision-making

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Image courtesy of visuals.nci.nih.gov

The intersection of race and health is complicated. But the emerging picture seems to be that health conditions that affect Black people disproportionately—such as kidney disease and maternal deaths—may have their roots not only in poverty or access to health care, but also in preconceived and unproven notions of race that affect medical decision-making. (emphases mine throughout)

In one sense, that’s a painful reminder of the pervasive extent of racism in our institutions. Right now we are watching Black people bearing a disproportionate burden of COVID-19—in part because of their preexisting conditions.

In another sense, it offers hope that by confronting and changing those preconceived notions, we can actually change health outcomes.

Of course we also need to improve our inequitable hodgepodge of a health care system and address issues related to poverty—such as food deprivation and environmental injustices (eg, housing in toxic areas).

But at the same time, we should be educating clinicians to take a new look at their decision-making when treating each specific Black patient–indeed, all minority patients.

As far as geneticists are concerned, to the extent that there are racial groups, there is greater genetic variation within the specific groups than there is between groups. That means that when the specialty societies that design algorithms to guide clinical decision-making have built in beliefs that aren’t scientifically based, they are obliged to go back to the drawing board.

The need to take a fresh look at the implications of these preconceived notions was raised in an important article in The New England Journal of Medicine: “Hidden in Plain Sight—Reconsidering the Use of Race Correction in Clinical Algorithms.” (I cite a couple of other sources in this post as well.)

The authors observe that:

“Despite mounting evidence that race is not a reliable proxy for genetic difference, the belief that it is [a reliable proxy] has become embedded, sometimes insidiously, within medical practice.”

They speak of “diagnostic algorithms and practice guidelines that adjust or “correct” their outputs on the basis of a patient’s race or ethnicity…By embedding race into the basic data and decisions of health care, these algorithms propagate race-based medicine….[and] may direct more attention or resources to white patients than to members of racial and ethnic minorities.”

For example, if you look at the results of your blood work, you may have noticed two separate readings for kidney function. The estimated glomerular filtration rate, or eGFR, has historically been based on four elements: the levels of creatinine (waste the kidneys remove from the blood), age, gender, and race. The higher the score, the better the kidneys are seen to be functioning.

But there’s one assessment for Black people and one assessment for everyone else. The original reasoning was derived from the flawed assumption that Black people have more muscle mass, and thus better kidney function.

So the assessment for Black people automatically adds points for better kidney function—regardless of the particular patient. (Do most clinicians even know the reasons behind the differentiation?)

The result can be disastrous:

“These higher eGFR values may delay referral to specialist care or listing for kidney transplantation.”

In fact, the authors note:

“Black people already have higher rates of end-stage kidney disease and death due to kidney failure than the overall population.”

The good news is that both physicians and medical students at some prominent universities have called for an end to this race-based kidney testing.

Several leading hospitals have already done so. And the National Kidney Foundation and the American Society of Nephrology have said they’ll establish a task force to evaluate this use. (This information is from another source.)

The NEJM article has an insightful table of “Examples of Race Correction in Clinical Medicine” that shows how race has affected a number of decisions routinely made by clinicians who are merely following the guidelines.

By specialty, they cite the tool affected by a racial correction, input variables, use of race, and equity concern. In addition to Nephrology, the specialties include Cardiology, Cardiac Surgery, Obstetrics, Urology, Oncology, Endocrinology, and Pulmonology.

Here are just a few examples:

Cardiology

“The American Heart Association (AHA) Get with the Guidelines—Heart Failure Risk Score predicts the risk of death in patients admitted to the hospital. It assigns three additional points to any patient identified as ‘nonblack,’ thereby categorizing all black patients as being at lower risk. The AHA does not provide a rationale for this adjustment….Since ‘black’ is equated with lower risk, following the guidelines could direct care away from black patients.”

And here’s the real-life implication:

“A 2019 study found that race may influence decisions in heart-failure management, with measurable consequences: black and Latino patients who presented to a Boston emergency department with heart failure were less likely than white patients to be admitted to the cardiology service.”

A similar situation exists with the calculators thoracic surgeons use to estimate complications and risk of death before deciding to operate. Here, too, the algorithm’s developers don’t explain how they arrived at their conclusions, but, say the NEJM authors, “When used preoperatively to assess risk, these calculations could steer minority patients, deemed to be at higher risk, away from surgery.”

Obstetrics

We know that Black women are up to three to four times more likely to die in childbirth than white women, according to the CDC. And though among poorer women, lack of access to care and poorer quality of care are significant factors, women who are not poor and are well-educated are also represented in these distressing statistics.

Dr. Ana Langer, Director of the Women and Health Initiative at the Harvard T.H. Chan School of Public Health in Boston has said:

“Black women are undervalued. They are not monitored as carefully as white women are. When they do present with symptoms, they are often dismissed.” 

One algorithm the NEJM authors discuss pertains to Vaginal Birth After Cesarean (VBAC)—assessing the risk of labor to a woman who has had a Cesarean section when she’s about to deliver another baby.

At present, the algorithm predicts a lower success rate for women identified as African American or Hispanic to have vaginal births. In the chart, the authors note that “the decrement for [women identified as ] black…or Hispanic…is almost as large as the benefit…from prior vaginal delivery or prior VBAC.”

The result: Nonwhite women in the US–even those who have had previous vaginal deliveries—have higher rates of C-sections than white women, despite the fact that successful vaginal deliveries are safer, lead to faster recoveries, and result in fewer complications during subsequent pregnancies.

Thus,

“Use of a calculator that lowers the estimate of VBAC success for people of color could exacerbate these disparities” and worsen the already high maternal death rate among Black women.

The NEJM authors say that these types of algorithms exist throughout medicine, and they cite studies to back up these assertions:

“Some algorithm developers offer no explanation of why racial or ethnic differences might exist. Others offer rationales, but when these are traced to their origins, they lead to outdated, suspect racial science or to biased data.” 

The racial differences that are apparent, they say, which are erroneously attributed to genetics, are most likely the result of the experience of being Black in America—“toxic stress and its physiological consequences.” Therefore, adjustments based on race make matters worse, “baking inequity into the system.”

The answer isn’t to ignore race, they stress. Doing so would “blind us to the ways in which race and racism structure our society. However, when clinicians insert race into their tools, they risk interpreting racial disparities as immutable facts rather than as injustices that require intervention.”

“Researchers and clinicians must distinguish between the use of race in descriptive statistics, where it plays a vital role in epidemiological analyses, and in prescriptive clinical guidelines, where it can exacerbate inequities.”

The NEJM authors propose three questions that physicians should be asking in the development or application of clinical algorithms:

–Is the need for race correction based on robust evidence and statistical analysis?

–Is there a plausible causal mechanism for the racial difference that justifies the race correction?

–And would implementing this race correction relieve or exacerbate health inequities?

As evidenced by the reexaminations of the eGFR and VBAC ratings, the efforts to correct these inequities have begun. Medicine must seize upon these efforts promptly in all specialties as an opportunity to strengthen the Hippocratic Oath: First, do no harm.

Annie

Continue reading “Black Health Matters Too: The Role of Race in Life-and-Death Medical Decision-making”

After Dogs Detecting COVID-19, What’s Next?

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Image courtesy of en.wikimedia.org

You may recall my recent post describing studies that demonstrate how accurately dogs can sniff out COVID-19. The answer to “What’s Next?” may be found on your wrist right now.

“Wearables” outfitted with artificial intelligence (AI) to report back health data may send a message to asymptomatic or presymptomatic people with the virus before they spread the disease. That means Fitbits, smartwatches, and heart rate monitors that cardiac patients strap to their wrists may help us fight against those dreaded spikes we’re seeing nationwide. The key is that these wristlets monitor heart rate.

In a fascinating discussion, Abraham Verghese, MD, Professor and Vice Chair in Theory and Practice of Medicine at Stanford in California, spoke with Eric J. Topol, MD, Professor of Genomics at The Scripps Research Institute in La Jolla, California. Topol is also the editor-in-chief of Medscape, which carried the video and transcript of their interview.

First, a couple of items that may seem surprising. You know how diligently everyone’s taking your temperature as a precaution? I’ve visited two doctors, my dentist, and my hairdresser over the past several weeks; each time, my temperature was dutifully taken before I’d stepped well into the reception area.

“But that’s so silly,” said Topol, “because…multiple prospective studies about fever and COVID-19 have found that large numbers of people don’t have a fever.”

Topol mentioned a large study published in Nature Medicine that found only 30% of COVID-19 patients had a fever. Another recent study, published by Color genomics, put that figure even lower: 12%.

So temperature taking may catch some potential COVID-19 infections, but not that many. However, it’s such a noninvasive and seemingly inexpensive method that it seemed to me worthwhile. Unless, of course, it’s causing a distraction, and that appears to be Topol’s objection.

Wth those study findings in mind,  consider that between 30% and 40% of COVID-19 patients are asymptomatic but are still shedding virus—and that presymptomatic people are also shedding virus and are as infectious, possibly even more infectious, than those with symptoms.

For these reasons, Topol calls temperature taking “a placebo.”

Verghese agrees.

“We learned too late that we didn’t emphasize masks enough and we overemphasized temperature measurements.”

Lest anyone be thinking, “Oh, these scientists; they don’t know what they’re doing,” I want to underscore here—because science and scientists are under such unjustifiable and dangerous fire now—that both men agreed the progress that’s been made with the coronavirus has been remarkable.

Said Topol:

“The science is moving at a pace that I’ve never seen—everything, from the structural biology of the virus and the antibodies to the virus from patient, to the design of drugs and vaccines and neutralizing antibodies. The sequence of tracing it temporally and spatially geographically through the world has been extraordinary.”

The point is that this is a very complex virus causing a worldwide pandemic. Equally important, scientific progress isn’t linear: there are bound to be erroneous assumptions, initial errors, blind alleys, and failed medication/vaccine clinical trials.

It’s always been that way. Many of us just haven’t followed the process so closely because we’ve never been in a pandemic before—in which there’s such pressure to move quickly and get things right (and in the US, I must add, ignorant political interference that has had lethal effect).

Topol did discuss testing problems, including the false negatives, the logistics of testing done appropriately to scale, and the expense and time limitation of all these one-time tests. He looks forward to home testing but believes that’s at least several months from now. (See also The New York Times for this article about better testing.)

The big question remains:

“How can we find people in a cluster or an emerging outbreak before it spreads more? Because we know, by the famous Pareto rule or principle, that 80% of transmission comes from 20% of the cases.”

Since we can’t test everyone constantly, the urgency is to locate and concentrate on those “early spreaders.” And that’s where the wearables show promise.

Apparently, such wearables had been generating great interest even before the pandemic, but are now attracting the attention of large research consortiums because of their potential to forewarn about infection with this tricky and highly contagious virus.

Acknowledging that the US is far behind most countries in controlling the spread, Topol said:

“Here is the opportunity to use sensors that get continuous data and would give us an edge.”

In a project named DETECT, begun in March, he and colleagues now have roughly 38,000 participants using a smartwatch or fitness band. Other studies are using rings.

In the first 30,000 people, they found changes in three indicators: increased resting heart rate, more sleep, and fewer steps. And all three indicators then correlated with symptoms and positive tests.

Topol’s group had previously used sensor technology in studying a flu-like illness. When their findings were published in January, a group in Germany developed a smartwatch app that’s being worn by more than 500,000 people; in China, 1.3 million are using such an app.

Verghese, impressed by the number of people involved in Topol’s study, asked two questions: have the results been rigorously tested?; and “do we get the signal early enough to make a difference in some way?”

Topol said they still have to validate the results, but in their Fitbit flu-like illness study, they saw the signal well before the CDC had even observed the presence of the illness. COVID-19 is even more suited to the technology, he believes, because of the large numbers of asymptomatic people.

Studies of asymptomatic people who were on the Diamond Princess cruise ship and in Korea found more than half of them showed the same lung abnormalities as people who’d had symptoms. The presumption is that their heart rates would have shown what they did not feel.

Amazingly, more than 100 million people in the US are currently wearing some kind of wrist sensor to monitor their heart rates. Twenty percent of Americans wear a fitness tracker, according to a Pew Research poll done in January.

I sense that if this approach is validated, it might escape the politicization we’re currently seeing over wearing masks!  Think that’s possible? Of course, it wouldn’t replace masks, but it might be acceptable to some of the diehard anti-maskers among us.

Topol points out that the measure isn’t as helpful on the individual level as it is in a neighborhood.

“If your heart rate goes up, you still don’t know why. But if COVID-19 is in your neighborhood, if there is a cluster, then that makes it more of a real signal.”

Then what? Suppose your Fitbit is yelling at you (digitally)—what do you do next? That’s when testing, tracing, isolation come in, says Topol—while we await more accurate home tests that could provide quick results.

As to the wearable alerts, he says:

“The issue is to get people to be citizen scientists….a lot of people like to get their data and like to get a notification that something in their neighborhood is showing a potential signal, without inducing anxiety. But I’d like to at least raise awareness. You don’t need everyone in the country to be a citizen scientist; you just need enough. We have every state covered but not densely enough yet, so that will be important.”

Verghese raised an important question about equity and access. Not everyone has a Fitbit, smartwatch, or heart rate monitor.

“How do we ensure that we truly are studying a representative cross-section of this country and that everyone has equal access to what is basically a public health issue?”

Acknowledging the gravity of the question, especially in terms of the statistics showing the far greater burden of the pandemic on minorities, Topol stressed that not everyone needs a device: if enough people in the area are alerted to a problem, “The people who don’t have this technology will still derive the benefit of knowing that there’s an outbreak potential in their area.”

I would hope that with this knowledge, there would be a concerted effort to ensure that sufficient numbers of wearables were available in areas most likely to see disease clusters.

But that’s not enough. Topol pointed out:

“The problem is that people in these underrepresented minorities and of lower socioeconomic status don’t have access to testing. They aren’t looked after. Many of them are afraid to come in because they could be deported, or who knows what could happen to them. We have a lot of collateral damage from the pandemic here because of our tenuous and, in many cases pathetic, framework of healthcare.”

It is deeply troubling that we continually confront the vast numbers of people, particularly poor and minorities, who are being deprived of decent health care in our still wealthy nation. But I was pleased to see that the question was at least asked and discussed in this conversation. I’ll be looking at additional ways healthcare has been inequitably skewed in the near future.

My questions for you: Do you currently wear a Fitbit, smartwatch, or heart rate monitor? If you do, would you like to have it inform you if you have possible COVID-19 symptoms? If you don’t wear one, would you be willing to for this purpose? And any other comments you’d care to add are, as always, most welcome!

Annie

Continue reading “After Dogs Detecting COVID-19, What’s Next?”

“My mind is a bad neighborhood that I try not to go into alone.” (Anne Lamott, Novelist)

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Image courtesy of wikimedia.org

These are times that are creating great and widespread anxiety, to be sure. Many people report experiencing nightmares. Few of us can remain fully unscathed as we’re forced to change our routines and cut ourselves off from the people and places that have offered comfortable reassurance.

And being alone with our thoughts does not, as Anne Lamott cleverly suggests, always provide us with the best company. We can be hard on ourselves by ruminating on our plights and getting stuck in a cycle of worries. 

For me, mindfulness meditation has a very calming effect, and I’ll share with you below one particular resource I find helpful—whether or not you are a meditator, and even if you’re a “fidgety skeptic.”

I also love these wise words from the renowned meditation teacher Jack Kornfield, which underscore so much about being human:

“If you can sit quietly after difficult news,

If in financial downturns you remain perfectly calm,

If you can see your neighbors travel to fantastic places without a twinge of jealousy; 

If you can happily eat whatever is put on your plate; 

If you can fall asleep after a day of running around without a drink or a pill;

If you can always find contentment just where you are…

…..You are probably a dog.”

It’s a tough time for the two-leggeds, as Internet sensation Pluto the Dog refers to us. (She seems to be having the time of her life; so far there’s been no interruption in her treat supply chain…) And if you haven’t seen her and need an instant lift, I encourage you to look for her repeat performances on YouTube.

Fortunately, there’s also a treasure trove of free material on the Internet to help us get through this terribly difficult time.

I don’t want to oversimplify this issue. Andrew Solomon, a professor of medical clinical psychology at Columbia University who has written about his struggles with serious mental illness, observed in The New York Times that nearly everyone he knows “has been thrust in varying degrees into grief, panic, hopelessness, and paralyzing fear. If you say, ‘I’m so terrified I can barely sleep,’ people may reply, ‘What sensible person isn’t?”

If you’re feeling the way Sullivan describes, you may need professional help. Even if you’re  just seeking some reinforcement, I won’t pretend the resource I’m recommending will banish your psychological or physical pain—or make it easier for you to ignore your sudden or worsening economic problems. 

But I hope if you’re looking for some way to help you better adapt to our truly bizarre situation, you’ll give it a look.

And you needn’t be a meditator to appreciate its offerings and to find these common sense approaches helpful.

The source is Ten Percent Happier: tenpercenthappier.com. I actually paid a discounted price for a phone app last year.

Now, and for the duration of the quarantine at least, the content is available for free on YouTube. 

Live sessions featuring some of the most prominent teachers in the world are aired at 3 pm weekdays and are subsequently available on video. I listen to them (I don’t always watch) each morning before I get out of bed.

Dan Harris, a correspondent for ABC News, is the founder. Harris has explained that he turned to meditation after suffering a paralyzing panic attack on the air. He’s since become immersed in mindfulness and has developed strong friendships with a number of the leaders in the field. 

But he remains ever the “fidgety skeptic” (his words) and is clear when he’s asked to recite or act in a way that doesn’t come naturally to him.

He will repeatedly interject about the scientific grounding of certain practices. I think this approach makes him a perfect host for a program that is far more universal than it might otherwise be.

Each session begins with Harris talking with the guest speaker, who briefly describes her/his background. The speaker then gives an explanation preceding meditation lasting about five-minutes—suitable for those who’ve never meditated before as well as more practiced folks. 

And then the speaker answers viewers’ questions—often my favorite part of the session, as the questions, while unique, underscore so many similarities in what we’re all experiencing. And the answers are invariably helpful. In their entirety, the sessions run for about 20 minutes.

The goal, Harris says, is to bring some sanity into this rocky time, and to build a community, realizing the loneliness experienced even by those of us who are not quarantined alone—because we’re cut off from so many whom we care about. 

Today I heard Rev. angel Kyodo williams (sic), trained as a Zen priest, describe ways to recognize the importance of being in the present moment by trying to look at things in a different way. 

She used the acronym SKY, suggesting boundless spaciousness, to counter the constraints of both being so isolated and experiencing fear in these unprecedented times.

S is for Self-care: We should radically protect our own health and well-being, assess our own situation and take steps to protect ourselves, such as practicing social distancing. She noted that since her health situation puts her at risk, she has become considerably more aware of the need for self-care.

K is for Kindness: That means being kind to both ourselves and others—for example, accepting the annoyance we may feel toward people who seem oblivious to the 6-feet distancing advisory, but not being rude to them.

Y is for Yearning: We tend to contract with suffering, but if we acknowledge that we wish things could be different and are hopeful people take care, we can move out of that mindset. She suggests writing down our yearnings in order to breathe space into our perspectives.

Here is a video of Rev. williams’s presentation.

I have been so pleased with the sessions to date that I’m doing what Harris suggests: spreading the word to help build a community when many people are feeling cut off. I hope if you think you may need something like it—or just want to investigate—you’ll give it a try. 

Annie

Continue reading ““My mind is a bad neighborhood that I try not to go into alone.” (Anne Lamott, Novelist)”

My Fraught Relationship With The Man-In-The-Box

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Jack in box vector image Courtesy of freesvg.org

I reallyreallyreally do not like inanimate objects talking to me. I avoid Siri, preferring to do my own research than to hear her voice—or to have her record my every Internet search (though I hold no illusions about privacy anymore…). I am not tempted to invite Alexa into my home to find that old Sinatra record for me, thank you very much. 

And back in the day when we actually got into cars and drove places, I always resented the high-pitched voice of that GPS woman, who on occasion directed us to dead-end streets and once recommended that we exit sharply to the right when we were in the middle of a bridge.

I’m not accusing her of malicious intent, but her satellite-guided bumbling was not a confidence-builder. I am perfectly capable of bumbling on my own.

Why then, do I invite the man-in-the-box into my life practically every day? It’s because he’s integral to The Device, which shall go nameless so that I’m not guilty of unintended promotion—or worse. 

Let me sidepedal a bit here and note that I am very receptive to integrative medicine, which brings together the best from East and West. My daily meditation, linking me to the Buddhism of 2500 years ago, has been a great help.

I do try to stick with practices that are evidence-based, and to maintain a healthy skepticism about things that sound extreme to me—Eastern or Western.

When several people whose opinions I respect raved about a physician who practices integrative medicine, I made an appointment.

I wanted to see whether she would offer me new, preferably non-pharmacologic approaches for handling my chronic conditions: specifically migraines that I know have an anxiety component, and mild hypertension.

Well, some of what she suggested made no sense to me. But she recommended The Device, which she felt might help alleviate these issues. And it turned out that she was right.

It wasn’t inexpensive—costing several hundred dollars—but it involved deep breathing, so I felt it was sufficiently safe and akin to the meditation that’s a valued part of my life.

The beloved neurologist who treats me for migraines thought it was a good idea, as it’s a form of biofeedback, which is an evidence-based method to alleviate migraines.

A description: An elastic belt holding a sensor is attached to a computerish small box, as is a pair of earbuds. I snap the belt around my torso and insert the earbuds. Then I listen to the instructions that the little man-in-the-box provides. Note: I am substituting The Device for its brand name. 

Here’s how a session begins:

“Lean back and relax and listen to the music as The Device detects your individual breathing patterns,” he tells me.

If I perform that difficult task to his satisfaction for several seconds/minutes, he says, “The Device has detected your individual breathing patterns. Now breathe according to the guiding tones.” I hear sounds—bom, bom—and I match my breath to the tones. 

Sometimes, as in this morning, he immediately tells me I’ve reached the “therapeutic breathing rate,” which means I’m really cookin’. More often, seconds/minutes pass as he goads me with that familiar refrain: “Breathe in, breathe out, breathe in, breathe out” before I reach that coveted goal.

Once there, I continue breathing in and out in sequence with the tones for another 14 “therapeutic” minutes (not sure why it’s that time length, but it always is) until he says, “The Device is turning off. Bye for now.” Let me tell you, I’m never sorry to part with him at that point.

And then I get to see how well I’ve performed by clicking on the box’s levers. Here’s where I realize my slight touch of OCD kicks in. I’m back in school, and I really want to do well. 

In fact, I usually do. The range deemed acceptable for the initial breathing rate is between 6 and 30 breaths per minute—the lower the better. I’ve never gone above 7.2; this morning’s readout was 5.2, which I guess means I had a pretty restful night’s sleep. 

The recommended final breathing range is 5-10 breaths per minute, and I’m nearly always below that—usually 4.8-4.9. Occasionally, I’ve gotten to 4.3, which is nearly Yogi territory, I think. More about that shortly. 

The Device also reports my synchronization rate (how well I synchronize my breathing with the tones) and my breath detection rate (how well the sensor can recognize my in-and-out breaths).

I’m usually right where I should be with those as well. Except if I cough or sneeze. Or hiccup. Then all bets are off.

But I’ve learned one especially bitter lesson. If my initial inhalations are too long while the sensor is assessing my pattern, once the tones begin, I wind up struggling to match them. And the man-in-the-box knows it. He chides me: “Don’t hold your breath!” 

Try breathing in for longer than you possibly can—and continue for 14 minutes—and you’ll see what it’s like. (Actually, just take my word for it; it’s not something a sensible person would do.) 

The lesson I learned: When using The Device, never-ever breathe in for long, lest the sensor monster constantly remind me of my failure.

In such instances, my synchronization rate would ensure a “needs additional work” message on my school report card.

He (my electronic tormenter) has also on more than one occasion said: “Try to breathe more evenly.” I make an effort not to take offense that he’s dissatisfied with my performance.

And he is oh-so picky about that sensor. “Tighten the sensor,”  he’ll command. Or  “loosen the sensor.”  Even “reposition the sensor.” His standards are high. I scramble to do his bidding. 

I used to strap on The Device just before bedtime, but I found all kinds of reasons not to go through the process then. So it’s now the first thing I do upon awakening—after taking a long drink of water to prepare my dry mouth for the routine.

Sometimes I wonder, as you may well, why I subject myself to this regimen-with-verbal-abuse on a daily basis. Of course, I always have the option of shutting the darn thing off.

But, while The Device hasn’t totally replaced medication, it really has done what the doctor said it might: migraine frequency diminished, blood pressure low-normal, anxiety lessened.

So I’m locked in to this challenge. Plus, in these pandem-icky days, I figure it’s not so bad to give my lungs a bit of a regular workout.

And then I meditate and express lovingkindness for all the nasty thoughts I’ve had about the bossy little man-in-the-box.

Annie

Notes From a COVID-19 Epicenter: Our Quarantine Begins

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COVID-19; image courtesy of state.gov.

This wasn’t the post I’d originally planned to publish. That one can wait for another time. This post is more timely. And since my story may become your story—if it hasn’t already—I thought I should tell it to you now.

I live in a medium-sized community in the eastern US. Yesterday, our mayor requested that we move beyond this new status we’ve just learned about: social distancing.

We’ve now been asked to self-quarantine, voluntarily at this point. We should stay at home, going out only to buy food or medications. We are suddenly activists in the effort to flatten the curve and slow the exponential increase in disease incidence. 

The community officials have been acting very responsibly—closing the municipal buildings and library and encouraging people to conduct their business online. (Woe to anyone without functioning computer and Internet connection, but that’s a story for another day.)

They’ve even stated the number of people who will be permitted to enter the food markets at one time: 50 for the largest; 25 for each of the smaller stores, with only one family member permitted per visit. I’m all for these restrictions, which seem well thought out to me.

As my husband and I are past 60, we are considered part of the vulnerable population. We don’t have the other conditions that would increase our odds of becoming severely ill—such as heart or lung disorders or diabetes—but our well-worn immune systems are better off not being called into combat against this particularly nasty bug.

I’ll note that we’re careful about our health and diet, don’t smoke, and are both gym rats. One of the hardest things about this quarantine is that even though we’d decided it was probably not a good idea to continue going to our gym, the gym announced today that it’s closed until further notice.

That deprives us of the most important man in my life: the personal trainer we work out with together once a week. (I’ve told the trainer that in my husband’s presence.) He has really strengthened us and made us feel we’re up to all sorts of challenges.

I had assumed that under the circumstances, even if I got the damn virus, I would be sick for a week or so and then recover. But I’ve since learned that it’s quite tricky, and even when people seem to be recovering, it can do a sneak attack that brings them to an ICU needing a ventilator.

My purpose in telling you this is not to create panic; I feel amazingly calm myself considering my basic catastrophizing nature. Mindfulness meditation works wonders for me: I don’t dwell on what may happen.

Similarly, I see no point in checking the balances on our rapidly crumbling retirement accounts—or spending more than a fleeting moment pondering potential breakdowns in our food supply chains and the availability of medicines I must take. 

But there are plenty of people who either aren’t getting or aren’t hearing the facts about COVID-19. The messages from the White House and the CDC are conflicting and confusing. Putting out a blanket limit on 50 people congregating in a single spot does not take into account the size of the spot (unlike my local regulations) and how much “social distancing” is possible therein. 

Such ambiguity may lead people to continue taking advantage of not having to be at work to meet with their friends in a bar; that’s definitely not smart. This is not your grandmother’s flu. It’s spreading more quickly than other viruses in the past. It’s also more lethal.

On March 14, our local hospital had 11 cases, and 6 of them (all younger than 60) were in the ICU. Another 40 patients were under observation. Those numbers are increasing rapidly, and they somehow haven’t made it into the state’s official count.

You know those N95 masks many people are talking about, which can be used only once and are essential to protect health care workers as they tend to infected patients? The hospital’s CEO said in an interview that those masks are running low statewide. His hospital had gone through 795 of them by 7 pm in a single day.

He described the past week as something he’d never before seen, even though he’d fought cholera in Haiti after the earthquake, when there were no medical supplies, and “even when we ramped up for Ebola.” He called this crisis “unprecedented.”

The CEO said a number of things that were quite concerning. One that disturbed me the most was that he’s given up on the Centers for Disease Control and Prevention, which had yet to confirm his hospital’s first case.

In his view—and this is something he wants people to know—testing is problematic. It’s more complicated than it’s been described. To be effective, it must be done under strict conditions with a sample taker appropriately outfitted with Personal Protective Equipment (PPE), and differing RNA assays make test sensitivity questionable. 

So at best, the tests are 90% accurate, whereas flu tests are 99.999% positive. He fears drive-through testing that shows someone is negative will give that person “a false sense of security.” He said he told the Governor his concerns. 

There are many experts with differing views; I’m noting his because he’s a highly regarded individual who’s working with labs—not to suggest that his opinions necessarily be used as guidance in individual decision-making. 

Testing in the US has certainly been botched, by nearly all accounts, but many point out, as this Atlantic article states, that knowing how many people have been tested would give us some sense of how far the disease has spread and “how forceful a response to it the United States is mustering.” Hmmmm….

Though our hospital CEO doesn’t want to incite panic, he does want people to take this disease seriously because in infected patients

“things can turn around very rapidly. We had a patient that we were thinking about releasing—he seemingly was recovering—and then, two days later, he was put in the ICU. The flu isn’t like that. People need to know this.” 

He encourages people to be responsible: stay home, avoid malls and theater and group activities for now.

“We need to sort of hunker down at home. Go outside if the weather’s nice in your backyard. That’s healthy and good. But we shouldn’t be out and about.”

That’s what we’re doing. Going into stores for food only when they’re not crowded. Avoiding situations where we’ll have to stand on line. Bringing our rapidly disappearing hand sanitizer with us when we’re out of the house, and swabbing our door knobs on the outside and inside with Lysol when we return.

(We’ve also made some hand sanitizer by mixing alcohol with aloe vera, but both ingredients are no longer available.) 

I heard one virologist say COVID-19 is most likely to linger for up to 9 days on metal and hard smooth surfaces. Clothing and porous surfaces seem not to be a concern. I haven’t found confirmation of this statement, however.

What else are we doing? Agonizing over whether to buy two or three small packages of tissues (8 each pack): they were going fast, and we felt we could use them to open doors once our hand sanitizer was gone. But was buying three packages selfish? 

We’re wiping down our cell phones (Apple said Chlorox wipes are OK) and other surfaces. Lifting weights and exercising at home, and taking walks in the late afternoon when few people are around. And yesterday we toured our small garden, buoyed by the sight of the first crocuses pushing their way through the mesh we’d placed over the hard soil to allow them to get a head start before the feeding faunas’ visits. So those back-aching hours planting bulbs last fall paid off! The appearance of those young green shoots couldn’t have come at a better time.

And we’re washing, washing, washing our hands. I find it so interesting that this devastating organism can be vanquished by plain old soap and water.

Finally, we’re still remembering to laugh. (See my previous post.)

My sister-in-law sent this cartoon today.

PHOTO-2020-03-14-07-32-36

My response was: “Gee, do you know where he got it? I could use some.” 

Do you have stories to tell about how you’re coping? I’d love to hear them. I hope you all stay safe.

Annie

Continue reading “Notes From a COVID-19 Epicenter: Our Quarantine Begins”