Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

Strategy in the Age of COVID-19: Just Assume You Are Wrong

“I” before “E” except after “C” and when sounding like “A” as in neighbor or weigh, and on weekends and holidays and throughout May, and you’ll always be wrong no matter what you say!!” –Brian Regan

Not surprisingly this came to mind as Beth and I were talking about the best, or right, or acceptable way to start to resume life outside of our houses. How to return to the office, go to the grocery store, visit a family member or a friend. Fantastically superistically smart people who spend their entire lives thinking about this kind of stuff haven’t been able to find even the tiniest kernel of agreement, and yet we poor intellectual peasants are out here picking at their intellectual crumbs as we try to do the right thing. Go out/stay in? Hug the grandchild or wave? Mask/no mask? You get the idea.

The issue of testing is a great example of the conundrum faced by both the intelligentsia and the hoi polloi. It’s not even as easy as test or don’t test. Nah, that’d be altogether too easy. You gotta decide which test. Do you have the virus now? 4, 5, maybe 6 tests to choose from, all of which are substandard when it comes to accuracy in a normal world. Which one do you choose? How many times must you be tested? How long between? Have you ever had the virus? Meh, same issues. All but the most recently pseudo-approved tests in both categories take days to return a result. Does it really matter, that result, after it’s been a couple or a few days? Is it better to choose a slightly less accurate test in order to get the result within minutes, or wait for a slightly more accurate result arriving soon come? Now decide if you should venture out based on your decision.

See? No matter what you do you’re wrong.

We have all lost sight, at least a super majority of our government officials and many of our non-governmental experts have lost sight, of what “flatten the curve” was meant to do. It all made so much more sense, and the resulting overshoot on stuff like saving PPE for the tip of the spear workers was more tolerable, when we had a clear mandate that could be graphed accurately: prevent the surge of infected individuals from flowing over the level at which our acute care facilities would run out of space and materials necessary to provide the highest levels of care. Easy. Easy to be right. There were no extrapolations necessary to see if you were succeeding; you used real data. The line below which you succeeded was a known number: ICU beds + respirators. Nowhere in the U.S. have we seen the tragedies of Lombardy where doctors had to decide who made it into the ICU and who did not. We saw the curve, we understood the curve, and we successfully flattened the curve.

So what’s been lost? It’s a little more difficult to understand the concept of the AREA under the curve. How many people either get sick with the virus or die from the virus. Very few of our experts showed the far right side of their graphs. Fewer still gave any explanation regarding the dirty little secret of “flattening the curve”: all you are doing is pushing out the infections and resultant deaths from the virus. Pushing them out further in time. Flattening the curve simply means that you are not having EXCESS deaths caused by insufficient acute care availability in an overwhelmed  system. Without either a vaccine to prevent infection or a medication that treats the virus such that people don’t die, the same absolute number of people will eventually become infected, same number of people will become sick, and the same number of people will die.

Let me say that again so that it is clear: flattening the curve saves only those excess lives lost to insufficient hospital resources during a surge. Over time it does not save lives unless a vaccine and/or treatment arises.

Once again, no matter what you do, just like “I” before “E”, if you persist in flattening the curve edicts you are wrong unless you have a hard arrival date for a vaccine or a treatment/cure. You see, lockdown policies such as those in place in much of the world now are not entirely benign when it comes to health. Or death. Lockdown policies that mandate isolation, especially those that make it difficult to take care of what would otherwise be well-controlled chronic medical problems, actually cause EXCESS deaths. How many? The cold reality is that not a single model is capable to telling us that. Or at least telling us with enough degree of certainty and accuracy that we could titrate the “flattening” policies in such a way that the EXCESS deaths caused by the lockdown are more tolerable to a society than the excess deaths caused by system overload. No flattening of the curve? Excess deaths from system overload. Extend the curve? Excess deaths caused by solitude, reduced access to typical medical care, and the well-known health effects of an economic recession or depression.

Are the experts saving lives by insisting on these draconian lockdown policies across the country? Sure. Today. They are saving the lives of those who would not survive a viral infection should they become infected today. Are these lives that will ultimately be saved from being ended by the virus entirely? As of today the answer is a resounding “No” despite the earnest pleas and declarations from the various governmental pulpits. Absent a vaccine or a treatment/cure the math is as inescapable as math can be: the area under the curve, flattened or not, remains the same if you look far enough to the right. Deaths from the virus will be equal over time.

The REAL curve, the one we’ve yet to see and the one we are unlikely to see from those same pulpits, is one that adds the deaths from the virus to the excess deaths caused by the lockdown policies. Preventable deaths from untreated or inadequately treated cardiac disease or cancer for example.  That curve will show that no matter what you do, at home or behind the desk where you sign the lockdown edict, you will be wrong. That’s what makes this all so discouraging for me. What makes it all so dark. You can’t be right. Like “I” before “, be it May or just any old today, no matter what you do you’ll be wrong. Literally the only thing that changes that is a vaccine or a cure, two highly elusive solutions, the  achievement of which historically takes years, not months. Only then does the curve flatten to zero. Only then can we say that lives in the absolute have been saved.

There is only one thing left now, and that is a vaccine or a cure. Whatever light remains in the shadow of the virus, it exists here. Will it be months as we’ve been told? Will this virus fall to a vaccine in months where prior scourges took years to defeat (HIV), while we still await victory over others (Ebola)?  We must all pray that in this one single instance the people who are leading us are not wrong. For if they are wrong, if the area under the curve is the same no matter what shape the curve takes, it will upon the souls of our Government, our elected and appointed leaders, that each excess lockdown death will weigh.

“I” before “E” as directed by “G” means that the weight of being right falls on them, not on you or me.

Sunday musings…5/17/2020

Sunday musings…

1) Lockdown 1. One of my annual meetings, some 15,000 typically in attendance. Cancelled weeks ago. Somehow they managed to transition the whole shebang to a virtual setup. How’d it go? No idea. After 8+ weeks of nothing but online Zoom-type “meetings” I just couldn’t make myself log on to yet another one no matter how many friends were watching.

Sasha took me for a walk instead.

2) Lockdown 2. “[F]acts and data are independent of your credentials.” Aaron Ginn

Some of the most educational (and educated) pieces on the corona virus have been published by a few of my ophthalmology colleagues. You read that right; the so-called “eye dentists” have done excellent work both fishing out interesting ideas for treatment and testing and assimilating available information to form some sort of coherent whole.

You may remember that the first doctor to sound the alarm in China was an ophthalmologist.

The point? There are all kinds of degreed and pedigreed experts who have been belittling and lambasting very smart people outside of their little professional circles for having the audacity to opine on facts that are available to anyone to parse. The possession of a degree or an appointment does not confer upon you an exclusive right to set policy, or advise those who set policy, in your area of study. It certainly doesn’t inoculate you from having your conclusions questioned by other smart folks who may see something different in the data.

Data are what they are. Ideas sprout from data. It is those ideas that should be addressed, not who it may be who proposes them. Lofty credentials do not entitle one to an exclusive on the ideas.

3) Leadership. Have you been watching the  epic 10-part series on the 6th NBA championship won by the Michael Jordan/Scottie Pippin Bulls? It’s fascinating for dozens of reasons, none the least of which is the insight we have gained into the leadership style of Jordan. MJ comes across in episodes 7 and 8 as, there’s really no way around this, kind of a jerk. He bullies, berates and belittles his teammates, pushing and pulling them to heights most of them were wholly unaware that they might reach. No one, it seems, was immune from his attacks, though they took on terrifically different forms when applied to different teammates.

We’ve seen this type of leadership before in otherwise lauded and revered leaders. Steve Jobs comes instantly to mind. Jobs was infamous for how badly he treated subordinates at all levels. His impatience with underlings who failed to deliver was matched only by the vigor and venom with which he made his displeasure known. Now you could surely say that Jordan spent his career in a perpetual zero sum setting; winning was the only acceptable outcome and there would only ever be one winner. Jobs, it should be noted treated every market his company entered as if it, too, was a zero sum game. It wasn’t enough to simply succeed, to be profitable. Nope. The goal was to win so completely that the competition left the game.

Was Jobs an asshole? During his career was Jordan? I have to admit that I simply don’t know enough about the rest of Job’s life, how he treated people who were not in his chain of command, to opine of his overall asshole quotient (though it is rather common knowledge that he was quite unkind to his daughter from his first marriage). Jordan, too, was private enough that one can’t really say what his non-winner life was like. Did he treat Bulls staffers (other than the GM) better than his teammates? The guy who parked his cars, did the laundry in the locker room, mopped the gym floor? If he did does that lower his asshole quotient? There are some who say that it was the naming of Bill Cartwright as co-captain that catalysed the dynasty. Does a toxic leader need a consoler to be effective?

One thing you can say about MJ and his leadership style is that there was no subterfuge involved.

4) Unlocked. We finally cracked. Just a tiny bit, but crack we did. Not being able to force myself to log on to a national meeting with my peers was the first little leak in the dyke. A couple of videos of the grandchildren we usually see several times a week and hadn’t for 6 or 7 days, the announcement that our closest friends here in town were moving. Yet another series of announcements that our “new normal” was going to be around for 18-24 months. It all just became too much. One tiny bit of good news–it turns out that asthma is not the high risk problem after extensive research–and we took stock of what it would mean to live for another year or two without a vaccine. In the end one must accept that up to 50% of our nation will contract the virus (though medical technology will inevitably reduce the % of people who die because of that).

Without putting others at risk the question one must now ask is what part of your life, which of your loved ones can you accept the risk of seeing because not seeing them is more a case of not dying rather than living?

All around us similar cracks are opening up for similar reasons. Mind you, this is not “we love to go out to dinner” so we’re putting ourselves out there to visit our favorite restaurants. No, as much as I pine for Veal Picatta served with a side of smiling snark on “Tina Tuesday” at one of our locals, this is much more personal. As close to need as can be. This is about seeing our children and their spouses, even if it’s 6 feet away, instead of viewing them on FaceTime. It’s a running, jumping hug from my Man Cub and a kiss on the cheek from his sister the Pipsqueak. A very special bottle of wine, 22 years in the waiting, shared across a ludicrously huge table for only four people, but around a real table pouring from the same bottle with cherished friends. No hugs or handshake there, but THERE.

There is an energy that exists in love extended and received in person, even if in person means 6 feet apart, maybe even a mask or face shield. That energy is real, and at some point being walled off from that energy is to be walled off from what it means to be alive. In no way am I telling anyone what it means for them to feel alive. It would be unforgivably presumptuous to tell anyone that they cannot live behind an impenetrable curtain of seclusion, or which of their people they can accept as so essential to living that being with them may be the source of acquiring the virus.

We may escape an interminable pandemic. A vaccine may be on the way along with all of the other blessings we each receive. Until then we must accept that we each have a responsibility to protect our fellow travelers from whatever risk we might personally represent. For ourselves we will all eventually need to come to terms with what it means for us to be living, and who it is we need to have along with us as we do.

“The Last Word” Credit: Men’s Journal

Anyone who knows me well knows that one of my very favorite drinks is called “The Last Word”. It’s also a huge source of frustration because so few bars, however hifalutin and pretentious, can make a decent one. But this is not an essay on drinking. Far from it. “The Last Word” is the running series on the last page of each issue of Men’s Journal in which an older male celebrity is asked to answer a series of questions about life. There’s nothing particularly unique or imaginative about either the endeavor or the questions asked. Still, it makes me think, and I thought it might be a fun thing for us to think about together.

Herewith, the most frequently asked questions. I’ll offer up my own answers in a follow-up post. Perhaps you might answer either here in the comments, on Facebook, or somewhere else I might find you.

 

Who were your heroes growing up?

What is the best advice you ever received and from whom?

Who had the biggest influence on you when you were younger?

Was there a life-changing book you read? Movie you saw? Adventure you had?

What is the trait you most admire in other people? Least admire?

How should one handle getting older (if you are, indeed, older)?

How should one handle criticism?

If you could select the guests for your dream dinner party, attendees living or dead, who would you invite?

Do you have any advice you’d like to have given to your younger self?

How do you want to be remembered?

 

There’s a whole lotta ground you could cover there. Pick a few or pick ‘em all. No rules here, just an opportunity to take a little stock, draw a few lines in the sand, look both forward and back. Write it down somewhere I might see it. Or not. Incorrigible naval-gazing bloviators like yours truly might turn each question into a an essay of its own, filling pages in the process. The poets among us will tell epic tales using fewer word than a Haiku.

That’s all part of the fun, eh?

 

 

 

 

Friendship in the Time of Corona

In a gentler time Beth and I were out to dinner with another couple. Mutual friends came up in conversation. They’d moved away a couple of years prior. Moved a couple of times, actually. “Have you heard from so-and-so?” “No. You?” “Uh uh.” “Huh. That’s funny. We thought maybe it was just us.” “Yah, I call every now and again. Text every so often. Crickets.” In an odd way it felt a bit better, for all four of us, that we weren’t the only ones who’d been left behind, as it were. Better, but still a bit sad and still a bit hurt. While we’ve all been home these many weeks we’ve thought about friends from the past. The longer our isolation goes the further back in the past we seem to go. Wondering, where did our friendship go.

Friendship is a bit of a journey. That’s not really news, though the journey evolves not only as one gets older but also in relation to societal evolution. T’was a time when the maintenance of a friendship forged on the battlefields of youth was almost expected to fade away, with only the faintest embers of memories still burning. It was natural. Common to the point of being expected, especially if friends moved far afield.

In order to keep the fires of friendship burning you need to stoke them. We marvel at the long-distance friendships of our forebears, brought to light in the letters they sent to one another. Can you imagine? Friendship maintained at the whim of the postal service? And yet, maintain they did, at least those friendships that were meaningful enough to make the effort. The dawn of the telephone age made it somewhat easier to do this, but expense was a barrier often too high to surmount, trumping the immediacy and intimacy of hearing a friend’s voice.

Friendships at the mercy of distance and time were friendships most often destined to become little more than memories.

Ah, but the world is so very different now. We have, each of us, a device that allows us to talk to anyone we have ever known, right now, for pennies. A text can be sent with an effort so trivial that we have laws to regulate when we should know better than to fire one off. As if that’s not quite enough, Facebook and Twitter are there for the asking, and the original “reach out and touch someone” revolution that is email will alert you when someone has messaged you on either of them. And now, in the age of Corona, we have all learned how to use Zoom. It is now so easy, the effort necessary to remain in contact is now so minimal, that what it means to stoke the flames of friendship has been turned on its head. Along the way it seems that our expectations of what will become of our friendships has changed as well.

We will have to re-order that, I think.

Beth and I have a number of friends with whom we shared many, many things, who have moved away from the little burg we call home. In truth, most were little more than friendly acquaintances, people with whom we were thrown together because of stage of life stuff like schools or sports or jobs. “Moving away” for these friendships is simply another way of saying the calendar has flipped, and these fade just like friendships in the days of the Pony Express. That’s OK, too; they are meant to fade because they weren’t really friends, people in whom you confided, people who confided in you, counted on you. They were “friendlies”.

Our new world of easy access to one another changes how we feel about people we really did consider friends if and when they move away. It takes only time, well, time and desire, to stay in touch. To stay friends. Ah…there’s the rub, eh? It’s so easy now–no hoping that they will pick up the phone, return the voicemail, reply to the email/text/PM/jump on Zoom or Facetime–that our expectations have changed. That resignation inherent in the historical timeline of all but the deepest, most meaningful friendships has been replaced with some kind of new expectation that we don’t have to let go, let the friendship go, simply because someone has gone somewhere else.

And it hurts, doesn’t it, when friends who were friends in person make it clear that moving away is actually just the same today as it was in the days of the letter and the rotary dial telephone. All but the truest of friends move on, and what we have now is not a gentle resignation and wistful sadness about our mutual loss, but rather a more acute and personal type, especially if we’d decided that the friendship had been worth the effort necessary to keep the fire burning. Moving means we are no longer friends. It is only natural to wonder, then, if we ever really were.

There’s a story here, of course, from days long before the Pandemic, but I won’t trouble you with it. You’ve got one too I’ll bet; only the details are different. There’s also a lesson I think, one that is grounded in the wisdom of yesteryear. Our world has changed in ways that were unimaginable to our parents and grandparents. Heck, even my Mom is now on Facebook (yikes!) and has participated in group FaceTime visits with her children and their spouses. Friendship, however, has not. It doesn’t matter even a little bit that it takes so little effort to connect in today’s world. What matters now is the same as what mattered when connecting meant eagle feathers and inkwells: having a friendship that was meaningful enough to make the effort. Friends reach out, and they reach back when you reach out, whatever reaching means on any given day in any given era. Friendship requires effort, and the effort required is most often more than can be mustered to carry a friendship over a lifetime. The arc of a friendship still ends most often as nothing more than warm memories, like the tiny embers of even the most magnificent bonfire in a dawn to come. Slowly, but ever so surely, only the memory of warmth remains.

We are all happier when we accept that most of our friendships will still be like this. Lucky are we if we have even a single friend who feels just the same about our friendship, whether we stoke our fire face-to-face,  side by side, or cross-country. Friendship was, is, and will always be about the desire to remain friends, not how easy it might be to express that desire. Remember this, and we steel ourselves a bit more against the sadness of a friendship which has been lost to time and distance.

Remember this, and we can still allow ourselves to be warmed by the memories that remain of the friendship that once was.

Mark Twain and Memory

“I used to remember everything, but now I only remember the things that never happened.” –Mark Twain.

Twain never disappoints, does he? There’s all kinds of meat on that bone. Is he saying that he no longer remembers things that really happened, only those things he imagined at the time, or imagines now? Or is he rather saying that looking back on his life he only remembers those things that SHOULD have happened, but didn’t?

Knowing Twain, my bet is that his answer would be:”yes.”

Memory is a funny thing. Partly accurate reportage, one’s memory is leavened by equal parts wishful thinking and regret. At least according to Twain. Think of your own narrative, the telling of your story. How much is fact, how much is embellishment (never let the facts interfere with a good story!), and how much is what you wish had happened? We were telling stories at dinner the other night, stories we all knew, ones we’d all taken part in creating and ones we’ve told countless times. Each time they are told they get a little better. Does this happen with you? Some of the stuff in our stories probably never really happened, but we remember it just the same.

But Twain also touches on regret in this quote, don’t you think? Things that could have been, or should have been, but for one reason or another, never were. Dangerous ground, that. Regret can turn the urn of happiness into a sieve. In his later years Twain was said to be increasingly bitter. One wonders if his regret fertilized the weeds in the garden of his memory.

Ticking time bomb, or soothing balm over time. Memory serves.

High Standards

A helpful thought as I prepare to reengage as a practicing physician and surgeon, opening my office and welcoming both my staff and patients.
There will doubtless be plenty of folks with an opinion of what I do and how I get it done. Here is a re-post of how I will try to carry myself.

 

“When you go out that front door be the best version of you that you can possibly be.” Lisa F., MD.

My good friend and colleague Lisa says this to her son when he leaves the house each day, but this is applicable to each and every one of us every one of our days. Whether you are a kid trying out different versions of who you are while eating breakfast, or a fully formed adult off to work, what better goal can one have than to be your very best you?

“I have such high standards for myself, and I’m so hard on myself because of that, I have no room inside left over for someone to come in and judge me.” Again, Lisa F., M.D.

I think this is really, really important. There is a subset of humanity that just simply holds itself to an unimaginably high standard. They feel that they must not only do more, but they must do it best. Because of this they are frankly harder on themselves than is really fair. Indeed, if they saw someone berating another person the way their internal voice talks to them they would probably lead an intervention. It probably doesn’t matter what you do, there are people in your world who wake up every day knowing that they have set nearly impossible goals for themselves.

What sets my friend Lisa apart is her incredibly healthy ability to realize that she is already under the burden of living up to nearly unachievable standards, and that the outcomes she seeks are often outlandishly ambitious. Because of that she need not surrender to the tyranny of someone else’s opinion, “what they think of [her]“. Now to be sure Lisa is of unassailable character and moral fiber; such an approach is not healthy if utilized by a narcissist, for example. Nor does it mean that she is incapable of seeking advice or learning from another. No, what she is able to do is pre-forgive herself when her best effort may not reach her own very high standard, and thus inoculate herself against uninvited external judgement.

This is a powerful lesson for anyone who sincerely gives their best when they walk out that front door.

Funny, whether you are attending a medical conference or a CrossFit seminar, sometimes the most powerful, actionable, and lasting lessons are not necessarily those that are taught from the podium. Be always and ever open to all of the learning available to you. Hat tip to my friend Lisa for being my teacher today.

Contact Tracing: Lessons from the AIDS Era for Our World Today

“Harvey told me to find a bow tie for a preppy. I hope you like it. Thank you for taking care of him. He really liked you.” –Mrs. K. May, 1987.

90,000 died in the U.S. 90,000 Americans died of AIDS before life-saving treatments became available. First it was gay men, then people who were addicted to injectable drugs who shared needles, and finally people requiring transfusions who were unknowingly infected by blood contaminated blood products. All from a novel virus that seems to have “jumped” to humans from another primate. 100% mortality.

90,000.

Now to be sure, AIDS is a manageable chronic diseases treatable with a pill in the U.S. (and most developed countries), but it still kills–what?–a million people worldwide. Some of that is due to a lack of access to a diagnosis, and in those 3rd world countries where the diagnosis can be made there is a lack of access for a number of reasons to the effective treatments. In those cases AIDS is still 100% fatal. If a diagnosis can be made an AIDS “hotspot” can be cooled, if not extinguished, through a variation of something we are now all becoming quite aware of, contact tracing and physical distancing. Sadly, in many of those 3rd world countries where AIDS is still endemic, these very basic public health interventions contravene unalterable societal norms and culture; the virus spreads and people die.

What does this have to do with us today as we address a new, novel virus that as of yet has neither cure nor medical prevention in the way of vaccine? I’d like to share a little history from the earliest days of the AIDS crisis in America, and a little story about my own experience as a young doctor just starting my career in medicine. Let me first be very clear about my place in that history. I am a straight, cis, white male born at the tale end of the Boomer generation. At no time in my life have I felt the sting of real discrimination based on either something I am, or something I am presumed to be based on what I look like, what I do, or who I am (my father did face discrimination as a Catholic, something which was largely a historical remnant but the time I came of age). As such my story and my thoughts about both what it meant to be gay in the 80′s and the possible impact of contact tracing in an epidemic or pandemic are sympathetic, based on observation, only.

Looking back my first encounter with anyone I could say I knew was gay was in the first week or so of my freshman year in college. The phone rang in my dorm room (landline, rotary dial, no caller ID), and the caller addressed me by name and asked if I was gay. As I recall I laughed a little, thanked him for asking, and said that no, I liked girls. That was it. He said thanks and hung up. Now of course as a child of the 60′s and 70′s I had most certainly come across many gay men by the time I’d made it to college, I was just clueless to this fact. There was a teacher in high school who was “outed” by a couple of kids from school after I graduated; they saw him coming out of a gay bar in Providence one night. That was pretty much it.

For the most part I just ignored the fact that there were gay men (and looking back, women, of course). Without really thinking about it I guess I figured that if I was indifferent to this part of my college mates’ lives then pretty much everyone else must be, too. It never dawned on me that being gay might have very real, very serious consequences when it came to very normal stuff like getting a job. I was totally clueless, in reality to most things that didn’t have any direct impact on stuff happening inside my own personal little navel-gazing bubble. Like everyone I kinda knew who might be gay, but again, I was indifferent. Even during a year when what it meant to be gay on campus was the year’s issue the only time I really paid attention was when one gay male student was interviewed on the college radio station about being attacked for being gay by a fellow student chasing him with a machete. And only then because the machete-wielding student was one of my close friends taking out his anger at being dumped by a girlfriend by swinging his sword at the squirrels along the driveway.

For the record neither the shaken (but mistaken) young man nor a single squirrel was harmed in the “attack”.

And then came AIDS. Those of us of a certain age recall that the initial publication was titled something along the lines of “Acquired Immunodeficiency in Homosexual Males”, I think first in JAMA if memory serves. I remember reading it in the med school library. Heck, I may not have even been out of the classroom yet. My presentation at the conclusion of one of my “away” rotations in ophthalmology was on the ophthalmic manifestations of this disease, soon to be re-named AIDS. As an aside I wrote that hemorrhages and focal areas of ischemia (cotton wool spots) were the signature signs of the disease, a statement that was shot down as incorrect by the retinal attending in the room. Turns out that I was technically right; hemorrhages and cotton wool spots DO result from HIV, while the entities that the professor pointed out were actually secondary opportunistic diseases. During my residency at NYU/Bellevue 50% of the inpatients on the medical floors would have full-blown AIDS. Every resident would become an expert in all things AIDS-related in and around the eye.

But it was in my internship in medicine at Rhode Island Hospital (RIH, a Brown University affiliate) that I would learn what it meant to be a gay man in America in the 70′s and 80′s. There were very few AIDS patients on the floors at RIH in the summer of 1986. I had one very special patient, Harvey K, who was on my service each time he was admitted that year. Openly gay, Harvey had been one of the earliest activists in the gay community, speaking out initially on issues of discrimination in general, and then as his life was upended by AIDS, speaking out while he could on the plague that had descended on his community. Harvey was unfailingly kind, generous, and understanding of his rather unworldly intern, cloistered as I was in my cis-straight world. He answered all my questions about what it was like to be a gay man in those days; he was  brutally honest about everything, including some of the activities that  led to rapid spread of HIV from a relatively small number of initial individuals who harbored the virus but did not yet have the disease.

This is the part of what Harvey taught me that applies, at least superficially, with where we are today. In its earliest phases AIDS was a disease transmitted almost entirely through sexual contact. Public health strategies to address this kind of disease propagation had been pretty standard for decades by the time AIDS arrived. Once a diagnosis was made a detailed list of contacts was then assembled. These people were in turn tested to see if they had the disease, were treated, and their contacts were similarly identified for follow-up. Similar tactics were used in the early days of TB as well, even though TB (unlike diseases transmitted by sexual contact) was not as easily and successfully treated with antibiotics. Harvey gently pointed out that yes, contact tracing could indeed prevent an infected individual from passing on the virus, and it could also alert his contacts that they were at risk to acquire the disease. The disease was fatal, but that was only one part of the issue.

Since only one small segment of society was affected AIDS at that time, being identified as a contact meant being identified as being gay.

Remember, this was in a time when being identified as a gay man had very real consequences. Not only could it affect your employment, but it is reasonable to say that the majority of gay men were not “out”, either publicly or privately. Nearly every major religion openly rejected these individuals, and more than half of the states in the U.S. still had laws on the books essentially making it illegal to be gay. One of the very first protest movements organized by the new gay activist organizations was to stop AIDS contact tracing before it started. As a newly minted physician, enthralled with science and quite sure that standard public health initiatives were mandatory to treat this new epidemic, it was left to my patient Harvey to teach me about the reality of large-scale medical intervention on vulnerable populations.

As we fast forward to our world in these days of the Corona virus and the varying degrees of societal “treatment” applied at the federal and state levels it is first necessary to be very clear that being told that you cannot go to work if you had contact with someone who is  test positive is not the same as being told that you have been in contact with someone who had AIDS in the 80′s. Not by at least one or two orders of magnitude, not. That’s kinda like saying being Catholic in the 70′s was the same as being Black. Again, not the same.

But one thing that Harvey taught me is the same. People who are in the contact strand are afraid of more than just the disease itself. They are also afraid of what having the disease, or even being associated with the disease will do to their life. Will they be able to go to work? Feed their family? Whether or not they do get the disease will someone tell them who they can see, where they can go, and what they can do? For better or for worse there are an awful lot of misunderstandings about COVID just like there were about AIDS. If they are are identified as a possible COVID risk will people think differently about them? Remember, unlike the gay men of the 70′s and 80′s who had decades to thicken their skin and steel their psyche against these kinds of feelings, the people who will be tracked now (most without the knowledge that they are being tracked, or have triggered a tracking tract) are experiencing this for the very first time.

Again, the true consequences are small, one or two orders of magnitude less than that faced by gay men in the earliest days of AIDS. But I’m sure that Harvey, as gentle and kind and understanding as he was despite his reputation as a fiercely powerful activist before he became ill, I’m sure Harvey would suggest that we seek to understand why people may rebel against contact tracing today. Just as surely as he would then go on to teach anyone who would listen (and eventually those who came after Harvey taught everyone to listen), that this is different. That we do not have the same concerns that Harvey and his friends did back then. While we can certainly discuss how it would be done and how consent would be given, Harvey would say that in this instance the population that is vulnerable will only be helped by “by the book” public health measures.

Harvey and I became friends of a sort. He needed some really terrible things done to him while he was in the hospital and forgave me each time I had to do one of them. I spent a lot of time just hanging out with him when I was on call. He was very, very smart, and every story he told was one that I would never have heard in my life to that point. As I said above, he was very understanding and kind. I’ve written many times that I’ve tried to live a life without regrets, never looking back at decisions and wishing that I’d done something differently lest my life be altered today by that change long ago. You know, the Butterfly Effect. When Harvey was discharged for what we both knew would be the last time I told him that I wouldn’t visit him at home; I wanted to remember him as he was that day. Still handsome. Smiling. Well enough to be happy he was leaving. I told him I didn’t want my last image to be what we both knew was coming. In retrospect I wish I’d had more courage, for I’d very much have liked more time with Harvey. I know I shook his hand, but I can’t remember if I hugged him.

I still have the tie.

 

 

 

A Difference of Opinion is Usually Nothing More

This is from “Sunday musings…” 4/13/14, six years ago today. Seems just about right.

 

When did a difference of opinion become a de facto conflict? When did the evaluation of another come down to whether or not they hue to a fine line of agreement on a single, or a few, or G0d forbid every issue? When did this phenomenon then morph into one in which a difference of opinion then becomes the basis for labeling another ‘good’ or bad’?

Am I the only one who’s noticed this?

I’m not talking about a difference of opinion which is then followed by a concerted attack, one that forces you to identify the holder of the other opinion as ‘bad’, and enemy. There’s nothing new to see there. One only has so many cheeks to turn. Eventually you need to fight or flee an attack, but that’s not what I’m talking about.

On a personal, local, and national level we could once identify broad stroke issues on which we could generally base a level of agreement or disagreement, very few of which would be a ‘deal-breaker’ when it came to civil discourse. The first part of this, the existence of broad stroke issues, remains true. What is fundamentally different in my mind is how un-moveable many of us have become on ever more minute details as we drill down from the 30,000 foot view. All well and good, I suppose, to seek fidelity to an ever more granular level of agreement on whatever issue is at hand, especially in this age when we have ever greater ways in which to find and connect with people of a like mind.

What I don’t get is the subsequent labeling of any and all others as “bad”. Unworthy. Lesser in some way because they do not agree at every level with a particular–very particular–point of view. As I remember it the “80-20″ Rule pretty much applied to belief systems as well as business: if you shared 80% of your beliefs with another that was plenty good enough to allow a friendship, and certainly enough to inoculate against a conflict. Now? Seems like something more like the “980-20″ rule: only the smallest amount of the most trivial difference of opinion is permissible. Anything more than nuance between people and they’re going to the mattresses. Anything more than nuance and we’ve identified something other, something lesser, something to destroy.

What’s up with that?

You could say that anything other than full devotion to a cause or a concept or a worldview is not pragmatism but something more akin to weakness. An inferiority of spirit, perhaps. You could say that nothing other than full devotion to some grand theme or concept is acceptable and brook no deviation from a one, true path. I would say that the world is infinitely too complex to approach life in this manner. I would further say that to do so needlessly isolates you from people who might very well bring infinite joy to your life despite differential nuance or even a fundamental disagreement on one issue. Living and letting live rather than identifying a different opinion as identifying the other as an enemy might just mean a more pleasant life filled with more people who might be better described as friends, or at least friendly.

At the very least perhaps we could just agree to disagree and be on our way.

Easter Sunday musings…4/12/Pandemic

Sunday musings…

1) Indicator. The Sunday paper circulars are interesting. 2, 3, 4 weeks ago the Sunday paper was stuffed with the usual ads from drug stores, Home Depot and the lot. I couldn’t figure out if that was a hopeful sign. Typically there are 15 or more circulars; today there were 3. No mystery here; not hopeful.

The economy has capitulated.

2) Masters. It’s Masters Sunday. Each year I ask that it be ok for me to be allowed to check out from any responsibilities, take command of the TV, and watch the final round of the Masters. Not gonna lie, not having a Masters to follow this year was by far and away the strangest sports non-event for me. Bigger than no Opening Day, no Final Four. CBS has come to my rescue, showing the epic final round of the historic 2019 Masters. It’s almost normal. Beth is doing something useful, I’m bloviating via keyboard, as useless as can be, sitting on my keister watching Tiger.

For the first time in a couple of weeks it feels almost normal.

3) Lockdown. How long can our largest medical institutions in cities not yet “surged” remain at 50% census? I am told that the ophthalmology division at the Cleveland Clinic is down 80% in the clinic and 90% in the OR. In the community taking its lead from CCF it is 90% and 99%. The Clinic (and others such as the Mayo Clinic) are predicting annual losses exceeding $1 Billion at their institutions. Countless patients have seen carefully planned medical care disrupted, further inconveniencing them and their families, and in many cases causing significant financial hardship layered on top of that which everyone else is suffering.

Why the big draw downs in care? So-called “non-essential care” has been shut down, pushed out in order that supplies of equipment (e.g. ventilators) and material (e.g. PPE) be warehoused so that it would be available when the inevitable waves of sick patients are blown in on the winds of COVID. Again, I’m not gonna lie, this particular rationale is a bitter pill to swallow. Enormous institutions with the power to simply float their own loans and cover a loss are complicit in the egregious denial of the coming disaster, failing as fully as the federal government to stockpile what was necessary to be ready. My patients, my staff, and I are direct victims of their lack of vision.

What prevents me from being engulfed by bitterness at this particular aspect of the pandemic is the real reason that “non-essential” care was reasonably shut down and pushed out: medical offices, clinics, and operating rooms working under standard operating procedures are quite simply incompatible with any form of physical distancing. If I go to work and work is normal nearly a hundred patients move through the office in a typical day. Along with them come all manner of family and friends. On my days in the OR 15-20 patients will have surgery, again accompanied by family or friends. It’s not just the patients who are at risk due to the nature of busy offices and OR’s, but all of the staff and doctors as well. And trust me, an eye doctor’s office isn’t the place that all of those missing masks and other layers of PPE have been hiding out. We have been out of masks at our office for weeks. I could protect neither my patients nor my staff.

How long?

4) Compassionate. Again, Twitter is the double-edged sword of my quarantine life. There are some really super smart people hanging out there, and in the spirit of general goodwill most of them have been on their best behavior when “talking” with smart folks who aren’t necessarily smart in their particular area of, you know, smartness. Others, on the other hand, have been just as arrogant and dismissive as ever.

Yesterday I was engaging in one of many discussions of using medications that are either not yet approved for, or whose use for treating COVID-19 would be off-label. Newer medicines without a clear-cut history from which to judge safety pose one very specific problem: can their use in cases of last resort, so-called “compassionate use”, be justified while the option of enrolling randomized, controlled trials (RCT) is available. On the opposite end of the spectrum, is it OK to use older medications with a known track record that includes a very strong safety record in the hope that theoretical benefits will be proven to be actual benefits, again when the option of enrolling patients in an RCT is available.

No less that Dr. Anthony Fauci, the DC biocrat (my term for him coined last week) advocated for what he called the parallel course of doing both, enroll RCT’s and provide medications on a compassionate use basis, when he was faced with another new virus that was killing people at an alarming rate in the 1980′s. When the AIDS crisis was new he realized that waiting for the definitive proof available (though sadly not always forthcoming) from an RCT would mean that people afflicted with HIV and suffering from AIDS would die while the academicians calculated. Safer, older medicines where likewise studied as prophylactic medications in much larger study groups while at the same time being given to large numbers of individuals outside the trials.

When I posted that our present crisis, that includes both the terribly ill at high risk of death as well as the barely afflicted who may or may not end up in the ICU, was analogous to the 1980′s and AIDS I was insulted and belittled by the academicians. Not willing to engage on the ethical and moral grounds of the “parallel course” they instead played king of the hill on the head of the pin of RCT dogmatism. The use of unapproved medications in the most dire circumstances without clear proof that they are not harmful was declared immoral; those willing to even discuss the use of new anti-virals outside of an RCT were labeled naifs without the mental chops to even be given a seat at the table. Likewise the off-label use of an older medication with a sterling safety profile for prophylaxis. There was a barrage of condescending straw man arguments and outright ad hominem.

Why post this here, today? Listen, there were two important conversational threads to be had on this issue yesterday. One on the how and why of RCT’s in both the very ill and those who might become so. The other, no less important, was whether a “parallel course” of compassionate use originally discussed during the AIDS tragedy of the 1980′s by no less than Dr. Fauci, was appropriate. One conversation is cut and dried,  mathematical in nature and wanting only the mechanics to implement. The other is an ethical discussion, one that requires a different vocabulary and one that is open to a wider group of conversant, the insular and dismissive instincts of the academicians notwithstanding.

There will be endless armchair quarterbacking in the months to come. Dismissing people like me, with or without the backslap of insults and derision hitting my backside like the proverbial door as I exited the conversation, will not likely make it any easier for those who demanded the pulpit resting on the head of that pin. It will be hard to offer much in the way of understanding after the fact to those who have extended so little now, in the heat of the battle, to those of us seeking only to understand.

I’ll see you next week…

Is That All There Is? Comparative Religious Studies At the Dinner Table

A partial re-post of thoughts about religion and the afterlife on the day that Passover begins in 2020…

 

Some of our best, most meaningful discussions occur when we are left alone unexpectedly, though I’ve no idea why this might be. Over a typical “Primal Zone” meal we continued an earlier conversation: how does the rel!gion of the Native Americans and other Aboriginal peoples account for basic scientific facts such as the existence and structure of the solar system? Do they even try? Does it matter?

This particular conversation actually started as we walked by the cemetery on Key West. Surrounded on all sides by water nonetheless, the prevailing sense there was dry, the mausoleums and headstones bleached as white and parched as any bones in a desert. Is that all there is?

Despite the surface differences, however dramatic and however loudly trumpeted, there exist great similarities among the world’s great rel!gions. I think these similarities are particularly striking when you compare those of the landed, the American Indian, the Australian Aborigine, any number of Amazonian peoples, separated by millennia and miles, all of whom preach a type of filial duty to the earth that sustains them. Ashes to ashes; dust to dust. An ethic of harmony to be propagated between everyone and everything alive.

This differs, of course, from the major rel!gions of the developed world in the endgame. Today the Christ!an world celebrates its greatest mystery, its most deeply held faith. There is something after the end, after the ashes, after the dust! Heaven, a favorable reincarnation, Paradise…the ultimate carrot as reward for a life lived according to remarkably similar guidelines. Funny as well, isn’t it, how similar are the guidelines in the Old Testament, the New Testament, the Koran, the tenets of H!nduism, and those of the Sioux.

Similar but for one thing: no carrot.

Ashes to ashes; dust to dust. Headstones bleached as white as the bones beneath. Is that all there is?

 

Blessings to all of my friends as they begin the Passover season.