Has the C.D.C shamefully failed us?

We have all eagerly watched, and anxiously awaited, the critical communications of the prestigious Center for Diseases Control and Prevention (CDC) during the pandemic’s peak. However, the failure to make an accurate epidemiological assessment at the beginning of the COVID-19 pandemic, the initial failure to develop an efficient test and the surprisingly contradictory guidelines on Social Distancing for the citizenry eager to receive the experts’ guidance, have certainly baffled us.

In a review article of The New York Times Magazine, Jeneen Interlandi analyzed the core causes of those system failures in what was, and still is, considered the premier infection surveillance in the world, whose guidelines are respected by all countries. She begun by informing us that last November a group of academics and Public Health experts created, via regular Zoom meetings, the Covid Rapid Response Working Group to analyze the guidelines to open schools for physical interactions. The local communities were bitterly divided over whether to allow the access of students to their classrooms, even though the latter had not been sources of infection.

She said: “So far there was no national plan for how to move forward, The Centers for Disease Control and Prevention was advising everyone to wear masks and remain six feet apart at all times. But that guidance was a significant impediment to any full-bore reopening, because most schools could not maintain that kind of distance and still accommodate all their students and teachers. It also has left many questions unanswered: How did masks and distancing and other strategies like opening windows fit together? Which were essential? Could some measures be skipped if others were followed faithfully?”

Interlandi attributed this inertia and contradictions to a dangerous phenomenon that had plagued the agency for years already: extreme politicization. Not only the agency has shown baffling clumsiness in their public dealings but, what was much worse, it was immobilized by the meddling of the Trump administration; some reports were altered at the last minute to “comply” with the false mantra that “the epidemic was under control” and that we should trust that “Daddy knows best.” At the state and local levels, the draconian powers of Quarantine were used for blatant demagoguery by unscrupulous pundits of all stripes. In order to conceal their utter ineptitude, the authorities shifted the burden of guidelines’ design to the local authorities, so they could “take the rap” if anything went wrong. As one of our Neurology professors used to say: “the worst policy is no policy.”

The Covid Rapid Response Working Group, located at the University of Harvard, stepped into the public plate to design “actionable intelligence” based on humongous amount of raw data—on infectivity and hospitalization rates, morbidity and mortality rates, etc.—that they had collected and analyzed from multiple sources across the USA; they devised county-by-county risk assessment tools, national testing strategies and contact tracing protocols that fast filled the knowledge void. In particular cases, like the operational guidelines for hospitals, this nimble group moved much faster that the pachydermilian CDC, struggling to catch up with them.

Since its creation in 1946, the agency has had to walk a “fine line” when dealing with the states and local communities where most of their authorities and administrators have always been wary of having “too much federal interference” in a turf they always considered as their own. Moreover, even after great successes, once the light of the public attention was turned off ( and it always does as the limelight depends on our fickle attention span) the mendacious politicians took advantage of it by slashing its funds and cutting staff. The scarcity of funds triggered many vicious internal fights for their apportionment. Some insiders have confided that everybody was fending off for only their interests, compounded by the reality that agency chiefs were unwilling or unable to cooperate.

Interlandi paints a bleak picture of the constraining corset that this sprawling organization (with scientific teams and field offices all over the USA and the World) must forcibly wear at present. “Despite that scope, the agency has little authority. Its officers can’t compel individual states to participate in its initiatives, for example, nor to include CDC scientists in local outbreak investigations, nor to share much data with the agency—even in the middle of a pandemic. It can’t force people to wear masks, or force local leaders to close (or open) schools…Aside from a few quarantine powers, the most that the CDC can do is issue guidance, which is unenforceable and –as the past year has repeatedly shown—just as likely to be weaponized as meaningfully employed.”

The atomization of the institutional arrangements with the states and the extreme focus on foodborne-pathogens (rather than the airborne ones like the coronaviruses) hampered its ability to conduct the necessary genomic surveillance for the threat. There is a great variation in the surveillance capabilities of jurisdictions, sometimes focusing on different parameters that suit their public and political interests. In the beginning of the pandemic the CDC was notoriously absent from the scientific discussions carried out by many teams all over the globe. A sorry shadow of it past.

The Biden administration has already taken bold steps to modernize the bureaucratic structure of the CDC, starting with the demise of a few honchos blocking reform. It has proposed increased federal funding in the budget and allocated some surplus Covid 19 funds to it.

Will that be enough to modernize it?

When we needed them the most, the CDC’s opinions were notoriously absent from the public sphere. They have certainly shamelessly failed us, the citizens of the USA, and the rest of the World.

Stay distant. Stay safe. Stay beautiful.

What do you think ? Please tell us.

Don’t leave me alone.

Stop playing around with Pandora’s Box

In Greek Mythology, Pandora was a noble lady whose husband entrusted her with a mysterious jar (later mutating into a box) that supposedly contained untold plagues that could decimate Humankind. Passionately wavering about opening it or not, her curiosity finally got the best of her: she opened it and unleashed its terrible contents.

After more than a year and a half of the devastating Covid-19 pandemic that has killed millions of innocent victims (including our uncle José Luis in Montevideo) and maiming countless infected people with still unknown long-term sequelae, we are all wondering the same: was the pandemic a natural phenomenon or man-made? Initially we did believe that the origin was the accidental transmission of a bat-virus into a human host in that all too infamous Wuhan market. However, over time, the possibility of an accidental leakage from a Chinese lab became more plausible.

Note. This reproduction of Lawrwnce Alma Tadema’s Pandora was taken from Wikimedia Commons.

https://commons.wikimedia.org/wiki/File:Lawrence_Alma-Tadema_10.jpeg

Nicholas Wade, a prominent science editor of the Bulletin of Atomic Scientists, wrote a great article that discusses the veracity of these two competing explanations. He said: “I’ll describe the two theories, explain why each is plausible, and then ask which provides the better explanation of the available facts. It’s important to note that so far there is no direct evidence for either theory.” This article is so clearly written and solidly based on known facts, that we will try to make a resume.

For months, we thought that the virus had originated in that wet market, but the later discovery of earlier cases not related to it, shattered that hypothesis. In that city stands the Wuhan Institute of Virology, which specializes in coronavirus research. When the possibility of an accidental leakage from a less-than-adequate security lab began to mass circulate in the public forum, a group of supposedly “impartial scientists” wrote a letter (not a peer-reviewed article) in The Lancet refuting it. Wade said: “It later turned out that The Lancet letter had been organized and drafted by Peter Daszak, president of the EcoHealth Alliance of New York. Daszak’s organization funded coronavirus research at the Wuhan Institute of Virology. If the SARS2-virus had indeed escaped from research he funded, Daszak would be potentially culpable. This acute conflict of interest was not declared to The Lancet’s readers, the letter concluded, “We declare no competing interests.”

The author explained that some scientists have been surreptitiously playing a dangerous game in academia and private institutions: creating viruses that are far more deadly than the ones found in nature. They claimed that they could control the scientific variables in a security lab and that their research would help prevent a future jump of these deadly pathogens into a human host. A far-fetched proposition.

The gain-of-function experiments aim  to enhance the virulence and transmissibility of pathogens by tinkering around with its genomic constitution. Some virologists in China and other countries have been studying these coronaviruses to change the composition of their surface spike proteins (the device the organism uses to latch on a human cell before injecting its genetic material into it) with varying results. Shi Zheng-Li—nicknamed The Bat Lady—lead several expeditions to dark caves to collect new specimens of coronaviruses and has worked at the Wuhan Institute.

Wade said: “Shi then teamed up with Ralph S. Baric, an eminent coronavirus researcher at the University of North Carolina. Their work focused on enhancing the ability of bat viruses to attack humans so as to ‘examine the emergence potential (that is, the potential to infect humans) of circulating bat CoVs.” He explained that they managed to take the backbone of the SARS1 virus and replace its spike protein with another one from a bat virus, which made it more virulent in human airways. They dubbed their creation as a chimera—a fantastic creature of Greek Mythology.

How could all these scientific undertakings happen “under the radar” of public opinion and, most importantly, the supposedly watchful eyes of public regulators? According to Wade, there is a most shameful conspiracy of silence in academia that prevents the diffusion of this critical information to the very ones they are supposed to be serving: US. During the past few decades, the scientific community has become so detached from the daily realities of common folks that, in their foolish hubris, have tacitly assumed that they can take these Life and Death decisions on their own.

They are totally mistaken. We want “a say” in decisions that, if gone wrong, can potentially wipe Humankind forever.

A message to these late age “apprentis de sorcier”: stop playing around with Pandora’s box.

And another message to the U.S. House of Representatives: check carefully what you are signing for. Do not fund more “gain-of-function” scientific projects as the risks for our species’ survival are too big.

In future articles, we will continue discussing these critical issues for our Health.

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What do you think? Please tell us.

Don’t leave me alone.

 

 

 

 

 

 

 

 

 

 

 

 

Lawrence Alma Tadema’s Pandora

https://commons.wikimedia.org/wiki/File:Lawrence_Alma-Tadema_10.jpeg

American politicians never fail to “show up” at the forefront

-“Sorry, Doc…We must first vaccinate the power players of South Florida…You have to keep waiting.”

That was the laconic and pitiful answer of the Chief of Pharmacy of one of the outpatient facilities in South Florida that has already received a batch of the precious Pfizer-BioNtech and Moderna vaccines upon inquiring when, as a licensed medical practitioner in Florida, we could come up to get dully vaccinated. The upcoming arrival of the Oxford-AstaZeneca and Johnson and Johnson vaccines will certainly follow the same “entitlement pathway.” The disgraceful planning of the Trump administration (leaving all the operational moves to distribute them to the ill-equipped states) has only worsened the awful Public Health picture of the worst month of the pandemic in the USA. What is left of the much vaunted Warp Speed is just a shameful priority given to Power and Privilege in the USA.

Note – This image was taken from Wikimedia Commons.

How can you justify that some unscrupulous politicians have long refused to wear masks in Congress and the White House, given mischievous messages about the severity of the pandemic and now jump the line to get the vaccine?

In an excellent article in The Washington Post, Fenit Nirappil, Isaac Stanley-Becker and William Wran wrote: ” Public officials and politicians are among the first in line for vaccines that have yet to reach all health care workers and wil not become available for months. They are showcasing their vaccinations on television and in social posts to encourage Americans to trust the injections that may spell the end of the pandemic. But some essential workers and other Americans are expressing outrage that they must wait for protection even as leaders who failed to control the pandemic first receive shots first.”

The silly argument that they are “doing us a favor” by demonstrating that “it is safe to get the vaccines” does not hold the minimal intellectual and emotional evaluation. Deadbeat politicians, we do know they are safe because thousands upon thousand of volunteers across the globe and hard-working scientists have already vetted them. We do not need to watch your hypocritical little smiles on TV to rub your “special privileges” on our faces. Who are you trying to fool? Certainly not he millions of dedicated health care professionals of all stripes that do treat patients.

Justice now for the equitable. rational and efficient allotment of the Covid-19 vaccines!

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What do you think? Please tell us.

Don’t leave me alone.

Agricultural workers should also get the vaccine first

Didn’t we enjoy the fresh cucumbers, tomatoes, and onions to prepare our salads?

Didn’t we count on fresh grapefruits, oranges, and apples to fix our smoothies?

Didn’t we emit a sigh of relief when we saw the well-stocked supermarket stalls?

Didn’t we pray to God Almighty to thank him/her/ihr for living in the USA?

Yes, we all did. But that bounty did not materialize only because the Holy Spirit touched the right elbow of our dear friend Todd Jones, enlightened CEO of Publix Supermarkets (with all due respect for his religious beliefs)

No, it happened because thousands of poor migrant farmers, usually born in Central America, toiled tirelessly first in Florida in the summer and then went up North. A similar phenomenon took place in California and Oregon.

On December 17, 2010, the 5 o’clock news program of Telemundo transmitted the words of the spokesperson of the Coalition of Immokalee Workers, a union founded in 1993 to defend the rights of thousands of migrant workers in Southwest Florida. Immokalee, on the western edge of the Everglades, has been dubbed as the Winter Tomato Capital of the World, producing that delicious fruit for U.S. consumers. He denounced that migrant workers were hard hit by the Covid 19 epidemic and he asked for more state and federal resources to assist them, no matter their legal status.

On June 18, 20120, Patricia Mazzei, a reporter for The New York Times, wrote: “Florida’s agricultural communities have become cradles of infection, fueling a worrying new spike in the state’s daily toll in new infections, which has hit new records in recent days. The implications go far beyond Florida; case numbers in places like Immokalee are swelling just as many farmworkers are migrating up the Eastern Seaboard for the summer harvest.” The migrant workers spend an unusually big amount of time with large groups in the fields and then go back to cramped living quarters, with family members and/or friends sharing makeshift bunk beds.  

The reporter was surprised to see a crew of Doctors without Borders, an aid group largely associate in our minds with major meteorological disasters or cruel wars, setting shop in the central market of the small city to inform and help people in need. The Public Health picture looked unusually grim six months ago, when she paid a visit, but now it is even worse, with many infected migrant workers in the neighboring hospitals and several of them already dead.

However, right now, we have one (and possibly two) good vaccines that are ready to be quickly deployed in the most affected areas of our society. We, health care workers, are grateful that we are at the top of the waiting list to be inoculated asap.

But shouldn’t that privilege also be extended to those unusually exposed because they feed us?

Vaccinate the migrant workers quickly and efficiently to achieve good immunity. Those critical workers of the food chain must be protected for their (and our) sake.

Justice for the migrant agricultural workers. Vaccinate them first at no extra charge.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse Burn-Out. Part VI Pulling rank

-“Doctor…I can’t stand when they interrupt me—just ‘cause they’re my superior.”

One of the sourer complaints that nurses (usually female) voice to us physicians (usually male) is that they literally despise when we pull rank to interrupt or silence them. In a respectful professional environment, the significant discussions should be carried out at a congenial peer-level, with methodical respect to other people’s opinions. Sadly, a few “dinosaurs” (not necessarily related to their age) are stubbornly “reminding” their subordinates that somehow their opinions should carry more weight per se. Paradoxically, most nurses know much more clinical and sociological details about our patients than we do as they are in closer daily contact with them. The irony of it.

Considering that in certain toxic environments, worsened by the terrible strains of this prolonged pandemic that is taxing the human resources in all health care settings, this flaw is still festering and affecting the attainment of good health outcomes, we believe that it constitutes a major cause of professional disenchantment of nurses. In these  times, we cannot afford to lose a single nurse. In our upcoming book Emotional frustration – the hushed plague we thoroughly discuss the reality and implications of carelessly interrupting women’s talk. Here is a book’s excerpt.

-“Doctor…Don’t want me to speak out —always f******interrupting me.”

Carla X. is young middle-level executive in a big American corporation that due to her great expertise in targeting the most dynamic segments of the markets is destined to climb much higher in the corporate ladder. However, she resents the not too subtle attempts by her less endowed male colleagues to sideline her in meetings. She argued that, in the latter, men use an antediluvian tool to bring her to keel and sabotage her impact on the discussion: the interruption of women’s talk.

The power dynamics in her job mimic the one prevailing in our society.          

Christopher Karpovitz et al. studied data from several groups to find out if there really was gender inequality in the deliberation process and if improving the feminine participation would eventually raise their authority within those groups. They found a significant gender gap in voice and authority that nonetheless could be erased if there was unanimous rule and a fewer number of women in meetings; likewise, it could be counterbalanced if women were present in higher numbers.[i]   Lynn Smith-Lovin and Charles Brody studied the speaker transitions in task-oriented groups to determine if men do interrupt women often. They said that: “Gender inequality in these task-oriented discussions is created by a mixture of attempts to use power and of differential success…Men discriminate by sex in attempts and in yielding to interruptions by others. Women interrupt and yield the floor to males and females equally.” [ii] Does their composition have an impact?

The same authors found that in all-male groups, individuals often interrupted each other; but when more women joined them, the number of interruptions fell. [iii] Another  requisite for advancement is to get proper credit for our words and deeds in order to rank appropriately in the institution’s formal evaluation for promotions.

Sean R. Martin et al. studied if there were gender differences in speaking up with data from cadets of the US Military Academy [iv]. The first mailed survey collected basic biographical information; the second one was delivered prior to a crucial two-day competition of war games, at the end of their training period. In the latter they asked to rate each member’s performance and standing to calculate individual scores. In the third survey, they measured the leader emergence score as members had to rank them as leaders. They found that: “men who spoke up with ideas were seen as having higher status and were more likely to emerge as leaders. Women did not receive any benefits in status or leader emergence from speaking up, regardless of whether they did so promotively or prohibitively.” [v]

-“Doctor…When I lead the way, men resent it—only because I’m a gal.”

Marjorie X. is a very proficient management expert that works in a medical supplies company; whenever she opens her mouth to pinpoint a defective process or an outlier member, men often disparage her with gross epithets behind her back. Paradoxically a few women also join in the fray…Talk about a brave new world. Diary USS Awareness – Is the silence of the seas teaching you the art of listening?

Ealy and Karay discussed a role congruity of prejudice toward all those women that dared to assume the pivotal leadership roles in our modern society. [vi]  These authors distinguished two major aspects in this generalized bad attitude:

  1. Perceiving women less favorably than men if they are viewed as potential occupants of leadership roles.
  2. Evaluating behavior that fulfills the needed attributes of a leader role less favorably when it is carried out by a woman.

Consequently, women are perceived less favorably in leadership roles, which can significantly gnaw at their real authority in times of crises of modern institutions. If women-leaders  should become mentors for other women that are trying to emulate them, the camouflaged opinion of their co-workers will certainly have an impact. In every organization there is a parallel structure of power that must be reckoned.”

Note– The feature image was taken from Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Nurses_in_the_1940s.jpg

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

 

References

[i] Christopher F. Karpowitz, Tali Mendelberg, Lee Shaker, “Gender Inequality in Deliberative Participation”,  American Political Science Review, Volume 106, Issue 3, August 2012, pp. 533-547, published online August 9, 2012. https://doi.org/10.1017/50003055412000329

[ii] Lynn Smith-Lovin and Charles Brody, “Interruptions in group discussions; the effects of Gender and Z

Group composition”, American Sociological Review, Vol. 54, No.3 (June 1989) pp.424-435. https://www.jstor.org/stable/stable/2095614

[iii] Ibidem as above.

[iv] https://en.wikipedia.org/wiki/United_Statees_Military_Academyen.wikip

[v] Sean R. Martin, “Research: Men get credit for voicing Ideas, but not Problems. Women don’t get credit for either” Harvard Business Review, November 2017.

https://hbr.org/2017/11/research-men-get-credit-for-voicing-ideas-but-not-problems-women-dont-get-credit-for-either

[vi] Eagly AH, Karau SJ, “Role congruity theory of prejudice toward female leaders”, Psychology Review, 20012, July; 109 (3); 73-98. https://www.ncbi.nlm.nih.gov/pubmead/12088246

The plight of American Health Care aides

-“Doctor…Now I get why all aides get fed up with my Mom—she’s impossible.”

Dianne X. is a successful corporate lawyer with a beautiful family that, due to the Social Distancing and sanitary measures of the pandemic, had to take her mother out of an assisted living facility and re-settled her in her home temporarily. She has a large house, with plenty of help, good resources, but all those accoutrements of a wealthy lifestyle are often not enough to make her mother comfortable as she has Alzheimer’s Disease. She had to change several times her live-in aide, but she lately found a middle-aged Haitian lady that seems to have “connected well” with her Mom. Appreciating the great help she represents, she willingly raised her salary. She can’t live without her.

Unfortunately, many workers in the USA that are engaged in the care of vulnerable individuals—teachers, day care workers, social workers and health care aides—do not receive the proper financial and labor consideration, even though many are well educated and trained. The large majority of them are women from Minority groups. The recent spate of adulation for all those that stayed in the first lines of care during the pandemic, even though many got infected, did not come along with a just raise in their wages, which has remained stuck at U$ 7.25—the Federal Minimum wage.

Kathryn E.W. Himmelstein and Atheendar S. Venkataramani published an article in the American Journal of Public Health that discussed “the racial/ethnic and gender inequities in the compensation and benefits of US health care workers and assess the potential impact of a $15-per-hour minimum wage on their economic well-being.” They studied the 2017 Annual Social and Economic Supplement to Current Population Survey to compare the wages, job benefits, and labor distribution of both the male and female health care workers of different socio-ethnic communities.

They found that: “of female health care workers, 34% of earned less than $15 per hour. Nearly half of Black and Latina female health care workers earned less than $15 per hour, and more than 10% lacked health insurance. A total of 1.7 million health care workers and their children lived in poverty. Raising the minimum wage to $15 per hour would reduce poverty rates among female health care workers by 27.1% to 50.3%.” During our medical practice, we have seen numerous women who, in spite of working full time, do not qualify for basic insurance coverage, including Medicaid. Their children might qualify for state and federal aid but they do not. This has been discussed in a previous article of this series called The Medicaid Coverage Gap.

The researchers studied the possible effects of raising the minimum wage to $15 of these workers and they considered two scenarios. In the first scenario, they assumed that there is zero elasticity for labor demand (meaning that raising the wages will not decrease the labor opportunities)  One of the most discussed issues in the challenge of raising the minimum wage to enable workers a better quality of life is that employers will either start laying off workers or simply stop hiring them. However, there is strong empirical evidence that in Health Care, due to the increased needs of an ageing population and the rising sophistication of medical services, that might not apply. There are much less incentives for dis-employment.

In the second scenario, they assumed that there was great elasticity of the demand for low wage-health care labor, based on a study done in Seattle, Washington state, that showed that raising the minimum wage to U$13 per hour produced a 9.4% loss of work hours for them.

In the first scenario, that increase in hourly wages would increase their average annual income by $7653 ($7682 for all women, and $8236 for Black, Latina and native American women) for an estimated value of almost U$ 45 billion, or the equivalent of a meagre 1.3% of the total health care spending in the USA. Moreover, it would lift almost 900,000 women and their children out of poverty and into the lower middle class.

In the second scenario, the socio-economic gains were more subdued as the average concerned worker would only get an increase of U$5103 ($5152 for all women and U$5769 for Black, Latina and Native American women) The total cost for the system was calculated to be U$24 billion; only 215,476 workers and 163,472 children were taken out of poverty.

It is clear that in both scenarios, there would be an improvement for those hard-working women and their children. Don’t we owe them, as a grateful society that appreciates their work, at least the gesture of discussing a wage raise?

Justice now for American Health Care aides!

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

 

Increased COVID-19 infection in Hispanics

In the USA there has been heated discussions about how the Covid-19 pandemic has affected different socio-economic, ethnic, and cultural groups. Hispanics constitute 18% of the country’s population—representing its largest ethnic and racial minority group—but they account for one in three—33%—of all the confirmed Covid-19 cases where the appropriate data has been collected. They have the highest age-adjusted rates of Covid-19 hospitalizations at 117 per 100,000 and the highest rate of mortality—one in five of the confirmed Covid-19 related deaths with good data.

Carlos E, Rodriguez et al., from the Milken Institute of Public Health at George Washington University and other institutions, studied the publicly available datasets to determine “the differences in county-level characteristics of counties with a greater share of Latino residents that the U.S. average (more than 17.8% of Latino population) compared to all other counties (less than 17.8% of Latino population) Additionally, we examined the association between the proportion of Latino residents and Covid-19 cases and deaths.” The County-level collected data included the following information:

  1. County population
  2. Percentage of Latinos
  3. Percent of residents aged more than 65 years old
  4. Percent of residents under 35 years old
  5. Percent of the under-65 population without health insurance
  6. Occupants per room
  7. Language spoken at home
  8. Ability to speak English

“Fourteen percent of U.S. counties (443/3143) are disproportionately Latino. As of May 11, there were 700.169 Covid-19 cases and 42,674 Covid-19 deaths in disproportionately Latino counties. Up to 91.2% of disproportionately Latino counties (404/443) reported a Covid-19 and 54.4% (241/443) reported a death versus 92% (2484/2700) and 49.4% (1335/2700) in all the other counties.” The incidence of the infection increased with a higher proportion of Latinos, especially in the Midwest and the Northeast regions of the country. The researchers found in the disproportionately Latino counties the following features:

  1. A younger population
  2. Lack of health insurance
  3. Greater number of individuals per room in each household
  4. Fewer number of monolingual English-speaking Latinos
  5. Greater number of monolingual Spanish—speaking or bilingual

Hispanics are disproportionately young and usually work in service industries—like the meatpacking plants—that, deemed as “essential” by the authorities, did not close during the pandemic and were more likely to expose their workers to infection as they demanded the physical presence of many workers clustered in small spaces. The monolingual Spanish speakers were more likely to be healthier, younger, and without the legal residency documents, which limited their access to health care. Moreover the undocumented immigrants are less likely to get the proper testing due to lack of insurance, inadequate coverage, and the ever-present fear of deportation.

The researchers call for more focused and committed policy planning responses to confront the Covid-19 epidemic in Latino communities, as due to structural barriers, the same polices for the general population might be not be as effective with them. They suggest expanding the access to Medicaid and Children’s Health Insurance (CHIP) programs for qualified non-citizens because Hispanics usually work in jobs that do not offer employer sponsored insurance and they have difficulty navigating the meandering modern yet highly fragmented health care delivery in the USA. The occupational risk in Latino communities should be studied with reliable data that, not only captures information for laboratory purposes, but also for hospitalizations and death certificates.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

 

 

 

SARS-CoV-2 infection rates in London health care workers

Since the beginning of the SARS-CoV-2 pandemic, health care workers (HCWs) have been valiantly performing their critical duties in spite of being very exposed to infection. Not only their ranks have been decimated by a surge of infections and deaths, but they also have contributed to the dire spread of the virus in their own communities. The possibility of a second wave of the infection has alerted the Public Health authorities to the need to properly determine the incidence of infection in their rank and file.

In the United Kingdom, the rate of infection in London is double than the rest of the country, which prodded several institutions to pool their human and material resources to conduct a prospective cohort study of HCWs between March 26 and April 8, 2020 in several city institutions. Clinical cohort studies can either be:

  1. Prospective: a group of participants is selected and then studied forward to find out if there are any changes from the baseline data.
  2. Retrospective: a group of participants is selected, and their past data is studied to find any meaningful features.

For this prospective cohort  they recruited 200 patient-facing HCWs from a National Health Service (NHS) hospital trust in London; they collected nasopharyngeal swabs for RT-PCR twice per week, symptom data, and blood samples monthly for high-sensitivity serology assays (ELISA and flow cytometry for spike glycoprotein) The median age of the participants was 34 years old. They found that 44% (87) of the HCWs had evidence of infection at any moment during the study. Based on the serological results, 45% (82) were seropositive one month after the starting date, 20% (36) seroconverted during the study period, 25% (46) were already positive at the study’s start and 21% (42) tested positive in at least one nasopharyngeal swab.

They also found a trend towards a higher infection rate in younger participants than in the older ones; 31 out of 56 persons younger than 30 years got infected, while only 10 out of 30 persons older than 50 years old actually did. There was a significant number of asymptomatic carriers as 38% of the 42 positive HCWs did not report any meaningful symptomatology within 7 days of testing positive for SARS-CoV-2. The median age of onset of symptoms for those that were positive RT-PCR until they reported symptoms was 4 days; none of the participants had to be hospitalized.

The researchers said: “Notwithstanding the short follow-up period, these results suggest a protective effect, correlating with the presence of spike protein-specific antibodies, on subsequent infection within a 1-month period in a high risk setting.”

The featured photo was taken from: By University of Liverpool Faculty of Health & Life Sciences from Liverpool, United Kingdom – Anenurin Bevan, Minister of Health, on the first day of the National Health Service, 5 July 1948 at Park Hospital, Davyhulme, near Manchester, CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=40414909

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What do you think? Please tell us.

Don’t leave me alone.

 

Leftover victims of the SARS-CoV-2 pandemic

On May 8, 2020, the U.S. Department of Labor issued its monthly employment report, which showed that the national unemployment rate jumped to 14.7% in April, its highest level since the Great Depression of the 1930s; it said that 20.5 million people had suddenly lost their jobs due to the country’s lockdown, erasing a sustained rise of employment of the past ten years. A more detailed analysis of those that are abruptly working part-time instead of full-time and those that are not counted showed that the unemployment rate might even be higher. Moreover, the tightening of the federal, state and county budgets will inevitably furlough many more people.

In the previous recession of 2007-2009, the majority of lost jobs belonged to men, as the construction and manufacturing sectors ground to a halt; but this time the real losers are often women as thousands upon thousands of their positions as clerks, secretaries, hairdressers, health care aides, travel consultants, stewardesses, airplane and ship chandlers, restaurant servers and cashiers, dry cleaning employees, etc., evaporate. Once the lockdown is finally levied, albeit in various progressive stages according to the local public health characteristics, many of the once thriving small businesses that used to predominantly employ women will be gone. And there will be hardly any credit for entrepreneurial initiatives as the banks will be reluctant to lend.

Not only did women hold most of the positions offered in the Education and Health Care realms—the hardest hit sectors—but they were also furloughed in greater numbers than men. In a Washington Post article, Heather Long and Andrew Van Dam said: “Before the pandemic, women held 77%of the jobs in education and health services, but they account for 83% of the jobs lost in those sectors…Women made up less than half of the retail trade workforce, but they experienced 61% of the retail job losses. Many of these women held some of the lowest-paid jobs.” A large proportion of those workers are single women with children and members of the Latino and Black minority groups.

These disadvantaged single women usually lack a strong social or family support, for which they disproportionately rely on their children’s school services for their care, instruction, and meals. If they cannot take their kids to school, they will not be able to resume their previous positions, even if they are asked back to work.

In order to re-start our economies we must first help the women that sustain it.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

 

Physician and Nurse burnout – Part V Suicide

The  stressed-out E.R. personnel of the New York-Presbyterian Allen Hospital

Got used to the company of the little sparrow flying over their place of penance

She was always the first one present when the doors of the ambulance opened

She was always the first one present when they took a patient to an exam table    

She was always the first one present when they hooked the whirring machines

She was always the first one present when the drilled routine of care kicked in

 But one day her heart could not resist so much suffering and stopped beating

 Plunging into the depths of their sorrowful spirits, she gave them a final cheer.

On April 27, 2020, Dr. Lorna Breen, chair of Emergency Medicine at the Columbia-affiliated hospital, committed suicide in her parent’s home in Virginia. She had been diagnosed with a Coronavirus infection, but she fully recovered; she was given a leave of absence from work and she decided to spend it with her folks. In a communication with The New York Times her father said: “She tried to do her job, and it killed her…Make sure she’s praised as a hero, because she was. She’s a casualty just as much as anyone else who also died.” [i] Her father said that she had told him that many patients were already dead when they opened the doors of the ambulances. She never had a history of Mental Health issues, but she seemed detached to him.

 Once a suicidal patient decides to act, a Buddhist peace of mind sets in.             

Physicians have been trained to face most of the stressful situation of our careers with a stiff upper lip and the steely determination to carry on, nonetheless. If you are taught in Medical School and  professional training about the values of fortitude and resiliency, you will be the last one to ask for any help. As a result medical personnel are hard hit by an unusual incidence of suicidal acts and attempts, which will surely worsen after the Coronavirus pandemic finally ends.

Unfortunately, there are personal and institutional barriers  blocking the remedies.

In a 2008 Health Affairs article [ii], Donald M. Berwick, Thomas W. Nolan and John Whittington coined the term “triple aim” to define the simultaneous pursuit of three objectives—improving the experience of care, improving the health of populations and  reducing per capita costs of health care—to fix the care system. In 2014, considering the increasing burn-out and dissatisfaction of physicians and nurses with medical practice, Drs. Bodenheimer and Sinsky argued that: “the Triple aim be expanded to a Quadruple Aim, adding that the goal of improving the work life of health care providers, including clinicians and staff.” [iii]

Professional burn-out is characterized by a most evident and ignored tragic triad:

  1. High emotional exhaustion
  2. High depersonalization
  3. Low sense of personal accomplishment

A – High emotional exhaustion

The increasing demands of payors, administrators and patients on the time and resources of the health care personnel produces a generalized dissatisfaction with the perceived quality of their delivered care services. The level of resilient frustration is so pervasively high in our system that physicians, nurses, technicians, receptionists, and other ancillary personnel are literally “counting the days” until finally the day of salvation arrives—their retirement date.

B – High depersonalization

The negative feelings and bad vibe will inevitably foster the emergence of cynicism and sarcasm in the ranks of providers, with the resultant degradation of their rapport with the patients and families. It is a self-sustaining vicious circle. Patients complain that they are being ignored and/or mistreated, which triggers more negativity and disdain for the staff. As a result, the latter keep their bad attitudes without the possibility of pausing for a moment and reflect calmly on the impasse.

C – Low sense of personal accomplishment

For the majority of us who have chosen the medical career, profit and social standing are secondary considerations. What we most value is the possibility of helping our fellow human beings and at  the same time enjoy the unique standing conferred by possessing a voice of authority. With the landing of the abominable “bean counters”  in both the public and the private payor system, our maneuvering room is being steadily curtailed. Our decreasing satisfaction not only fosters our  early retirement but also all kinds of drug and alcohol abuse in our ranks plus the potential of one day, out of the blue, start mulling about the unthinkable.

Shanabelt et al. studied the incidence of burnout with work-life balance in the US physician and general workforces in 2011 and 2014 to compare the results and significant trends, using the Maslach Burnout Inventory; they invited more than 35,000 physicians to participate and 19% completed the survey. [iv] They said that:  “54.4 % (n=3680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.50 % (n=3310) in 2011.Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty.” They found minimal differences in the general workforce between those years.

Early on during our training, a taciturn hitchhiker steps into our cockpit.      

Douglas A. Mata et al. conducted a meta-analysis of 31 cross-sectional  and 23 longitudinal studies of the incidence and prevalence of depression in resident physicians.They found : “the overall pooled prevalence was 28.8 % of participants, ranging from 20.9% to 43.2% depending on the instrument used, and increased with calendar year.” [v] One in four physicians-in training has depression.

To glean more information on this issue, Lisa S. Rotenstein et al. extracted data from 167 cross-sectional studies and 16 longitudinal studies from 43 countries. They found: “the overall pooled crude prevalence of depression or depressive symptoms was 27.2%…Depressive symptom prevalence remained relatively constant over the period studied…In the 9 longitudinal studies that assessed depressive symptoms before and during medical school (n=2432), the median absolute increase in symptoms was 13.5 %.” [vi] They also found that only 15.7% sought medical treatment for their symptoms. There is a tall price to pay.

Amy M. Fahrenkopf et al. studied the incidence of medical errors among resident physicians of three urban children’s hospitals by evaluating the depression with the Harvard National Depression Screening day scale, the burnout using the Maslach Burnout Inventory, and the rate of medication errors per resident per month. They found: “24 (20%) of the participant residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed. Burn-out residents and not-burnt out residents made similar rates of error per resident month.” [i]

There are several factors that block physicians, and other medical personnel, to seek the needed counselling. The crazy work schedule of physicians and residents, the confidentiality issues that might affect the licensing status of practitioners, the personal issue of loneliness and divorce, all contribute to it.  

We have dawdled about writing a book on Physician/Nurse burn-out                 

Lorna’s valiant sacrifice shook our torpor and took us immediately to task

(This article is based on our upcoming new book Emotional Frustration- the hushed plague)

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

References

[i] Amy M. Fahrenkopf, Theodore C. Sectish, Laura K. Barger, Rates of medication errors among depressed and burn out residents: prospective cohort study. British Medical Journal. 2008 March 1: 336 (7642) ; 488-491. Doi: 10.1136/bmj. 39469.763218 BE. https://ncbi.nlm.nih.gov/pmc/articles/PMC2258399

[i]  Top E.R. Doctor Who Treated Virus Patients Dies by Suicide, The New York Times, April 27, 2020. https://nytimes.com/2020/04/27/nyregion/new-york-doctor-suicide-coronavirus/

[ii] Donald M. Berwick, Thomas W. Nolan and John Whittington, The Triple Aim: Care, Health and Cost, Health Affairs, May/June 2008. https://doi.org/10.1377/hltaff.27.3.759

[iii] Bodenheimer T., Sinsky C., From triple to quadruple aim: care of the patient requires care of the provider, Annals of Family Medicine, 2014, November-December; 12(6)573-6. Doi:10.1370/afm.1713. https://ncbi.nlm.nih.gov/pubmed/25384822

[iv] West CP, Dyrbye LN, Shanafelt TD, Physician burnout: contributors, consequences and solutions, Journal of Internal Medicine 2018 June 283 (6) 516-529 doi 10.1111/joim. 12752. Epub 2018 March 24. https://ncbi.nlm.nih.gov/pubmed/29505159/

[v] Douglas A. Mata, Amarco A. Ramos, Narinder Bansal, Prevalence of depression and Depressive Symptoms among resident physicians. A Systematic review and Meta-analysis, Journal of the American Medical Association, 2015, December 8: 314(22) 2373-2383. Doi: 10.1001/jama 2015.15845. https://ncbi.nlm.nih.gov/pmc/sticles/PMC4866499

[vi] Lisa S. Rotenstein, Marco A. Ramos, Matthew Torre, Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation among Medical Students, Journal of the American Medical Association. 2016 Dec.6:316 (21); 2214-2236. Doi: 10.1001/jama 2016.17324. https://ncbi.nlm.nih.gov/pubmed/27923088