We’re On An Adventure

Rainbows everywhere

Today we did something crazy. We drove from Missoula, Montana to Eureka, Montana and back to give a friend a ride back to civilization from their family’s compound after they tested negative for COVID-19. What a great chance to show everyone this amazing place I live!

I did say rainbows

Beautiful Montana

These are all from today

I am blessed to live in a place of wide open spaces and the optical illusion that creates a bigger sky

Where glaciers collide with clouds

Flathead Lake is always a welcome sight

Flathead Lake is a gem

We hit a bit of rain on our way, but it eventually subsided.

As with any good Montana road trip you have to stop for the wildlife.

Don’t worry – they move eventually

You’d never believe this is one of the major shipping routes across the US border into British Columbia, now would you?

Nearing Eureka as it begins to get darker

Blue sky still visible at 9 PM? Not for long!

Near Trego, Montana the last bits of day find their way into this beautiful night

We managed to catch the sunset on our way in to town

As I’m pleased to share with you some of the magnificent clouds we witnessed about 15 miles south of the Canadian border at the port of Roosville

As we return from Eureka we see signs reminding us to social distance and stay close to home. Missoula County and Lincoln County both have 0 active cases. Our friend safely in tow, they are also high risk, have been isolating, and need to get to Missoula for a doctor appointment that cannot be done over a video chat.

Whitefish looks desolate. There’s no one on the roads here. It makes sense – Flathead County is among the hardest hit in the state – every case that’s been traceable has been connected to travel. Flathead County is where the airport for West Glacier and Whitefish is. We head south toward Kalispell.

So helpful

We stop in Kalispell to charge the car and use a disposable barrier for handling the charging cable. Charging will require a couple of hours.

It’s dark, so the pictures aren’t going to be very interesting for the rest of tonight. We will be safely back in Missoula soon.

And there’s your Montana road trip during this crazy time. The world is a mess. Stay safe – hold your family close.

Publication Announcement!

The above picture was created using https://inspirobot.me/ – it seemed appropriate for some of what the past couple months have felt like

I submitted my first piece of COVID-19 related writing. And…

Stigma Fighters published my poem Alexithymia in 2020 America! Hop on over there and check it out? Leaving a comment and sharing it would be even better.

This is also a good time to mention that I have a poetry collection called “One Hundred Different Skies” coming out in Summer 2020. Once I have the cover art finished I will be making the collection available for digital pre-order.

I’ve already received great feedback from a couple of beta readers and I’m loving all of it. This might sound weird, but I love hearing when someone dislikes one of my poems if they can tell me why they dislike it. I find it really helpful to me because as I’ve been working through cases where someone can tell me why they dislike something, I find that I can understand their viewpoint and am willing to edit and try to rewrite sections to improve the work.

I accept that there are few things harder than editing poetry in the world of writing. But there’s nothing more rewarding than a poem that accurately captures an experience. My beta readers are AMAZING.

As always, thank you for taking the time to read this post and if you haven’t heard it today: you are loved and you are valued.

Aversion to Masks? How Masks Make A Difference

Why Wear a Mask?

Source: https://www.maskssavelives.org/

An organization called Masks Save Lives is currently calling out a link between “low mask acceptance cultures” and how badly COVID-19 outbreaks are affecting these areas and their failures to flatten the curve once outbreaks began. Research potentially supports this division, a 2009 study in Australia found that the data could not be assessed for if cloth mask usage reduced seasonal infections in the public due to low compliance by participants.

The CDC now recommends wearing masks and numerous websites have come out with instructions on how to make a cloth one (here’s one!). However, is there something to the cultural divide? We’re going to look at the United States specifically (though the next Tweet is from the UK).

An example of the reaction someone gets going to the store wearing a mask in England – one of the countries accused of having an anti-mask culture by the organization.

Why Do People Not Wear Masks?

Social Acceptance

Mask acceptance is not as easy as mandates and public health advisories. Beyond the scientific and home care acceptance, it must not be seen as a threat. Previously the lack of compliance in the Australian study may have been related to an element of social acceptance, however this was not studied at that time. If someone is uncomfortable wearing a mask they won’t. One community that may feel this impact are ethnic and racial minorities in the United States. One 2010 study investigated the barriers to mask wearing among urban Hispanic households in cases of upper respiratory infection. The findings concluded that these communities required higher risk perception scores before adopting face mask usage. This lead the researchers to conclude that face masks are unlikely to be effective for this community in the case of seasonal or pandemic influenza like conditions. The participants voiced concerns about social acceptability of masks within their communities – if they would be viewed as the source of illness – while others mentioned potential embarrassment.

Many have long dealt with violence related to the use of masks. Assumptions related to suspicion of crime, gang activity, and other racial profiling can making wearing a mask uncomfortable.

Legality

In the state of Virginia it is illegal to wear masks in public, though after the CDC’s announcement the law no longer applies.

§ 18.2-422. Prohibition of wearing of masks in certain places; exceptions.

It shall be unlawful for any person over 16 years of age to, with the intent to conceal his identity, wear any mask, hood or other device whereby a substantial portion of the face is hidden or covered so as to conceal the identity of the wearer, to be or appear in any public place, or upon any private property in this Commonwealth without first having obtained from the owner or tenant thereof consent to do so in writing. However, the provisions of this section shall not apply to persons (i) wearing traditional holiday costumes; (ii) engaged in professions, trades, employment or other activities and wearing protective masks which are deemed necessary for the physical safety of the wearer or other persons; (iii) engaged in any bona fide theatrical production or masquerade ball; or (iv) wearing a mask, hood or other device for bona fide medical reasons upon (a) the advice of a licensed physician or osteopath and carrying on his person an affidavit from the physician or osteopath specifying the medical necessity for wearing the device and the date on which the wearing of the device will no longer be necessary and providing a brief description of the device, or (b) the declaration of a disaster or state of emergency by the Governor in response to a public health emergency where the emergency declaration expressly waives this section, defines the mask appropriate for the emergency, and provides for the duration of the waiver. The violation of any provisions of this section is a Class 6 felony.

Code 1950, §§ 18.1-364, 18.1-367; 1960, c. 358; 1975, cc. 14, 15; 1986, c. 19; 2010, cc. 262420; 2014, c. 167.

Modifications Needed

I was unable to find documentation online of how those with disabilities that inhibit the use of masks are handling the situation or even recommendations for these individuals on how to stay safe. If you find anything, please tell me.

In other cases we need to consider family caregivers, and children, both needing modifications and not. Many children struggle to wear masks, particularly infants and toddlers. The primary reason most experts encourage children to wear masks is to prevent them from giving it to others, rather than to prevent them from contracting the virus themselves. But the CDC still insists that all children over the age of 2 should be wearing a mask when they leave the house. I am looking for further resources – at this time I have heard about this problem from friends that are parents.

The American Academy of Pediatrics has released the following guidelines for masks and children with special health considerations:

-If you must go outside or to a place where you are not able to practice social distancing with an infant, cover the infant carrier with a blanket, which helps protect the baby, but still gives them the ability to breathe comfortably. Do not leave the blanket on the carrier in the car or at any time when the baby and carrier are not in direct view.  

-Children who are considered high-risk or severely immunocompromised are encouraged to wear an N95 mask to best protect themselves.  

-Families of children at higher risk are encouraged to use a standard surgical mask if they are sick to prevent the spread of illness to others.  

source: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/masks-and-children-during-covid-19/

In terms of the minimum effectiveness and materials? An Experimental Study of Efficacy of Gauze Face Masks published in 1920 the researchers concluded that cloth masks had basic minimum requirements that had to be met in order for a mask to have a “restraining influence on the number of bacteria-laden droplets possible of inhalation”. Part of this involved a balance between the number of layers, thread count, and breathability. If the mask is too dense as a result of the layers and thread count then “breathing is difficult and leakage takes place around the edge of the mask”. That leakage of air is what they proposed caused the reductions in efficacy observed. Research such as this resulted in recommendations of a minimum of 300 thread count fabric still used today.

Cost Prohibitive / Unable to Obtain

We’ve talked about poverty before. This can impact obtaining supplies, time to make a mask, and many other life factors that are none of my business and we need to be understanding. Others are unable to sew or are unable to put a mask on for themselves (see “modifications” above).

Do Cloth Masks Really Help?

We began asking this question a long time ago. In a 1920 study on gauze masks looking retrospectively at the data from the 1918 influenza pandemic regarding the infections contracted by healthcare workers, authorities’ primary criticism was that the weave of the fabric was too loose. Though the study still concluded that masks did not demonstrate to have a degree of efficacy that would warrant their compulsory application during an epidemic, they argued that masks should not be abandoned entirely. I’ll leave it in their words:

Studies made in the Department of Morbidity Statistics of the California State Board of Health did not show any influence of the mask on the spread of influenza in those cities where it was compulsorily applied, and the Board was, therefore, compelled to adopt a policy of mask encouragement, but not of mask compulsion. Masks were made compulsory only under certain circumstances of known contact with the disease and it was left to individual communities to decide whether or not the masks should be universally worn.


The reason for this apparent failure of the mask was a subject for speculation among epidemiologists, for it had long been the belief of many of us that droplet borne infections should be easily controlled in this manner. The failure of the mask was a source of disappointment, for the first experiment in San Francisco was watched with interest with the expectation that if it proved feasible to enforce the regulation the desired result would be achieved. The reverse proved true. The masks, contrary to expectation, were worn cheerfully and universally, and also, contrary to expectation of what should follow under such circumstances, no effect on the epidemic curve was to be seen. Something was plainly wrong with our hypotheses. We felt inclined to explain the failure of the mask by faults in its application rather than by any basic error in the theory of its use. Consequently, Bulletin No. 31* of the Board of Health brought out the fact that where it was sought to control influenza by compulsory wearing of masks certain obstacles developed. These were:


First, the large number of improperly made masks that were used.

Second, faulty wearing of masks, which included the use of masks that. were too small, the covering of only the nose or only the mouth, smoking while wearing, etc.


Third, wearing masks at improper times. When applied compulsorily masks were universally worn in public, on the streets, in automobiles, etc., where they were not needed, but where arrest would follow if not worn, and they were very generally laid aside when the wearer was no longer subject to observation by the police, such as in private offices and small gatherings of all kinds. This type of gathering with the attendant social intercourse between friends, and office associates seems to afford particular facility for the transfer of the virus. If, as seems probable, the virus is droplet-borne, this form of contact, where people are conversing with one another, would, of course, be much more dangerous than crowd association of strangers, even under the circumstances of gathering in churches and theatres. We were not satisfied, however, with this seemingly perfectly satisfactory explanation. We felt it to be imperative, if the mask were not to be permanently discredited, that more definite information be obtained concerning its uses and limitations. If, as we believed, the gauze mask is useful as a protection against certain infections, it would be unfortunate if its uncontrolled application in influenza should result in prejudicing critical and scientific minds against it.

The American Journal Of Public Health.

A 2008 Study that came out in PLoS One found that wearing homemade cloth masks reduced hypothetical infections after spraying people with a simulated contagion.

A 2011 review of “Physical interventions to interrupt or reduce the spread of respiratory viruses” found that …

Respiratory virus spread can be reduced by hygienic measures (such as handwashing), especially around younger children. Frequent
handwashing can also reduce transmission from children to other household members. Implementing barriers to transmission, such
as isolation, and hygienic measures (wearing masks, gloves and gowns) can be effective in containing respiratory virus epidemics or in
hospital wards. The more expensive, irritating and uncomfortable N95 respirators might be superior to simple masks. It is unclear if
adding virucidals or antiseptics to normal handwashing with soap is more effective. There is insufficient evidence to support screening
at entry ports and social distancing as a method to reduce spread during epidemics.

…meaning that isolation, hygiene, and barriers like masks were effective.

On a lukewarm note, a 2013 study found that they were “better than nothing” against droplet transmission during an influenza pandemic.

Health Belief Models are one of the most mad scientist or the most Psy Ops things about public health. How do you get an entire population to do participate in something that will help be better for everyone else in the long run – like washing hands? In 2014, a literature review of cloth mask usage was published in the Singapore Medical Journal taking a different approach to the use of cloth masks in the context of a Health Belief Model.

A later 2015 study in BMJ Open found

Cloth masks resulted in significantly higher rates of infection than medical masks, and also performed worse than the control arm. The controls were HCWs who observed standard practice, which involved mask use in the majority, albeit with lower compliance than in the intervention arms. The control HCWs also used medical masks more often than cloth masks. When we analysed all mask-wearers including controls, the higher risk of cloth masks was seen for laboratory-confirmed respiratory viral infection.”

With such mixed reviews being published, why wouldn’t we be hesitant to recommend masks when they’re being advised as only a last resort?

When is a mask not a good idea?

Masks can lead to inhaling your own infectious droplets from a sinus infection and spread it to the rest of your airways.

Here’s an anecdote. I am having trouble finding papers to support this, but this is the current hypothesis my immunologist and I have as to how I got that month long pneumonia in March 2020.

I had a sinus infection and I was wearing a mask. Then, I aspirated droplets from my sinus infection leading to a lung infection. This lung infection eventually developed into a pneumonia. This is an instance of when a mask is not a good idea. Circumstances when you can aspirate your own droplets from a sinus infection or from an oral infection would be while exercising, crying, or dealing with temperature or humidity swings that would result in a runny nose.

Other people who should not wear masks? The CDC recommends against masks for anyone with breathing problems, such as shortness of breath, children under the age of 2, and “Anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance.”

TL;DR

  • Wear a cloth mask if you can and assume good intent for everyone wearing a mask. They aren’t doing anything suspicious. Don’t call the police.
  • Masks work more than nothing. Please wear them, but wear them smartly. They do not make up for poor hygiene practices.
  • Some people can’t afford the supplies to make cloth masks, or they need modifications for their unique needs, or they cannot make the mask themselves. There are resources for that.
  • Children’s masks need consideration based on your child’s needs.
  • Masks are not always a good idea. Inhaling your own droplets can lead to pneumonia not related to COVID-19.

Thank you for reading this. Without you I am shouting into an ether. If you enjoy and want me to write more of these please share this or comment below with what you would like to see me write next.

I started writing this article on 8 April, 2020 and stopped because I needed a break from writing about coronavirus related topics. I will be continuing to update this post-publication.

How Behaviors Impact Coronavirus Spread & Confirmed Case Reporting

Part 1 – Introduction to Issues

This is a pretty loaded topic. Breaking this one up into several parts. In this post I’m addressing limitations to medical accessibility, such as uninsured rates, caregiving, and religious exemption from government advised or required disease control practices, such as social distancing. Let’s talk about human behavior and how that may impact the vulnerability of your location in the United States to coronavirus.

Accessibility, Uninsured Rates, and Alternative Medicine

Source: https://www.census.gov/data-tools/demo/sahie/#/?s_searchtype=s&s_agecat=1&s_statefips= You can play with this viewer too! Go play with census data and learn about the United States.

There are many reasons Americans are uninsured. Being uninsured will ultimately lead to limited access to healthcare. Due to decisions that were made regarding how to implement mandated healthcare, the poor were punished for not being able to afford exorbitantly priced healthcare. I don’t care who you blame for it not working. Point is, it didn’t, and now we’re sunk. You may notice a similarity between the map above and the maps in my previous post on the closure of rural hospitals and poverty. Texas and Oklahoma are currently set up to be the two of the hardest hit states by coronavirus because these are uninsured populations that feel they cannot seek already-limited healthcare (because hospitals closed). This means that they turn to alternative medicine at home and don’t call a doctor due to the cost. Alternative medicine, though potentially complementary (waiting on research), doesn’t involve providing ventilators to people drowning from their own viral lung inflammation. Alternative medicine doesn’t necessarily involve reporting confirmed cases to the state, either.

Luckily, telemedicine is slowly stepping up the game at reducing costs and improving accessibility, but until we have Point of Care testing that allows for mass screening that could be distributed to a population via the health department – good luck. The FDA still strictly prohibits self administered tests. This is one of the major outstanding limitations preventing telemedicine from serving our most underserved and vulnerable populations in the United States during this pandemic.

Religious Exemption

Source: http://childrenshealthcare.org/?page_id=24

Religious exemptions for medical care are a real thing. I know there are people reading this that are going to think, “but no one in their right mind is thinking that now!”

Oh honey, I wish I could say that was so. Let me first introduce you to What’s The Harm. Even without coronavirus, people are and will be dying due to lack of access to medical care in part because their families opt out via religious exemptions. When this is combined with alternative methods gone wrong and cultural factors, the vulnerability of this population is amplified by pre-existing public health issues.

Part of the states’ Stay At Home orders have meant the discontinuation of standard church gatherings and not everyone is taking it so well. Across the United States, churches are challenging these orders by stating that they are restricting freedom of religion. The continued in-person gatherings of worship services and other church functions result in COVID-19 outbreaks within communities. The Palmer Grove Baptist Church in Burke County, Georgia is one example from today, 31 March 2020. Another example: a choir practice when there were no positive cases reported in the county lead to an outbreak due to asymptomatic transmission. In Arkansas, California, Florida, Louisiana, Oklahoma, South Carolina, Tennessee, Texas, Washington, and Wisconsin, churches have risked or spread COVID-19 to members through gatherings or other church related events. As long as church closures are seen as a threat, these communities will be at higher risk for impacts from COVID-19.

I’ll be making a separate post dedicated to addressing the religious exemption issue in a culturally sensitive manner. Stay tuned for part 3.

Home Care For The Sick

One of the most wonderful things about America is that we are a country of caregivers. By acting as a caregivers we enter others’ homes or share homes with them to ensure their wellbeing. Remember that map from this other post on poverty and rural hospital closures?

When we care for the sick at home, a variety of other factors come into play that may delay or prevent access to medical intervention or reporting. Cultural norms around illness, including distrust of the medical system, preference for home care, and family caregiving will play their roles in the spread of COVID-19.

Source: https://www.cdc.gov/aging/caregiving/caregiver-brief.html

This means that children and older family members that do have symptoms may not have access to medical intervention, documentation, advice, or have sufficient care or separation from family members. While these deep-rooted beliefs come from a nurturing and caring place of love, it is important that cases at least be documented. These practices currently put families and communities at high risk of having the virus spread within them. While we do have recommendations for caregivers and home care instructions for coronavirus patients, they are not practical options, nor sufficient for the average family in America.

Home Burials

Source: https://www.romemonuments.com/home-burials – great website. Highly recommend reading more there!

In Part 2 – Home Burials and Funeral Industry

Thank you to anyone reading these commentaries and predictions. Without you I would be shouting into a void.

Poverty And Coronavirus: How Bad Could It Get?

Source: https://www.census.gov/library/visualizations/interactive/2014-2018-poverty-rate-by-county.html#

Let’s talk about poverty and how it plays a role in pandemics (specifically covid-19 and the current state of things in the US).

First, to get this out of the way ,

Poverty does not mean someone is…
dirty
diseased
uneducated
deserving of their position
being punished
has made mistakes
is suffering consequences
or any of that B.S.

Now that that’s out of the way. Let’s move on.

Source: It’s a zoomed in version of the map above, y’all. I’m from the Chesapeake Bay and you can see West Virginia, Tennessee, and Kentucky at high risk just by consideration of poverty.

Impoverished areas tend to have worse health care with low availability than areas of higher average income. And it has only gotten worse over the past 4 years. This means that in these areas everyone is of a much higher risk category when it comes to having community impact from covid-19. There are a couple factors playing into this, but let’s start with the accessibility question.

Closure of Rural Hospitals

Rural hospitals often serve impoverished areas. Because healthcare in the United States is privatized it is not secure. Based on whether or not a larger medical network parent hospital corporation thinks a hospital is profitable, a hospital can be closed down. This is not a new problem. It’s been going on for the past decade, quietly, while everyone else focused on all of the other aspects of healthcare. Except for rural communities where we banded together and started figuring out Ag worker clinics and other ways to cover vitals needs. But guess what: that can’t do crap against the coronavirus.

Since coronavirus entered the United States, West Virginia saw the closure of Fairmont Regional Medical Center at the hands of California owned Alecto Healthcare Services. Other hospitals across the United States are closing and laying off workers to reduce costs and shift resources within these greater hospital networks, like Alecto Healthcare Services. This reduces the resources available to impoverished or communities that might not make these networks as much money. Another example is Missoula, Montana where Western Montana Clinic laid employees ahead coronavirus in a similar way.

Source: https://www.bloomberg.com/news/articles/2020-01-09/hospital-bankruptcies-leave-sick-and-injured-nowhere-to-go

Bloomberg reported back in January that hospital closures were becoming a concern prior to the coronavirus hitting the United States media’s attention. The article references hospital networks taking these actions as a means of weeding out “weaker facilities”.

“Some of the more recent closings are the result of large health systems weeding out weaker facilities. That’s the case with hospitals run by Community Health Systems Inc. and its spin-off, Quorum Health Corp.

All of the areas where these hospitals once were are at much higher risk of having their remaining healthcare systems overwhelmed.

Source: https://www.bloomberg.com/news/articles/2020-01-09/hospital-bankruptcies-leave-sick-and-injured-nowhere-to-go

Under the Trump economy, hospitals have suffered immensely as measured by the Polsinelli TrBK Health Care Services Distress Index (tracks bankruptcy filings in health-care). Not only has this president set our healthcare system up to fail during his entire time in office, he is now trying to deny all responsibility. I don’t identify with a political party in the United States, but seriously.

Essential Employees

Essential employees include delivery drivers, manufacturing employees, gas station workers, grocery store check out clerks, health care workers, government workers, and all of these low-paid minimum wage jobs. Who makes minimum wage?

Source: https://policy-practice.oxfamamerica.org/work/poverty-in-the-us/us-minimum-wage-map/ Darker areas of map represents the concentration of workers being paid under $10.10/hr.

Many of the essential employees that are still going to work are the same ones making minimum wage. They are also the ones living in low income areas where healthcare is suboptimal, easily overwhelmed, and is far away. Assuming they can afford it at all.

Notice something that will make your heart break? Where did all of the hospitals close?

Update: as of 31 March 2020

Source: https://coronavirus.1point3acres.com/en (8:49 PM MST) – Where’s all of Oklahoma’s testing?

I’m not a religious person, but I ask if you read this to pray for those communities. This is where flattening the curve is both most important and least likely to happen. For further reading on how the US is doing with that check out this post here.

Happy to update this and answer questions, plus dress this up with additional research.

Thank you for reading – without you these would just be shouts into the ether.

Is the US flattening the curve? Yes. Significantly? Who knows.

How do you describe that feeling of watching numbers climb and realizing that you’re watching in real time the most global example of what you’ve studied and taught your entire adult life?

Dread? Excitement? Existence?

When teaching about pandemics we teach students to look retrospectively at the numbers of those that have recovered versus those that have died. We make estimates on the numbers of those that were actually infected based on documentation available (or more recently – on documented confirmation). At about 6:00PM on 27 March 2020 twice as many people had died of covid-19 in the United States as have recovered. Seeing those numbers broke my heart for a moment, so I had to talk it out to myself somewhere.

https://coronavirus.1point3acres.com/en as of 6:26 PM MST 27 March 2020

It’s too early to call what it will look like in the United States in terms of our final numbers with covid-19. At this time these numbers are skewed by post-mortem testing and testing criteria that limits test accessibility to those already in need of medical intervention over home care.

Things might look scary, but don’t give up hope. Update 30 March 2020: and reporting started coming in of recoveries! Part of why this reporting may have been delayed is due to stringent testing criteria.

https://coronavirus.1point3acres.com/en as of 12:47 AM MST 30 March 2020. The criteria most are going by: 2 negative covid-19 swabs with a minimum of 24 hours separation.

The reason for this standard is that there is a very high false negative rate with the rt-PCR based test. If anything goes wrong along the way – say there’s a bad reagent, too low of a sample of viral particles, or something goes wrong that invalidates the test it will come back negative. This is the bane of every graduate student that has ever done rt-PCR. They will tell you their horror stories, especially if they were from poorly funded labs.

For some additional hope.

There’s this amazing power of graphs. We can look at growth of reported cases overtime to project the number of cumulative reported cases in the United States in the future.

I started keeping these to track the projection if we stayed on an exponential number of cases reported (aware of typo – did not plan on using this graph for anything originally)

Even as we have expanded albeit limited testing across the United States the overall rate of growth of total cumulative cases is slowing. While this hope is based on very limited data, could it be that we may actually be flattening the curve?

Equation is changing – are we flattening? I’m not sure. We added a zero. [Does some math]. I don’t know if that’s significant yet.

We’re able to see the slope change as the day to day numbers change. Thus, we can see when our efforts are working. (See below)

Source: https://coronavirus.1point3acres.com/en has the ability to build graphs showing how the US has slowed growth from 28% to 25%. That 3% isn’t much, but it’s something.
Source https://coronavirus.1point3acres.com/en But remember that our reporting is primarily coming from one place right now. Go to the website and visit this graph – it’s actually a movie!

This is part of why we need accurate reporting above anything else. The numbers that only require home care matter. In order to accurately understanding the danger of a disease we have to know how many people have it and are acting as asymptomatic or low symptomatic carriers. This influences anticipatory healthcare planning decisions for patients and facilities. I will address this a bit more later in regards to the limitations of cultural understanding around death, dying, and disease.

Update 30 March 2020: Exciting New Graph! If we start looking at the growth in the number of reported cases since improved surveillance across the United States started around March 19th – Yes, the US is kind of flattening the curve. But not enough. We’re also not far enough in to predict the peak.

We can be hopeful. As of 30 March 2020 we were set to diagnose our 500,000th case on 4 April, 2020. Flattening the curve is succeeding in different parts of the country. I will be addressing this in a new post. As a brief update as of 12:01AM 1 April, 2020, we have moved that projection out to 5 April, 2020. My model is limited by not knowing what the current daily max testing capacity of the United States is yet.

Update 5 April 2020:

Hey, look! We didn’t hit 500,000 cases. That’s incredibly comforting and is a fantastic sign. That said, we still have a backlog of COVID-19 tests, an untested positive population acting as a reservoir to continue infecting our healthy population, and we have no control over this. At this point, it is believed that SARS-CoV-2 will become a seasonal illness in the United States.

Source: Same as before

Remember how I said before that the 500,000th case had been pushed out to 5th April? Now, that’s 6th April, 2020 if only looking at the cumulative cases since the 15,000th case in the United States. What if we look at since 23 March? On this day we had approximately 46,000 confirmed cases, with the next day climbing to 55,000 confirmed cases. This is the date we should look at to consider since 50,000 cases reported.

Source: same as before

It’s not changing. There’s enough growth in of confirmed cases in parts of the country that any flattening is being overwhelmed right now. America’s current check up isn’t doing so hot.

A website for further seeing how your area is doing with flattening the curve. It is grading the United States with a D, and I agree.

PPE Shortages

It’s not the fault of our healthcare workers and everyone needs to show gratitude. The United States is facing extreme PPE shortages, resulting in healthcare workers being put at risk for infection and at risk for being vectors of covid-19. Hospital acquired infections have long been a problem in the US due to poor hygiene practices among staff and invasive devices used in hospital settings such as catheters, PICC lines, and IVs. While this has been combatted over recent years by the installation of improved educational programs and the implementation of disease control specialist positions in hospitals and clinics, these measures are useless without sufficient PPE. Washing hands and hand sanitization does only so much. We dedicate a lot of research time and money to this topic.

Diagnostic Testing Has Barriers

Point of Care rapid testing is a luxury afforded us over the past ten years (and toward the end of the 20th century) for strep throat, influenza, drug screenings, and other common “ailments” that bring you in to say hello to someone like me (only using quotes because I included drug screenings). The fact that we have this soon to be available for the coronavirus at all is incredible. Not only will this help with disease surveillance, but we have the ability to accurately study a pandemic in real time on a scale like never before. We could have the ability to intervene and institute true quarantine measures assuming we roll out extensive Point of Care screening for everyone.

But until then, can I even trust this data?

Rituals Around Disease, Death & Dying Complicate Things

How many people are dying at home untested? Remember that across America we have incredibly diverse customs about death and dying.

I recently spoke with friends in New York City and she mentioned that she knew members of certain cultural communities that though they were symptomatic were not getting tested. Part of why this happens is because of cultural beliefs around illness and dying. It’s going to be scary and everyone is reacting in ways that may deter them from getting tested. This will limit our surveillance and will also result in transmission within communities.

In the American South (where I’m from) families conduct home hospice even during severe illness out of pride and the cost of healthcare. Once the family member has died they will contact the local mortician. While it might no longer be legal to do home embalming and many states have prevented home burials, this has never stopped families from caring for the dead. Caring for the ones we love as a final act is one of the most essential acts as a family member that is often robbed of Americans elsewhere across the United States. In twenty to fifty years will we need to do go all paleovirology/anthrovirology (actual fields!) on disinterred bodies to get the actual numbers? Or will we go the route of China with incinerating covid-19 presumed bodies without testing? Will we go the route of the US during 1918? Will we burn it all?

Another thing to consider with any pandemic is how the rituals around death in the home contribute to the spread of a disease. This paper regarding the Ebola pandemic addresses why it is important to understand how we culturally handle death in times of pandemic in order to appropriately control spread.

Future Questions We Will Hopefully Answer:

As we look into ways to protect our healthcare workers with limited PPE we should be reminded that there are other ways we control the spread of disease.

Are healthcare workers on PReP faring better?

Many of the antivirals in PReP and PeP are being tested in the treatment of covid-19. Healthcare workers in Emergency Medicine have recently started turning to PReP and PeP to prevent the spread of HIV as a result of blood born pathogen exposure. Are these healthcare workers faring better than those not on PReP? Only time will tell since the number of workers on PReP reporting is still rather low.

What percent of the population needs to participate in social distancing in order to flatten the curve?

There’s isn’t actually an exact percent. What’s critical is that those at highest risk of being effective vectors for covid-19 during the transmission period of infection while shedding virus are able to infect as few other people as possible. This is a complicated question I’ve broken down into a couple parts.

Who actually needs to be on a stay-at-home order / essential workers only order for us to flatten the curve?

Go Fill Out Your Damn Census So I Have A Better Map

On the U.S. Census map above population density is shown in dark areas. Are you in that darker half? Stay. The 🦆 Home unless you are an essential worker.

Are you NOT in the darker half? Then you should be worried if you hear that there’s community transmission in your county. At that point practice social-distancing.

But you’re not out of the woods yet my friends. I have some more criteria for you:

How far away does your closest neighbor live? If you live in an apartment building – you should stay home. Live out in the country? Congratulations you lucky son of a gun! We’ve shown those city slickers that living in the underserved parts of America with crappy, dying economies that have been sputtering out and suffering at the hands of a global economy and evil corporations ain’t so bad, now is it? Or is it.

How far away is the closest interstate, highway, airport, train station, and other means of connection? Ever go to the gas station close to those things? May want to rethink that. Those are going to be your highest risk areas.

There’s a certain percentage of the population that can’t participate in the Stay at Home orders. It’s not their faults and they should be treated with the utmost kindness. They are taking huge risks. If you are a member of this population there are ways to assess how high risk your workplace is (if you’re interested). The actions of everyone else helps to make up for that by creating distance and reducing the number of people available for transmission at all. I know that’s a little messed up, but that is part of the theory behind it.

Source: https://www.census.gov/library/visualizations/interactive/2014-2018-median-age-by-county.html#

What is the median age of your area? Serious question though. Also, how old are you? Yes, this disease is affecting young people and those with conditions that make them more vulnerable. But I want you think about what kind of threat you are posing to the other people in your area by being a vector. If you live in a dark blue area, even if there hasn’t been a reported case in your county yet – staying home or social distancing is protecting this vulnerable population. You don’t want to have helped transmit the first.

source: https://www.unacast.com/covid19/social-distancing-scoreboard

(Update 5 April 2020) What Is Your Social Distancing Score?

You have thought about population density. You have thought about your median age group and how that plays into susceptibility of your area. The actions of those around you also put you at risk. In the flattening the curve check ups on New York, Pennsylvania, and New Jersey I talk about how important social distancing is right now and how big of an impact it is going to have on what we see in the future, such as the one vs. two peaks in New Jersey. But remember that not everywhere can social distance. Pay attention to the areas graded “F” as we address poverty below and in this post here.

Source: https://www.census.gov/library/visualizations/2019/comm/family-gatherings.html Do you live in a multigenerational household or live close by to family and see each other often?

Do you live in a multigenerational household or live close by to family? Do you see them often?

You absolutely need to be trying to stay home. These stay at home orders are critical to you. Illnesses like this can spread through families like wildfire. We love our families, right? Keep our families safe. If you are an essential business employee, it is even more important that you protect your family and isolate from them if possible. In many cases there is caregiving. This is addressed more in this post.

Source: https://www.census.gov/library/visualizations/interactive/2014-2018-poverty-rate-by-county.html#

Do you live in an area that is severely impoverished?

I hate asking this question because it is loaded. Click here for further reading on an additional opinion regarding race and healthcare inequality relating to poverty. Problems with the wealth and resource gaps in America demonstrates the huge gap between the way we treat people and I’m from a deep blue dot on the Chesapeake Bay where those resources aren’t available.

Disease outbreaks are worse in areas where poverty is not appropriately addressed. If you live in an area like this, you need to take stay at home orders seriously and the problem is, you can’t. And it’s not your fault. Our government and humanity are failing you.

I made a new post to address this more. Point is: stay home if you can, but be compassionate with yourself if you can’t.

What is determined to be essential and how do they determine what percentage of the workforce can be considered essential?

Oh. See, here’s the fun part. They don’t. They think of essential services, not the total number of employees this prevents from participating in social distancing. The state governments will figure out why this is really really dumb pretty fast, especially since many are now seeing hiring booms in those fields (like gas stations and weed delivery). I’m not an economist or a business person. People need to eat. This will be a strain on efforts that has to be monitored.

If people are interested in hearing me rant about the topics I’m actually an “expert” (by degrees and academic research/teaching background only) in let me know. If you are I’ll actually go back and edit this rant and dress it up a bit.

Thank you to anyone reading this. Without you this is just a shout into the ether.