Killing Grandma

The children are beginning to break. Brodie is quoting from Joe Rogan podcasts and Teddy is suggesting we’re the last family on the block actually enforcing social distancing. They’re very tired of screens and…us. They are looking to adults for answers and assurances, and we don’t have them. With summer right around the corner, they fear this stunted life is going to drag on and on: a purgatory without restaurants or movies, spike ball or sleepovers. School is being overly optimistic (when they aren’t being completely cagey) and hints school in September. So if they’re going to be sharing desks and germs in the fall, why can’t they play videogames together in our basement now?

Friends, the because it could kill grandma argument has worn thin. The invincible teenager trope endures. We need a plan and real answers to the repeated question:

“When can friends come over?”

My kids have fantasized about having a “chicken pox party” emulating our own moms from the ‘70s who organized play dates with our spotty classmates so we would “get it over with.” They mused that if all teens purposely contract COVID-19 and become immune at least they could return to some sort of normalcy? In their fantasy no one gets particularly sick, goes to the hospital, dies, or inadvertently kills grandma. In this fantasy they’re also willing to sacrifice their friends with underlying conditions or other hidden and unknown risk factors. I guess. It’s just a fantasy where the invincible teenager trope is reality.

One of their friends is saving money to pay for his own antibody test, desperate for some proof that he should be allowed the free reign usually afforded high school seniors in the last marking period. The odds that any sort of tipping point of teens are antibody positive and immune are probably low; but then again, they were swapping pathogens freely until mid March and could have been asymptomatic. If we don’t test them, too, we won’t know. And because we don’t know, we’re acting out of the abundance of caution necessary in these unprecedented times—which they hear as “because I said so.”

So what do we do? Children sense hypocrisy and inconsistencies more keenly than my puppy hears the rustling of snack wrappers. Right now a reasonable person could ask why golf is allowed, but not tennis? As beaches and pools, restaurants and salons, summer camps and daycare centers open, it will get more and more difficult to justify why my kids cannot play NBA 2K on the same couch with their buddies.

SO WHAT DO WE DO?

As we move forward, we are going to need to be personally responsible for our own safety and for the havoc our kids might wreck on suppressing a second spike. Are you, or do you live with, someone who has risk factors that would predict a more severe or deadly course of COVID-19? You should probably continue to WFH if you can, limit grocery runs, hold off on social situations in confined spaces, and know if your kids are acting in less socially distant ways. If you feel like your nuclear family is at a lower risk, you might feel more comfortable getting that pedicure, braving the beach bar, or letting little Jenny’s friend sleep over. But a short week after we begin to do these things, a lot of us are going to get sick. And the ones who don’t know they’re sick–and are shedding virus all over the place– could easily be our kids.

Once we start doing normal things, we’re going to forget that the goal of social distancing was never to prevent us from contracting coronavirus at all… just not all at the same time. Basic psychology predicts that we’ll erroneously assign a lower risk of contagion among people we know. I mean, they’re our friends! No one has symptoms! But coronavirus is the honey badger of diseases: corona don’t care.

Parents are already allowing small, local quaran-teen groups, swear they are shielding them from the at-risk and elderlies, and trusting them to self-police a group with no assurances that it is COVID-19-free. Is this advisable? Low risk? Nope. And though it may be inevitable, the safety of this is pure fantasy. Also, though I love them deeply, teenagers lie all of the time. The children, and unfortunately permissive parents who let them share recycled air in rec rooms and basements, are going to push the boundaries of what is safe. Epidemiological models and tales of super-spreaders at clubs, cocktail parties, and churches predict that it only takes one asymptomatic carrier to kill grandma.

Even the strictest mandates won’t prevent everyone from contracting COVID-19: it’s too contagious. As those rules are lifted, it’s up to all of us to protect each other. Here’s what we’re suggesting for Summertime at the Lee House:

No hangouts inside. It is safer to meet up in the fresh air (on the deck, around a pool, in the backyard) where the likelihood of swapping spit droplets is minimal. Activities need to be limited to ones where they can stay 6 feet apart. Tennis? Yes. Spike ball? Riskier.

No car-pooling. If absolutely necessary, everyone is wearing a mask.

Chemo precautions. When I was in treatment, the kids had to change their clothes and wash their hands before they could see me. After (outside!) hangouts with their buddies, they need to decontaminate when they come indoors. Let’s be honest, teen boys need daily if not more frequent showers. They should also be carrying Purell in their pockets.

Honesty. This will be the tough one. Grandma & Pop Pop and A-Ma & A-Gong have been quarantining since early March and miss their grandsons. Right now we’d feel comfortable having them visit because the only place my kids have been is Zoom School. But if our boys aren’t honest with us about their own vigilance to social distancing and hygiene as opportunities arise, the elders cannot visit… not without risking killing grandma.

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My boys have already grown tired of me suggesting a walk on the beach as an activity… and it’s not even June. Good luck with your kids. xoxo

The Re-Opening

What day is it? It’s definitely Friday, but Day Fifty Something for Lees on Lockdown. At this point most of us are well past the biblical 40 days of temptation and testing, but I think we’re collectively doing all right. From my screens, I see people reaching out to help those struggling mentally, financially, and spiritually. Our Steps to Success fundraiser could only be held via email blasts and status updating, but somehow raised more money for low-income students than we thought possible. Those who know how are sewing masks; those that don’t are buying them and delivering. Free meals, sidewalk chalk encouragements, Teddy Bear hunts, crooning from city balconies, family dinners, and Lisa on YouTube. This is the good stuff.

I’ve let loose only two primal screams of rage that were mostly directed at teenage boys WHO HAVE ONLY ONE JOB SO GET OUT OF BED ALREADY OMG WHY ARE YOU ASLEEP, but otherwise we’re safe and home and healthy, if also drinking far too much. One night after salivating over episodes of Salt Fat Acid Heat, I looked at our sleepy puppy and suggested to Bernie that we call it a night. It was 9:30. NINE-THIRTY. We hadn’t even finished the Pinot Gris.

Like all of you, I feel like I should be accomplishing stuff with all of this time. In addition to actual work that needs doing (65 manuscripts in the queue), maybe I should be learning to knit? Shredding old tax returns? Teaching Hero useless tricks? Shaping my eyebrows? Something. Instead, this cartoon pretty much sums up every day:

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H/T to Tom Fraatz for posting this from @instachaaz

Zealot Sister lives in Georgia, so we’ve traded thoughts about the safety of doing the things their governor is letting them do. She has no plans for urgently overdue tattooing (wtf), but is going to brave the world and odds to attend to her grays and nails. Is that bonkers?

Probably not. Her county isn’t a hotbed of positive cases. But then again, they haven’t tested everyone, so who can say? With strict hygiene and mask compliance, could it be safe? Safe enough? Honestly, I don’t know. But we’re Americans and not typically great at rule-following when doing so feels like an affront to our personal liberty—or even just makes our glasses fog up. Really, we’re gonna be the worst at this re-opening thing.

Here’s what I do know: as the country starts allowing us to eat together and permanently ink each other–either in a stepwise sort of scientific way or as a recklessly impatient public experiment– my phone is going to blow up the same way it did when the WHO finally said “pandemic.” I’m happy to be your go-to non-practicing physician and immunologist, but at the beginning, I had more answers. Now, nothing seems certain. And as a scientist, when nothing seems certain, it is because we don’t have data.

The smartest people are offering models and recommendations that seem to change daily, but they are still guessing at how many of us have been exposed. The R naught, or coefficient of infectivity—essentially how contagious a virus is—was originally estimated between 2 and 3 for COVID-19. Newer data suggests it could be twice that. And if asymptomatic virus-shedders getting their gel tips and lowlights can infect 5-6 people, a second spike bigger than the first might be inevitable. An R naught over 5 also means we need to wait until over 85% of us have “beaten” coronavirus before we can spring the kids from Zoom School and back to square pizza Fridays in a brick and mortar way in the name of “herd immunity.”

Are we willing to risk the morbidity and mortality of thousands more to achieve this? Or should we suffer this no-end-in-sight life without dine-in restaurants, grandma hugs, or Sox games until a vaccine or miracle treatment is widely available? More importantly than when this ends is how.

Most of us are itching for sero-positive proof as a Get out of Jail Free Card to get back to a pre-COVID-19 existence, and a quick and widely available antibody test will give us a clearer picture of where we stand immunologically. But it won’t be the panacea we crave. Most if not all tests that have been authorized for use are only allowable through the Emergency Use Authorization (EUA) pathway. Doesn’t mean they are bad tests. They’re just tests that haven’t been… tested. And as a result there could be a significant number of false positives because coronaviruses are as common as, well, The Common Cold. There can also be a significant number of false negatives because your plasma cells pooped from combating COVID-19 have stopped making IgG because your memory B cells can always pump out antibody later, if needed.

Do you wanna know how these tests work? You can Google ELISA or trust me when I tell you that they slather a shmear of COVID-19 surface protein onto the bottom of a teeny plastic well and test if your blood is carrying antibodies that stick to it. Some identify IgM antibodies—the first ones your body uses to fight disease—suggesting a more recent response to an exposure. Others detect IgG antibodies—made by B cells that “learned” a bit more about the invader, and indicate a later or resolved infection. Some tests can detect both. But the antibody to the shmear doesn’t prove that they actually neutralize the COVID-19 you transferred from the grocery cart to your nose. The test doesn’t mean your antibodies are effective warriors, it just means they stick to the COVID-19 protein shmear.

What will an antibody test tell us and how can it shape our path forward? It will give scientists more data, but only as much as a stack of Polaroids from the table centerpieces will tell you about how great the wedding was. The IgG assay is only a snapshot. To wit, if we tested everybody right now, we’d likely find that far fewer than 85% of us have mounted an IgG immune response to COVID-19. Herd immunity is likely many months (and deaths) away. What is the power of your personal IgG positive test? Scientifically, not much other than proof that you were exposed. Also, your laminated IgG+ CoronaCardTM might not protect you from a newer, mutated version of the virus… and we have no idea if or when a COVID-20 will emerge.

SO WHAT CAN WE DO? I think the only way forward is to learn from countries that take personal hygiene (mask-wearing, hand-washing, forbidden handshaking and double kissing) seriously. We can dramatically reduce transmission if we maintain the 2-meter rule as much as possible, wear masks, and act like reasonable people in the midst of a pandemic. It won’t be forever… just until we have more data, a treatment, a vaccine, or herd immunity. As the country opens up, we’ll move about in different ways that protect others and ourselves, and I hope we’ll be patient and kind as everyone gets on board. Seven weeks ago I could meet you bare-faced at Starbucks, kiss you hello, catch a late movie, or watch the Celtics with thousands of fans. We’ll get there again. Just not tomorrow or because your governor said you can. Slowly, surely, with caution, common sense… and a mask.

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Buying these from Remy supports #Masks4Meals, providing food for caregivers at Mass General… and they’re wicked cute.

Day 14: I miss my girlfriends

The twin girls across the street love my puppy. Almost every time I round the corner to the front yard, one of them runs out the front door in PJs or calls from a second floor deck to yell, “Hi HERO!” Their SIP time includes homeschooling, so I’m not surprised they’re staring longingly out windows looking for any diversion at all. With great pride they told me (always a leash apart) that school math is super easy for them, then with gloomy faces reported that Russian math was going to start up again soon. At almost 10 they are bursting with chatter and stories. I’ve only gotten to know them over the past month of Hero-walking and quarantining, but they’re magnetic the way all girls are, times two. I love their driveway chalk pictures and, you know, just all of the… girl stuff.

With Bernie still in and out of the hospital, it’s #Flattenthecurve Day 14 for Lees with no in person contact with anyone at all except all of these boys, the dog included. I’ve never lamented not having daughters because most of my favorite people made them and let me borrow theirs. But now I’m stuck here with ever-hungry seat-lifters and I’ve become Monica:

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I’ve also become a bit Monica with the cleaning… 

I miss Women’s Bible Study: a weekly reset that just isn’t the same when we’re not in a circle on couches giggling and praying and sometimes crying together. (Bible Study is a full contact affair, emotionally and physically.) I miss coffee with girlfriends: a lifeline to sanity, a sounding board for complaints, a no-judgment zone to share successes and worries. I even miss chatting with moms on sidelines. OK, maybe like one or two of you. You know who you are. When I picture Life after COVID-19, it involves margaritas with The Stockton Women, a fierce collection of cousins who share Grandma Mid: the hilarious, loving, smoking and drinking matriarch who loved each one of us the best.

I also miss restaurants a ridiculous amount. Meal planning and preparation and clean up is now a three times a day thing–often at different times, plus snacks. I miss meals out where my only responsibility was ordering and eating. And take out isn’t the same. Those of you also rinsing plastic containers for the recycles and marrying leftovers into Tupperware are feeling me on this. IT IS NOT THE SAME.

Talking to the twins’ momma on my multiple daily Hero walks (always a leash apart), I recognize she has zero down time. She’s working while homeschooling and entertaining her almost 10 twins who still need her supervision for things like slime-making and movie-approving. Meanwhile, I’m here with a puppy and teenage boys who sleep until 2pm. What a waste of resources that I cannot invite the girls over to make cupcakes, let them watch unapproved Netflix specials, and try on silly formalwear from the back of my closet…

… girl stuff.

 

 

 

Coronavirus 101

Jason started feeling sick. Not “COVID-19 sick” he wrote, but definitely sick. Though his presenting symptoms were not the classic myalgia/sore throat/cough, I told him what I’m telling everybody:

Assume it’s COVID-19.

Don’t Panic, is the first and hardest instruction to follow. But yesterday Jason earned an A+ in Coronavirus 101: What To Do When You Get Sick During a Pandemic. Jason realized he did not need medical attention, and stayed home. Jason knew COVID-19 testing was not necessary because even if he tested positive, there are no medicines to treat coronavirus (though new ones are being tested in a controlled, scientific way)… so he stayed home. Also, Jason’s COVID-19 status wouldn’t alter his behavior because he was already self-isolating, by staying home.

Social media is bursting with criticism: “I went to/called the doctor with xyz symptoms and risky exposures, AND THEY REFUSED TO TEST ME.” Angry, scared, and looking for people to blame, test-seekers are also unwittingly lowering the confidence we need to have AND SHOULD HAVE in our front line medical staff. And while they are out in the world attempting to tap limited resources unnecessarily, they’re potentially spreading COVID-19 or other pathogens. I’m going to repeat this a million times:

COVID-19 TESTING IS NOT MEDICAL CARE.

And this:

If you aren’t sick enough to consult a doctor or need the ER, you need to stay home.

This is Day 8 for Lees on Lockdown. We’re not protecting ourselves so much as shielding other people. Bernie was in and out of the hospital until Monday, so we’re assuming all four of us have been exposed and could be shedding virus with no symptoms. Does this mean after 2 weeks of isolation we can start sneaking in short visits with people who promise they have been at home, where no one is symptomatic, and everyone promises to wash their hands?

No. Nope. Not yet. No.

The most common text message in my phone right now is asking how long will this go on. And friends, there are no answers for this. We only have mathematical models, daunting statistics, and sobering graphs from experts who predict a more immediate crisis before any possibility of returning to a world where there is lots of toilet paper. But China reported no new local cases yesterday, and I’m clinging to that. Can you envision a cascade of mini celebrations as each city in the US begins reporting 14 straight days with zero positive tests? We’ll get there.

If you stay home.

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This t-shirt exists, and I want it.

A message for young people: quit it, and stay home

Dear Young People,

If you don’t kill us with your refusal to adhere to social distancing, we’ll all be hen-pecked to death by your annoying insistence on meeting up with friends. So quit it, and stay home.

The messaging that COVID-19 is less lethal to your age group–which is true, thank God– is being translated by some in your age group as “we won’t get it,” which is really really really untrue. Instead, because you have already been everywhere (school and sports and Starbucks) and with everybody (ditto) you’re carrying a risk of having contracted COVID-19 that is not zero. People your age are also more likely to walk around shedding virus while having no symptoms at all.

Some of you have become armchair epidemiologists and are manufacturing relative risk estimates based on positive COVID-19 reports in your area. Whatever you are guessing, you’re wrong. We aren’t testing enough people to know what the community penetrance is. Even if you arrived at the hospital right now and with the classic presentation (body aches, fever, cough, and fatigue), they wouldn’t test you for COVID-19 unless you were sick enough to be admitted. And though very few of you will get that sick, some of you will. Instead, you’re more likely to infect 2-4 people (that’s the R naught) every time you insist on going over to Emma’s.

Also, I don’t care what Emma’s family is allowing. Social distancing means you stay home. And if you have to go out–and let’s be honest, you don’t– you stay 6 feet away from other people. We’re also not buying your “I’ll go to the grocery for you” or “just gonna run up to Panera for a sandwich.” Children, please.

On Wednesday, I gave a COVID-19 overview to high school seniors who told me they hadn’t gotten much more information than, “wash your hands.” On Wednesday, which was just 72 hours ago, they didn’t entirely believe me when I told them schools would be canceled by the next day. I showed them graphs that prove how contagious COVID-19 is, and said out loud what no one is telling you: some of your grandparents will die if we do not slow its spread. You know what those kids aren’t doing now? They aren’t asking to go over to Emma’s.

Things might get grim, but right now you have an opportunity to help save lives by doing something you already love to do: stay home and play with your phone. Make some TikToks. Learn how to skateboard or practice your three-pointer. And armed with science (R naught! Homeschooling done for the day!), you can be an ambassador for public health just by telling your friends you’re not meeting up with them at Shake Shack.

Tell them to quit it, and stay home.

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Remember summertime when you didn’t know who these guys were? They are the definition of VIRAL. Related: the Hype House needs to be shut down. #socialdistancing

So you think you have coronavirus…

In a day or two, nearly all of us will have a version of this story, and this is just one example of many that I’ve gotten within the last 12 hours:

So, my wife went to Starbucks with Beka yesterday… and Beka called this morning to say she has a fever and there is a woman in Beka’s lab who is self-quarantined because her husband was in Spain for a conference in February and he’s sick. Should I be worried?

By St. Patrick’s Day, this story will be met with, “She went to STARBUCKS?” incredulity. But right now, and in the next couple of days, all of us will have a similar risk to assess as the friend of a friend of a friend that was exposed gets closer. Here is my take home message if you read no further: you are most likely going to be absolutely ok.

I write about COVID-19 yet again because my phone is on fire, because the high schoolers I spoke to yesterday were absolutely starving for information, and because you guys are reading and sharing. Many of you are leaders of organizations in your own spheres and I APPLAUD YOU for taking action early to cancel events that put us within 6 feet of each other. Your caution is helping to #flattenthecurve and will ultimately conserve resources if not save lives. By now you’ve seen that awesome graphic showing how even if we don’t prevent a single infection, by merely stretching out the rate at which that happens, fewer people die.

Here around Boston, schools are beginning to close. Unfortunately, not all of them yet, but let’s try to be kind while everyone gets on the same page. There is so much conflicting information circulating, new and alarming data hourly, and our own very human fear and skepticism to overcome. By now, I hope most of us are being mindful of how risky that Starbucks stop could be, but even the most vigilant of us will have a “Beka story” soon.

So you think you could have coronavirus… what do you do? Here is what the large medical centers are recommending right now:

Don’t panic. 80% of infected patients experience a mild or moderate course that requires NO medical treatment.

If you have no symptoms, there is nothing to do but self-isolate. Most people show symptoms within 5 days, but during that “incubation period,” if you have been infected, you are contagious even though you feel fine. THIS IS WHY WE’RE CANCELING EVERYTHING RIGHT NOW. If you think your exposure is especially risky (e.g., your college student home from abroad is feverish and coughing) you have an even bigger responsibility to self-isolate. Some patients have not reported symptoms for up to 2 weeks, which is why these “mandatory quarantines” are for 14 days.

IF YOU GET SYMPTOMS, COVID-19 looks like this: tickly throat progressing to sore throat, low grade fever, body aches, and all of those things that make you say, “ugh, I’m definitely coming down with something.” Abdominal pain, diarrhea, nausea, and vomiting are also being reported. Sneezing, runny nose, and postnasal drip is NOT how COVID-19 presents.

IF YOU HAVE COVID-19, symptoms could escalate to a persistent, dry cough and high fever. Testing kits are still not universally available and providers are hamstrung by strict criteria that indicate their use. But you don’t need it. You can call any number of hotlines if you have questions, but remember that 80% of the time, COVID-19 will run its course and you will get better within two weeks. The recommendation is that you STAY HOME and treat with Tylenol, lots of fluid and rest, hot showers to help with cough, and limiting contact with housemates. That last bit will, obviously, be difficult.

YOU NEED TO GO TO THE DOCTOR IF… you have shortness of breath and feel like you are worsening to point of needing care, and/or you are over 60, and/or you have co-morbidities like diabetes, heart disease, or are immunosuppressed. Those with risk factors should set a low bar for seeking medical attention if symptoms are consistent with COVID-19 infection. Our Taiwanese friends have offered this simple test: if you are sick and cannot take a deep breath and hold it for 10 seconds, you need to seek medical attention immediately. (NOTE: if this “breath test” is easy for you, it does NOT mean you are negative for coronavirus.)

If you have decided you need to go to the doctor, CALL AHEAD. The instructions for how each center is handling presumed COVID-19 infections are changing daily. In public, you should wear a mask (or get one as soon as you get there).

And now I leave you with a hopeful message from J.P. Hong, our dear friend from the Asan Medical Center in Korea… and the future:

“First comes denial and then confusion and then you will see so much rapid change and development in the next few days…. it will be incredible how we adapt…. and hopefully see the better side of humanity as doctors volunteer and various innovations occur to fight the virus.”

Those who have bravely canceled events and schools and gatherings are past denial, but most of us are still muddling through the confusion. I hope these guidelines help as all of us inevitably acquire our own Beka Stories.

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COVID-19 Isn’t A Snowstorm

It’s been two weeks since I wrote about COVID-19, and in that time the virus has extended from a handful of countries to over one hundred, from two cases in two states to over 400 cases in 35. And though those numbers still sound low, I urge you to calculate how many degrees of separation you are, RIGHT NOW, from someone who is quarantined (or should be). Here in Boston, most of us are at one or two.

Still, there’s a whole lotta this being shared:

The FLU kills thousands and so does heart disease and the whole country isn’t losing weight and buying Pelotons and most people will be fine or don’t even know they have it so why is THE MEDIA making everyone freak out and buy toilet paper to last until Christmas?

These arguments from exasperated acquaintances on social media are troubling me. The state of Costco shelves and price gouging of Purell tells us that a LOT of people are heeding warnings and preparing to hunker down. A candid picture from Teddy’s glee club performance (which should have been canceled, but we’ll get to that) caught a kid coughing into the crook of his arm. So maybe a little bit of hysteria is a good thing? I mean, for the first time in history, men are washing their hands after peeing? But there are plenty of articles, cable news talking heads, a sizable fraction of your Facebook friends (and occasionally our own political leaders) who insist this “hype” is overblown nonsense.

They’re wrong.

First, all of us should unearth our binders from favorite college professors and revisit the definition of false equivalence. Arguments comparing COVID-19 with other diseases—diseases that have vaccines and medicines and data and more history on the planet than a handful of months—are not valid. If we shouldn’t be overly concerned with COVID-19 because the flu also kills lots of people, does it follow that we can quit reminding women to get mammograms all of October because heart disease is actually more common? That’s how false equivalence arguments fail. Further, calling fear of a probable pandemic “hypocritical” when a person’s daily life does not already include safeguards against more common ailments is just unhelpful when it isn’t unkind. Finally, insisting this virus with a “low” mortality rate is not worthy of travel bans, event cancelations, and school closures entirely ignores a really enormous and valuable and loved set of people at real risk of dying.

The CDC put together this comparison to staunch flu-is-like-COVID-19 arguments… and why I’m worried about veteran teachers, grandparents, and most people in our church pews.

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Since I wrote the last essay, my phone has been binging regularly with requests for advice. Bernie saw patients well beyond his office hours on Friday because everyone wanted his medical opinion on their travel plans and to discuss their relative risk. Should my parents come to the kids’ piano recitals? Should we go to Europe for Spring Break? Can I take the boys to the YMCA pool? Are you going to the PTA meeting? Can we go to the basketball game? Can we fly to Colorado to go skiing? The answer to all of these is no.

No no no no no.

COVID-19 isn’t a snowstorm. A rapidly spreading virus cannot be approached with the same sliced bread and bottled water hoarding preparation. We should not be trying to fit all of the activities in before it “really hits.” It’s here, people. Our churches, classrooms, stadiums, yoga studios, airplanes, and grocery stores are black ice. We’re already at risk because we failed to heed the warnings from Wuhan to be vigilant. I find this quote from Mike Leavitt, former Health and Human Services Secretary particularly poignant:

“Everything we do before a pandemic will seem alarmist. Everything we do after will seem inadequate.”

The only way to protect yourself and your family is with good hygiene, by limiting your errands to those where you can stay 6 feet away from people, or by just staying home. Is this impractical? Yes, for a lot of people. Yes, but it is also all we have. And kind of guessing that everything will be ok and this will just die out as the weather gets warmer isn’t really how viruses work. Behavior modification is the only way to prevent widespread dissemination of a disease that could kill a significant number of our cancer patients, grandparents, disabled friends, and asthmatics. If you can afford to miss things—especially if you are over 60 and/or have other health issues—please do that. Stay home. Your pets will love you even more, and you’ll stay healthy.

It should be telling that medical professionals are canceling meetings daily. Residency interviews are being held via Skype. Morbidity and mortality conferences are on hold. Faculty dinners are being rescheduled. As a division chief, every day Bernie has another cancellation to consider, and continually chooses to limit exposure. He passed on the Celtics game last night because he has cancer patients who are relying on him. We’re canceling our trip to London because those same patients will need to reschedule their operations (and caregiver and child care plans) should he get quarantined. It seems reasonable for an otherwise healthy person to risk COVID-19 exposure because for 80% of patients the course will be mild. But what if your exposure risk leaves you quarantined for two weeks? How many other people and their livelihood will be affected by your forced absence? And should you become infected, how many of your close contacts are people in the very high risk category? In that light, is the glee club choir assembly really worth it?

We should all be weighing what is “worth” the risk right now very heavily, especially if you have the luxury of opting out of things that, let’s face it, really aren’t all that critical. In lieu of any “herd immunity” to protect us (since none of us is immune), the best we can do for those of us who cannot afford to miss work or take public transportation right now is to reduce their exposure. Drive to Vermont to ski instead of flying to the Rockies. Videotape the piano recital. Watch the Celtics on TV. Not forever… just for now. We cannot discount the potential spread of COVID-19 as we would an exuberant StormWatch meteorologist tracking a Nor’Easter that could easily be just a dusting. COVID-19 is here, it’s spreading, and it only looks like a few scattered flurries now because we have yet to do any sort of adequate testing or data acquisition.

But there’s black ice out there, people. The WHO has listed its first objective to “interrupt human to human transmission…” so let’s help them do that when we can.

 

 

Go, and Do Likewise– COVID-19 and Kindness

Casual conversation, Facebook and Twitter threads, and the occasional bad joke indicate that Americans are already experiencing fatigue from media panic around the coronavirus epidemic. Citing statistics to suggest influenza is “worse” and admonishing the press for fear-mongering when only a few thousand people have died are, well, really bad takes on this. When an old friend innocently queried his Facebook buddies if we (Americans, I guess?) should be freaking out, most in the thread agreed that this is mostly media hype.

Um… no.

Let’s start with xenophobia, and then we can get into the immunology and medical stuff.

Three weeks ago, the Globe ran a story about anti-Chinese racism experienced by students since the epidemic began. I asked my boys if they were hearing any bad jokes (or let’s be honest, checking to see if Teddy was making any) when my husband piped up that it had happened to him already.

It was a crowded elevator in the hospital. Bernie was wearing his ID (and probably a freakin’ bow tie) and entered the lift with his team. “Are you… um… feeling OK?” she asked. Taken aback, he said he answered noncommittally, but everyone knew what she meant. He wasn’t flushed, feverish, or rolling luggage plastered with Wuhan stickers. The only way he looked… was Asian.

We spent a large part of the night giggling with the kids and crafting humorous, nasty, goofy, and smug responses to bank for future elevator-type inquiries. But I argued that if people are terrified enough to be casually racist toward a DOCTOR in a HOSPITAL, maybe the best response is kindness. Or, you know, just saying, “I’m not Chinese.”

Three weeks later, in spite of an alarming spread to 24 infected countries, there is an air of conspiracy about COVID-19 on this side of the Atlantic. It’s a Chinese bioweapon. It wouldn’t exist if Asians didn’t eat weird food. A quarter million people have died and China is covering it up. These theories all share the same theme: coronavirus is something that is happening to other people. And those people are a half a planet away and maybe eat bats and probably their government is lying and plus there’s, like, a billion of them. A since deleted Facebook comment said the virus was just culling “low hanging fruit.” This was meant to be funny.

Do we typically crack jokes and make silly memes when people are dying? Maybe this is who we have become. But after 20 years married into an Asian family with kids that don’t look white, as the TikTok teens would say, “this one be hittin’ different.” I jumped into my friend’s Facebook feed to share what the experts are telling us about COVID-19, but I didn’t write what I was really feeling. I didn’t admit that your, “it’s just a virus, calm down” sounds brutally insensitive to me. If COVID-19 is just virus that (so far) is killing mostly Asians… who cares? (I’m guessing its spread to Iran will garner a similar lack of sympathy.)

We may never learn the origin of this virus, or how it jumped from animals to humans, but let me tell you really loudly: IT DOESN’T MATTER. What does matter is that coronavirus is very contagious and coronavirus kills people. What does matter is that it is spreading at an alarming rate and there is no vaccine, no known drug treatment, and (over here) few kits to test for it. Most people (80%) will have a mild course of the disease and data show that until we have a system for identifying and isolating them, they won’t present for treatment for two weeks—two weeks while their viral load doubles daily and they are feeling well enough to ride subways, go to school, eat at restaurants, and infect at least 10% of their close contacts.

The scariness is not in the lethality of the virus, but its scale. Around 13% of infected individuals will endure a more severe course and 6% will be critical enough to require mechanical ventilation. If we cannot keep the sheer number of infected patients low enough, there simply won’t be enough hospital beds and ventilators to go around.

During a two hour debrief and Q&A on the WHO site, the leader of the fact-finding trip paints a picture of Chinese hospitals KICKING ASS at containing what will certainly be called a pandemic. They built a 1000 bed hospital in mere days. They shut down the entire city and created a culture of awareness that has reduced the time a contagious patient is at large in the community from 15 days to 3. Outlying cities mobilized entire medical teams and all of their equipment to go into Wuhan to treat patients and staunch the mortality rate. Bruce Aylward, the WHO expert who just returned from China, confessed that if he contracted the disease, he would want to be treated there.

China learned from the SARS epidemic ten years ago and had some preparations and plans in place. We are woefully unprepared. As I write this, COVID-19 has reached California, and this patient has no known ties to China or close contacts of infected individuals. It’s here now, and it is only a matter of time before we need to implement the transmission lessening tactics that we have not even begun to teach.

Here’s what we do know and what you can do. First, most patients suffering from COVID-19 will report a history of fatigue, malaise, and body aches; 88% will have a fever, 66% will have a dry cough, but only 4% report a runny nose. This is not an upper respiratory disease. Test kits so far have been hard to get and unstable. In China, CT scans are being used to identify a pathognomonic pattern of the pneumonia that can progress in a significant number of patients—a wildly expensive prospect if we need to scan thousands here.

Based on studies of other coronavirus strains, scientists report that it could live on surfaces up to 9 days. Forget masks for now, and Chlorox wipe your counters. Coughing etiquette (into the crook of your arm), frequent hand washing, and strict vigilance about exposing others if you have a fever (and prompt reporting) are simple things we can do now. Chinese citizens have been incredible about self-quarantining, and in public they maintain the 2 meter rule of how close you are allowed to get to others.

Some epidemiologists are estimating ultimately 40 to 70% of the population of the planet could be infected. I repeat, there is no vaccine and no treatment, therefore, no way to stop the spread of the disease aside from behavior modification. However, statistics show that 80% of those infected will be OK. Many won’t ever know they ever contracted COVID-19. For yet unknown reasons, children seem to be less affected than older patients, but co-morbidities like underlying diseases, smoking and vaping, and immunosuppression more often lead to respiratory and even multi-organ failure. If there was ever a time to convince teens to put down their vape pens, it’s now.

Should we be panicking? No. The vast majority of us will not die from this infection even if most of us ultimately contract it. But the “othering” of the disease and the refusal to recognize what it is and how it will affect all of us is unhelpful and insensitive. Replace your beer bottle memes with useful facts, recognize that “only” a small percentage of deaths are of real people with valuable lives and families that are devastated, and pray for the health care workers everywhere who will take care of us in spite of the risk to themselves.

And wash your hands.

Prayer for Healing