Trump’s Wobble-Gait Problem

By DANIEL STONE, MD (3)

President Trump’s wobbly walk down a ramp at his recent West Point visit along with his awkward  two-handed drink from a water glass have stirred recent speculation about a possible undisclosed neurologic issue such as early Parkinson’s Disease.  Although no specific conclusions can be drawn from these observations, they raise important questions regarding the President’s health.    

Trump would not be the first president to conceal health problems.  Toward the end of Franklin Roosevelt’s presidency, his blood pressure rose alarmingly.  As no drug treatments existed his doctors could recommend only that he stop smoking, lose weight and avoid dietary salt.  Less than six months after an un-knowing public re-elected him to a record fourth term, FDR predictably suffered a fatal stroke.  The public was similarly unaware of John Kennedy’s Addison’s Disease, a condition that required daily injections to replace the adrenal hormones his body could not make. 

The known facts about Trump’s health are concerning enough.   Despite taking a statin drug to reduce his cholesterol, Mr. Trump’s age and risk factors at his 2018 physical predicted a 16.7%  risk of a heart attack over ten years, as estimated by a standard American College of Cardiology risk calculator.  Trump was taking a statin at the time of that exam to lower his cholesterol.  As cholesterol levels on a statin may not reflect risk as accurately as un-treated levels, the calculator may under-estimate his true risk.     Although Trump’s doctors tout his health they seemed to be concerned about cardiovascular risk as they subsequently quadrupled his statin dosage, placing him highest dose of the most potent statin available.    In addition, the President’s annual exam revealed that his weight recently drifted up into the obese range, which means additional coronary disease risk along with an increased chance of stroke, chronic kidney disease, diabetes and several types of cancers.  

Continue reading

Flunking the COVID Test

By JEFF GOLDSMITH  

The halting and uncertain response to COVID in the US is a tragic civic embarrassment.    While other countries have snuffed out the Covid-19 virus, the US seems to be grinding on toward 200 thousand deaths despite flinging trillions of dollars at the problem.  As summer approaches, the US shows every sign of declaring victory long before the foe has left the field.  Americans may be losing interest in COVID but COVID has not lost interest in us.  

What happened?   Several trillion in lost economic output, massive dislocation of American families and disgraceful disparities in health risks based on race and socioeconomic level all point to a breakdown in a key civic function. No readily deployable testing capability, critical shortages of protective gear, unappreciated and unresolved conflicts between federal and state health authorities, and critical failures in our core federal public health agency, the Centers for Disease Control and Prevention all played a role.  In retrospect, it is clear that US public health effort- $93 billion in spending in 2018, or 2.4% of total health spending, for a population of 327 million people- was grossly inadequate for the magnitude of societal risk. We spend nearly eight times as much on the military.   

Successful public health requires social solidarity and trust both in science and in government.  All are in short supply.  Early statements from political leaders about how this is no worse than the common cold or the flu and was going to “just go away”,  and the fact that the initial wave was concentrated in greater New York (New Jersey, Connecticut, Long Island, etc.) helped lower the national sense of urgency.   

Aggressive early testing would have been confirmed that the disease was, basically, already everywhere in the country by late March, and was not, in fact, just a “Blue State problem”. The failure to deploy testing early led to a far more destructive and costly national economic shutdown than was necessary; the economic cost of a “flash depression” could have been avoided with better planning and more decisive leadership. 

But in those parts of the country initially grazed by the pandemic, an uglier reality surfaced. It was not merely a failure of leadership that hurt us but a failure of followership as well.  As protests against lockdowns proliferated, the signs told the story.  ““My Rights Don’t End Where Your Fear Starts” read one.  “Liberty for Safety- No Deal” read another.  But a sign at a “Re-open Tennessee” rally in Nashville in late April said it all in just three words:  “Sacrifice the Weak”, a jarringly un-American sentiment if ever there was one.     

In addition to underestimating their own risks, and failing to embrace measures that reduced risks for others, many of those initially spared the virus rationalized that the immediate and tangible costs to them of COVID countermeasures far exceeded the costs to others of an unchecked pandemic.  Those “others” were probably going to die anyway (e.g. older folks, people with chronic disease risks like diabetes, workers in meat processing plants, etc.) in some other part of the country that they didn’t care about. It is easy at a distance to dismiss the reality that the typical COVID fatality lost an average of eleven years of life expectancy!

Thanks to all of this, we are likely not in a second wave but rather a continuation of the pandemic in parts of the country spared the first wave.   Eighteen  states, including Texas, Florida, Georgia, the Carolinas and California,  saw increased COVID caseload over the past week.  Leaders in many states will be extremely reluctant to backtrack, and recommit their states to aggressive social distancing, which, again, would not have been necessary if they were well enough organized to test, trace and isolate- the three keys to an effective response to a viral threat.  

And it simply isn’t as if a coherent public response to this threat was impossible. Other countries (New Zealand-22 deaths, Taiwan-seven deaths, Hong Kong- four deaths) succeeded in surmounting this threat while we failed.   It’s not that the sacrifices demanded in their citizens were somehow less onerous than those that were demanded of us Americans.  What these countries did in common:  rapid diagnosis of a major threat, decisive action to sever all (not just ideologically indicated) international arrivals, universal and uncompromising lockdowns, aggressive scaling up of testing, mobility tracking and follow up.    Most of these countries were also smaller in population, had decisive executive leadership willing to take political risks and showed broad-based respect for authority in the face of the crisis.

Even though this crisis is far from over, the next pandemic is a “when”, not an “if”.  Obvious ingredients of a successful response to the next pandemic include:  multi-level planning for rapidly scalable viral testing, a secure medical supply chain,  generous stockpiles of protective gear, an agreed-upon protocol for care system deployment (to protect ongoing health care functions and workers), recruitment and training protocols for emergency workers and contact tracers and assignment of responsibility for covering high risk “hot spots” such as nursing homes, distribution facilities and food processing plants.  A thorough going and bipartisan review of the Centers for Disease Control  and a commitment to increase federal as well as state and local public health funding is also essential

In a functioning country, these would be achievable steps.   However, logical planning and decisive action may be too great a lift for a fractured, angry and distracted nation.  Two key functions- public health and law enforcement- appear to have lost legitimacy with broad swatches of the public.  Our largest political party seems to be the “Are You Kidding Me?” Party.     A failed state cannot protect its citizens against much of anything.  

A society riven increasingly by tribal resentments, fear and suspicion of any leadership is a society at risk.  The failure of the US to respond effectively to the COVID emergency is ominous, because it has shown societal divisions deep enough to paralyze the country from responding to other threats, be the other emerging diseases, a deep economic downturn, aggressive and unprincipled foreign adventurers, or terrorism foreign or domestic.   

 In the Congo, a comprehensively “failed state” if ever there was one, the unofficial national motto is:  “Débrouillez Vous”, loosely translated as “Figure it out yourself”.  This cannot be where we end up.   It seems so obvious that if we are to be an actual country,  we need to take better care of one another, and that we are stronger as a country if we trust one another and work together to address our common challenges.  

Jeff Goldsmith, Ph.D. is a health policy analyst based in Charlottesville Virginia and President, Health Futures Inc.  

Of Ventilators & Ventilation: Engineering the Coronavirus Out of the Workplace

By NORTIN HADLER, MD (2)

We are all reeling from the language of the COVID-19 pandemic: fatality rates, spread, PPE, distancing, pneumonia, anti-viral drugs, ventilators, second wave, vaccines, serological testing, etc. All of this focuses on the infection with the SARS-CoV-2 coronavirus, and for good reason. People are sick and dying from this infection. However, there is murmuring that will grow in volume as COVID-19 subsides: Will this happen again? Is the annual flu season to become more alarming in the future?  Will we forever be waiting for vaccines and anti-viral drugs with bated breath? 

If we step back and view this nightmare from the perspective of infectivity rather than infection, there may be a way out of this conundrum. Coronaviruses are one of several categories of virus with a proclivity for human respiratory infection. Coronaviruses join Influenza, Ebola, SARS and MERS as respiratory riboviruses. These viruses are tiny bundles, virions, containing a little RNA and not much else. Left alone, little happens. But if they manage to get into a target cell, they commandeer the cell’s metabolic machinery to do their malevolence. They get to their target cell because we inhale them as virions that are aerosolized or carried in the droplets that are produced when infected people exhale. Droplets that are not inhaled settle on surfaces, including surgical and N95 masks, where water evaporates freeing virions to aerosolize unless they are somehow bound to the surface. They are so tiny that even the N95 mesh is an inefficient barrier. One would need filters with such tiny pores that they would impede inhaling.

Infectivity of these riboviruses and probably severity of disease are dose dependent. The more virions one inhales the more likely one is infected. That’s the reason physical distancing is advised. However, these riboviruses retain infectivity for many hours on surfaces during which air currents can launch them and keep them afloat. That’s of little concern out of doors where they are diluted, but not indoors. Modern architectures and civil engineers are well aware of issues that relate to stagnation in built environments. HVAC systems are designed as a compromise between the need to recirculate air for the sake of efficient heating/cooling while turning to filters and air exchanges for the sake of air purity, particularly with regard to inert particulate materials. Concerns about airborne illnesses are seldom primary. In most hospitals, certain rooms are designed as “reverse flow” rooms for patients with contagious diseases with exhaust mechanisms so that the room’s air is released to outside the building, not back into general circulation in the building. Some operating rooms, particularly orthopedic surgical suites, have lamellar flow ventilation to decrease the likelihood of introducing an airborne pathogen along with orthopedic hardware. But otherwise hospitals and other workplaces are not designed with regard to infectivity.

Continue reading