Sunday, May 31, 2020

An epidemic of inequality

On June 23, 1982, when I was six years old, Vincent Chin, a Chinese American resident of Michigan celebrating his bachelor party with friends, was bludgeoned to death with a baseball bat by two white men. Ronald Ebens and stepson Michael Nitz, auto workers who had both been affected by competition from Japanese companies (Nitz had been recently laid off), hurled racial slurs at Chin, whom they mistook for being of Japanese descent. Both men were charged with second-degree murder and pleaded guilty to manslaughter, which typically carries up to a 15 year jail sentence. Instead, Judge Charles Kaufman fined them a total of $3000 and sentenced them to 3 years' probation, stating in a letter that "these weren't the kind of men you send to jail."

Outraged Asian Americans in the Detroit metro area and around the nation took to the streets to protest the verdict. As documented in the final episode of the PBS documentary "Asian Americans," this senseless murder was a particularly bitter pill for Asian Americans to swallow; after a century of being labeled the "model minority" and doing everything we could to blend in, we were in fact still viewed by most whites as "perpetual foreigners."

Chin's family eventually brought federal civil rights charges against Ebens and Nitz, the first time that this statute had been used for a hate crime against someone other than African Americans. Although Ebens was sentenced to 25 years in prison, the verdict was overturned on appeal. Chin's mother Lily, who died in 2002, was quoted as saying: "What kind of law is this? What kind of justice? This happened because my son is Chinese. If two Chinese killed a white person, they must go to jail, maybe for their whole lives... Something is wrong with this country."

Something is still wrong with this country. Although reported hate crimes against Asian Americans had been declining since 2003, and in 2017 were a small fraction of the number reported against black, Muslim, and Jewish Americans, this changed with the arrival of COVID-19. Fueled by politicians throughout March calling SARS-CoV-2 the "Chinese virus," Chinese Americans, and other Americans of Asian descent who are confused with being Chinese, have increasingly been the targets of racist tirades and worse as the pandemic spread throughout the U.S.

Meanwhile, in the words of a Medscape commentary, COVID-19 has "unveiled a tale of two Americas," as it has ruthlessly exploited entrenched health disparities in black and Hispanic Americans who have long suffered the effects of structural racism. Nationally, black Americans are three and a half times more likely, and Hispanic Americans twice as likely, to die from COVID-19 than white Americans. You can see this on a local level in the District of Columbia, where the largely minority-populated Northeast and Southeast quadrants have had many more cases diagnosed than the largely white Northwest quadrant, and black residents (who comprise just 46% of the population) have suffered a stunning 86% of the deaths. As Ed Yong wrote in his latest article in The Atlantic:

Vulnerability to COVID-19 isn’t just about frequently discussed biological factors like being old; it’s also about infrequently discussed social ones. If people don’t have health insurance, or can afford to live only in areas with poorly funded hospitals, they cannot fight off the virus as those with more advantages can. If people work in poor-paying jobs that can’t be done remotely, have to commute by public transportation, or live in crowded homes, they cannot protect themselves from infection as those with more privilege can. These social factors explain why the idea of “cocooning” vulnerable populations while the rest of society proceeds as normal is facile. That cocooning already exists, and it is a bug of the system, not a feature. Entire groups of people have been pushed to the fringes of society and jammed into potential hot zones.

Thousands of Americans have taken to the streets this weekend to protest the murders of George Floyd and Ahmaud Arbery by Minnesota police officers and self-appointed vigilantes, respectively. Whether the offenders will receive punishments commensurate to these crimes, or if they will be let off with slaps on the wrist, like Ebens and Nitz in 1982 or George Zimmerman in 2013, remains to be seen. But in a larger sense, the protests are about more than simply the unjust deaths of individuals. They are about the continuing tolerance of too many Americans to fatal inequalities in our systems of justice, housing and health care that stack the deck against persons of color and rob them of more than a decade of life. Whether it's the President of the United States repeatedly lying about the impact of COVID-19; the closing of essential hospitals in underserved minority or rural communities; or a modern-day epidemic of amputations in black Americans in Southern former slave states; these protests are an expression of deep-seated rage about an epidemic of inequality that men and women in power have long minimized, dismissed or ignored.

Wednesday, May 27, 2020

Multisystem inflammatory syndrome associated with COVID-19 in children

One of the few comforting findings in the COVID-19 pandemic has been that most children older than one year of age have a less severe clinical course than adults. A large case series from China suggested that about half of infected children have mild symptoms (acute upper respiratory tract infection or gastrointestinal symptoms, including diarrhea) while only 1 in 20 develop hypoxia, respiratory failure, or other organ failure. In a U.S. case series, two-thirds of infants younger than 12 months were hospitalized; the corresponding figure in older children was 5 to 15 percent. As a pediatric infectious diseases specialist at New York University told a New York Times reporter, "The idea that children either don't get COVID-19 or have really mild disease is an oversimplification."

On April 7, Hospital Pediatrics published a case report of a 6 month-old infant who was hospitalized for classic Kawasaki disease and had a positive result on a reverse transcription polymerase chain reaction (RT-PCR) test for COVID-19. At that time, it was not clear if the COVID-19 diagnosis was coincidental or associated with this rare vascular inflammatory condition. On May 7, the Lancet published a report of a cluster of 8 cases of children with hyperinflammatory shock (atypical Kawasaki disease, Kawasaki disease shock syndrome, or toxic shock syndrome) who presented to a children's hospital in London during a 10-day period in the middle of April. Within one week, more than 20 children with similar clinical features were admitted to the pediatric intensive care unit (PICU), half of whom tested positive for SARS-CoV-2. Around the same time, reports in a pediatric journal described severely ill children with COVID-19 in Washington, DC and New York City.

In Bergamo, Italy, the incidence of Kawasaki-like disease increased 30-fold between February and April at the height of the epidemic. Compared to a historical group of children with Kawasaki disease prior to the pandemic, these children were older and had a higher rate of cardiac complications. Investigators in France and Switzerland described a series of 35 children (31 of whom tested positive for SARS-CoV-2) who were treated in PICUs for acute heart failure due to a severe inflammatory state.

On May 14, the U.S. Centers for Disease Control and Prevention (CDC) issued an official health advisory to provide information to clinicians about multisystem inflammatory system in children (MIS-C) associated with COVID-19. The case definition for MIS-C is as follows:

- An individual aged < 21 years presenting with fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND

- No alternative plausible diagnoses; AND

- Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms.

Fortunately, standard treatment for Kawasaki disease (described in a 2015 article in American Family Physician), including intravenous immunoglobulin, corticosteroids, and aspirin, thus far appears to be effective in treating MIS-C associated with COVID-19.

**

This post first appeared on the AFP Community Blog.

Wednesday, May 20, 2020

The end of the beginning?

On November 10, 1942, after British forces led by Generals Harold Alexander and Bernard Montgomery decisively defeated a German-Italian army led by the "Desert Fox" (Field Marshal Erwin Rommel), at the Battle of El Alamein in Egypt, Prime Minister Winston Churchill gave a speech where he memorably declared of the war against the Nazis, "Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning."

Although the progress of the fight against the COVID-19 in the U.S. remains, in the words of science writer Ed Yong, a "patchwork pandemic," the numbers of new cases of and deaths from the virus have either stabilized or are heading downward in most states and in the Washington, DC area, while hospital and public health contact tracing capacity has been growing. Practically every state has started cautiously easing restrictions on movement and public places and allowing shuttered businesses to reopen with social distancing measures in place. Although some politicians would like to declare victory over the virus, this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.
After I deployed this Twitter survey, some colleagues in medicine and public health suggested that I had left off some important terms, notably "social distancing," "exponential growth," and "flatten the curve." I agree. Notably, though, all four options received votes, and the top vote-getter, herd immunity, did not quite receive a majority. So I thought I'd provide my perspective, as a family physician and population health teacher, on what each of these terms mean and how they have sometimes been misinterpreted by the general public.

Herd immunity: the concept that once a pathogen has infected a certain percentage of the population (how much depends on how contagious it is) and they have developed immunity, there are fewer susceptible hosts, which not only slows the spread but also indirectly protects non-immune persons. For vaccine-preventable infections like measles and pertussis (which causes whooping cough), herd immunity is especially important for protecting persons who have contraindications to immunization (for example, infants too young to be vaccinated or immune-compromised persons).

However, for COVID-19, some have suggested that rapidly achieving herd immunity should be a national goal, even in the absence of an effective vaccine. They pointed at Sweden, an country that stands alone among developed nations in not instituting an economic lockdown (though mass gatherings have been banned and social distancing is still strongly encouraged). Nonetheless, by early May, only about 25 percent of the population of Stockholm had developed antibodies to SARS-CoV-2 and Sweden currently has the highest per-capita COVID-19 death rate in the world without any perceptible economic benefits. In New York City, in March and April the epicenter of the pandemic in the U.S., a study found that only 1 in 5 people had antibodies to the virus - far short of a herd immunity threshold even though hospitals and morgues were overrun and 1 out of every 400 people died. As Five Thirty Eight calculated, "If the [COVID-19] fatality rate is around 0.5 percent and 70 percent of Americans have to get sick before their immunity starts protecting others, that means more than 1.1 million people would die." Personally, I think that the most likely projection of 140,000 U.S. deaths given existing social distancing measures is a national catastrophe, but 1,100,000 deaths is totally unacceptable.

Quarantine: refers to the isolation of persons who have been exposed to a contagious disease for the maximum duration of the time it takes from the time of exposure to becoming symptomatic. For COVID-19, the recommended duration is 14 days. This is not the same thing as "self-isolation" of persons with known infections or "lockdown" (government-mandated travel restrictions). Yes, I intentionally misused this term in my previous post, but "self-isolation / lockdown reading" just sounded too weird.

Contact tracing: refers to the practice of identifying and contacting persons who have been exposed to a known infected individual so that they can be assisted in quarantining themselves and connected to resources (including health care) if needed. Smartphone tracking apps can help facilitate this process, but are not a substitute for real people working the phones. If you are interested in learning more about becoming contact tracers for your states and communities, Johns Hopkins University is offering an excellent free online course on this topic. For contact tracing to be effective in preventing new COVID-19 outbreaks, however, it is critical that the general population trusts the tracers and adheres to their recommendations. In a widely suspicious community, riled up by armed protests about government encroachment on their freedoms (to travel to one's second home, to work out at the gym, to go bowling, etc.), I worry that many people may ignore public health workers telling them to stay home, and will continue infecting others.

Antibody testing: blood testing for antibodies to SARS-CoV-2 that can help determine if an individual has been exposed to the virus. My colleague Dr. Mark Ebell has pointed out that with current far-from-perfect tests and a low prevalence in most communities (particularly in persons without respiratory symptoms), false positive test results will be common. Most critically, even a "true positive" antibody test result does not guarantee that an individual is protected from COVID-19, or for how long. We just don't know yet how durable immunity is or how long it lasts. So if you get a blood test that suggests you have antibodies, don't discard your mask or stop social distancing because you think you can't get infected or infect others.

Tuesday, May 12, 2020

Quarantine reading list: my collected book reviews

Whether you are self-isolating at home because your state remains under a stay-at-home order, you had recent close contact with someone with COVID-19 (as have several members of the White House's Coronavirus Task Force), or you have been presumptively or definitely diagnosed with the disease yourself, you may have more time to read. If you are interested in reading about a health topic other than the current pandemic, here are links to all of the book reviews I have written for Family Medicine and Common Sense Family Doctor over the past decade.

Generally positive reviews:

Range: Why Generalists Triumph in a Specialized World, by David Epstein (2020)

Pulse, Voices From the Heart of Medicine. Editor’s Picks. A Third Anthology, edited by Paul Gross, Diane Guernsey, Johanna Shapiro, and Judy Schaefer (2017)

Ending Medical Reversal, by Vinay Prasad and Adam Cifu (2015)

Epic Measures, by Jeremy N. Smith (2015)

What Every Medical Writer Needs to Know, by Robert B. Taylor (2015)

The Great Prostate Hoax, by Richard Ablin (2014)

Between the Lines: Finding the Truth in the Medical Literature, by Marya Zilberberg (2012)

Your Medical Mind, by Jerome Groopman and Pamela Hartzband (2011)

Overdiagnosed: Making People Sick in the Pursuit of Health, by H. Gilbert Welch (2011)

The Color of Atmosphere, by Maggie Kozel (2011)

The Immortal Life of Henrietta Lacks, by Rebecca Skloot (2010)

Medicine in Translation, by Danielle Ofri (2010)


Mixed reviews:

Health Systems Science, edited by Susan E. Skochelak and Richard E. Hawkins (2018)

Fractured: America's Broken Health Care System and What We Must Do to Heal It, by Ted Epperly (2012)

In Stitches, by Anthony Youn (2011)


Another source of book recommendations is my annual top ten favorite public health and health care book lists from the past five years:

2019
2018
2017
2016
2015

Finally, I highly recommend two notable new books by the above-named authors: Dr. Vinay Prasad's Malignant: How Bad Policy and Bad Evidence Harm People with Cancer (which I peer reviewed and later endorsed for the Johns Hopkins University Press) and Dr. Danielle Ofri's When We Do Harm: A Doctor Confronts Medical Error.

Saturday, May 2, 2020

Sacrifice

The late Senator John McCain has long been one of my heroes. His story is familiar to most Americans: as a 31 year-old naval aviator during the Vietnam War, he was shot down and captured by the North Vietnamese in October 1967. He remained a prisoner of war for five and a half years. During that time, he was frequently subjected to unimaginably harsh physical and psychological torture, including two full years in solitary confinement. It may be less well known that he had an easy way out. After his father, a U.S. Navy Admiral, was named commander of all U.S. forces in the Vietnam theater in mid-1968, McCain's captors offered to release him. By this time, McCain had lost 50 pounds and was near death. Nonetheless, he refused, citing the U.S. military code of conduct, which advises officers not to accept special favors from the enemy and to agree to be released in the order they were captured. It's likely that McCain was motivated not only by adherence to the code, but by solidarity with his fellow prisoners-of-war, many of whom had endured captivity for considerably longer.

Americans have now endured several weeks of "shelter-in-place" or "lockdown" orders enacted to mitigate the effects of COVID-19, which as of May 2 had claimed nearly 65,000 lives nationally, including more than 2,000 in DC, Maryland, and Virginia. As states begin to cautiously loosen public health restrictions in the hope of restarting their economies, there are increasing signs that many citizens are losing patience with social distancing: cell phone data show increased movement outside of homes, large crowds in California turned out to protest beach closures, and heavily armed men invaded Michigan's state capitol to protest the governor's stay-at-home order.


I've written before about the "girl in the well" phenomenon, a psychological effect that causes us to be captivated by news about one or small numbers of endangered persons (remember the Thai Cave Rescue in 2018?) but shrug our shoulders when thousands or millions are at risk. If you don't personally know anyone who has been hospitalized or died from COVID-19, you might be wondering if the continuing sacrifice is really worth it. You miss going out to dinner with family and friends, worshiping with your faith community, watching or participating in your favorite sports. Maybe your child or favorite niece or nephew won't be able to attend their prom this year or experience the thrill of an in-person graduation ceremony. Maybe you wonder: is the cure worse than the disease?

I am a doctor, but I'm not on the front lines. Thus far, all of my patients who have had COVID-19 have recovered, and most haven't needed to be hospitalized. But the hundreds of patients who have been admitted to my hospital haven't been nearly as fortunate, and some, sadly, aren't making it out alive. Every day at the office (yes, I still commute to a physical office, even though I haven't seen a patient in person in more than a month), I strongly advise my most vulnerable patients to stay home or keep their distance from others when they must go out for grocery shopping or exercise. But I can't protect them adequately without your help. You can take the easy way out: start getting together with friends again, discard the mask - and frankly, odds are that you, personally, will probably be okay. Or, in the patriotic spirit of John McCain, who championed a "cause greater than self," you can stoically endure this shelter-in-place for as long as it takes to flatten the curve on this unprecedented pandemic, out of solidarity for millions of potential victims you don't know but who are depending on you to do the right thing.