Vaccine Website Up and Running

As of Monday, March 8, 2021, the new online COVID vaccine registration portal is up and running at www.etxcovidvaccine.com. A result of the efforts of a volunteer group known as the Deep East Texas Partnership working with the Angelina County & Cities Health District, the website contains a simple to use bright red link to sign up for the vaccine as well as links to CDC and vaccine information and a link for those interested in volunteering to help with the vaccination effort.

 

The website details who is eligible to be vaccinated – currently Phase 1a (front line healthcare workers and residents at long-term care facilities), and Phase 1b (people 65 yrs. and older and those 18 yrs. and older who have chronic illness; education and child care personnel; employees, teachers and staff in pre-primary, primary and secondary schools; Head Start and Early Head Start programs; and licensed childcare providers). In the first couple of days that the website was live, more than 2,500 people signed up to get vaccinated. For those who cannot register online, they can still call the health district’s Coronavirus Call Center at (936) 630-8500, Monday - Friday from 8AM - 4PM.

 

This website and registration process is the result of many volunteers and organizations in the community coming together to implement what arguably should have been set up earlier. This paper justifiably was concerned about the missteps in preplanning for and coordination and implementation of a hub vaccination effort for Deep East Texas. Recently, however, they were unduly critical of what has essentially been a community volunteer effort to make up for lost ground and get a vaccine registration website up and running. I am grateful for the volunteer partnership that quickly raised a quarter million dollars and organized an army of volunteers to increase our vaccination rates. Sincere thanks are due to the TLL Temple Foundation, Angelina College, the Civic Center staff, and the many volunteers who have gone above and beyond to work with the health district, demonstrating what a community can do when it comes together.

 

So how are we doing with the vaccination effort locally?

 

As of March 9, 2021, 18.4% of the total US population has received at least one shot (23.9% of those age 18 and older). Texas is several percentage points behind the national rate at around 15.2% of the total population. In Angelina County, 12,484 people 16 years and older have received at least one dose (14.4% of total county population, or 18.6% of the eligible adult population). Yes, we are a little behind. The convention center hub is vaccinating 1,200-1,500 people a week. They have capacity to increase that number. With local, regional, and state leadership pressing our case, the hope is that a greater number of vaccine doses will be allocated to our Deep East Texas hub soon. After all, Hardin and Orange counties apparently are allocated so many doses that they have opened their COVID-19 vaccine appointments to anyone.

I have been heartened to read that more and more Americans are willing to get vaccinated. A recent Pew Research survey shows that 69% of the public intends to get the COVID-19 vaccine, or already has, up from 60% in November. This is incredibly encouraging news. About three-quarters agree that a large majority of Americans getting a vaccine for COVID-19 (i.e., achieving herd immunity) would help the US economy. We must keep heading that direction! Just this week, the CDC issued new guidance for those who have been fully vaccinated, including relaxed restrictions on indoor gatherings. There is a light at the end of the COVID-19 tunnel!

 

Regrettably, as David French points out in The Dispatch, “vaccine hesitancy breaks down sharply along partisan and religious lines, and that hesitancy is so profound in white Evangelical communities that it could disrupt the quest for herd immunity.” He notes that Evangelical vaccine hesitancy is both an information problem and a spiritual problem, with White evangelicals being the least likely to say they should consider the health effects on their community when making a decision to be vaccinated. As I have urged many times before, loving our neighbor is the heart of the gospel. For true believers, that love requires – no, demands – action. Two obvious and public actions to love others are mask wearing and getting vaccinated. I have been encouraged by those I know in the faith community who, with few exceptions, are planning to get (or have already gotten) vaccinated. In my estimation, Lufkin has long demonstrated that it is a living, loving community, far more willing to help others than most communities. Let’s hope our final vaccination numbers prove me right!

 

The www.etxcovidvaccine.com website will be an ongoing source of regularly updated information about available vaccines, vaccination locations, and the overall eligibility and registration process. Use the website; it is the easiest, most efficient way to get registered. But if you or your loved one do not have internet access, call (936) 630-8500. Either way, get vaccinated as soon as you are able. Together, we will we protect our community.

Bruised Arms and Bruised Egos – They Will Heal

I have never seen people so grateful to feel flu-like before! Those who have been able to get their COVID-19 vaccinations are happy people. They are proud of their bruised arms and temporary achiness. They walk around with their head a little higher, with a little more spring in their step. It is as if a huge weight has been lifted off their shoulders, even though they still need to be safe.

A sore arm and temporary flu-like symptoms are a small price to pay for extraordinarily effective and safe vaccines. It turns out the Pfizer and Moderna vaccines are virtually 100% effective at preventing hospitalization and death from COVID-19. Out of more than 30,000 trial participants who received either vaccine, only one person became ill enough from COVID-19 to be hospitalized. The Johnson & Johnson vaccine looks to be equally effective at preventing severe illness and hospitalization. For those who have been reluctant to get vaccinated, this excellent news should be quite reassuring.

We are still in the midst of a severe outbreak in Angelina County. As February began, Texas was seeing a 20% decrease in coronavirus cases. However, Angelina County remains in the midst of an “extraordinarily severe outbreak” and at an “extremely high risk” level. Governor Abbott even surged a Department of Defense team to Lufkin to help with our high rate of hospitalizations. Angelina County has had more than 7,350 cases of coronavirus infection since the pandemic began with225 deaths, more than twice the death rate as Texas. Eighty-one of those deaths have been this year.

Unfortunately, most people have yet to get their first shot. They wonder when that day will come for them. The simple fact is, in order to vaccinate more people, we need more vaccine. Much has been made of the delay in getting Lufkin designated as a hub for coronavirus vaccinations, a designation that allows the state to send vaccine in greater numbers than we have been receiving thus far. Our collective frustration arises from the fact that we consider ourselves a healthcare hub for deep East Texas. We have high standards. We know what we can accomplish when we put our mind to it and work together.

Early vaccination efforts were scattershot based on who got vaccine. Each individual entity that received doses – hospitals, clinics like Urgent Doc, the Angelina County & Cities Health District, pharmacies – barely had the manpower to administer the vaccine they were allocated, much less the large volume needed going forward.

As this paper pointed out in last weekend’s frank editorial, we are frustrated that we weren’t one of the first places to be designated a vaccine hub. The hub designation “delay” clarified that communication and cooperation across organizations is an absolute must going forward. Egos have been bruised, not just vaccinated arms. No single person or organization bears all the blame. Lessons have been learned and it is time to move on.

While we were pointing fingers over the hub designation, we overlooked the fact that we are actually vaccinating people at a faster rate than the state and national averages. As of February 4, the day before Lufkin was designated as a vaccine hub, 8.2% of the US population had received at least one shot. Texas was at 7.2%, embarrassingly behind our neighbors New Mexico, Louisiana, Arkansas, and Oklahoma. Yet, 6,384 people in Angelina County had received at least one dose – 9.46% of the eligible population. Even before hub designation, more than 11,000 doses had been shipped to Angelina County since the start of vaccinations. That’s a good start, and a credit to both hospitals, various pharmacies, Urgent Doc, and the health district. But the demand for vaccine is astronomical. Brookshire Brothers – God bless them! – stopped taking names on their vaccination waiting list when an astounding 130,000-plus people had signed up.

Can we do better? Of course. We must. We need to be vaccinating several thousand a week, every week. A fabulous local volunteer effort, organized by Jane Ainsworth and Patricia Jones, will help Sharon Shaw and the Angelina County & Cities Health District get there. Angelina College is organizing staff and student volunteers and offering student nurses to assist with vaccinations. AC’s Krista Brown and Sarah Alvis will help with website and social media marketing efforts once registration and reporting software has been obtained. The TLL Temple Foundation has stepped up to help with that purchase. Rep. Trent Ashby is making sure the state gets more vaccine allocated to us, now that we have hub designation. The more we know, the more we realize this absolutely was going to require everyone’s support. It takes a village to vaccinate a village!

Still, the public needs ongoing information and reassurance. We expect transparent, timely, and reliable pandemic information. The health district, city and county need a designated pandemic spokesperson whose job it is to share facts and educate the public; otherwise, we will be consumed by rumor and fear. What exactly is “the plan” that got us the hub designation? How many are expected to be vaccinated over what period of time? Who goes when? How do people get on “the list” and have confidence that they won’t be forgotten when their appropriate time comes? What are we doing to assure equitable distribution to Black and Hispanic communities and to those who don’t have access to social media and online registration? Tell us, then tell us again; don’t make us beg for information.

I am grateful a more comprehensive vaccination machine is getting ramped up and ready to go, in the end due to the very cooperation, communication, volunteer spirit and get-it-done attitude that make Lufkin and Angelina County a special place to live. We shine as a city and county when we all work together toward common goals for all our citizens. That’s a #LufkinStrong shot in the arm we all need!

All I Want for Christmas

“All I want for Christmas is a new vaccine…” It has a nice, catchy ring to it, don’t you agree? Though several COVID-19 vaccine successes have been announced, thanks to President Trump’s Operation Warp Speed, it is unlikely any of us will get a shot in the arm until after the New Year. For most, the wait will be months longer.

Sometimes the best presents are the ones we have to wait for. As a child, there was a string of years where my main Christmas gift was late, and I would have an IOU under the tree. Probably the most memorable such present was when I was fourteen years old. I was into photography and wanted an SLR camera, but they were expensive and hard to come by – at least in Midland, Texas. There was no internet shopping in 1975! My father had a friend who was going to Japan (where electronics were cheaper) and he was able to get one shipped to us, but it was not going to arrive by Christmas Day. There’s a reason we use the word ‘ship’ when we talk about package delivery, and the ship with my camera on board took six weeks to cross the Pacific. When that camera finally arrived, I definitely could say it was worth the wait!

Now we all wait on a COVID-19 vaccine.

According to the office of Texas Governor Greg Abbott, Texas is ready. The Department of State Health Services (DSHS) developed a Vaccine Distribution Plan and is working with health care providers to enroll in the DSHS Immunization Program to be eligible to administer these vaccines once available. Over 2,500 providers have already enrolled in the program. The Texas Division of Emergency Management (TDEM) is prepared to assist the swift distribution of COVID-19 vaccines and treatments.

I have followed the COVID-19 vaccine development and approval process for months now. I can tell you I will be 100% confident in any vaccines authorized or approved by the Food and Drug Administration (FDA). FDA Commissioner Stephen Hahn has written, “We are committed to expediting the development of COVID-19 vaccines, but not at the expense of sound science and decision making. We will not jeopardize the public’s trust in our science-based, independent review of these or any vaccines. There’s too much at stake.”

As a healthcare worker, theoretically I’m slated to be in an early cohort to get vaccinated. I haven’t heard any local details yet. The job of deciding “who goes first” falls to the DSHS COVID-19 Expert Vaccine Allocation Panel (EVAP). A Guiding Principles document recommended COVID-19 vaccine allocation be based on the following principles: protecting health care workers; protecting frontline workers; protecting vulnerable populations; and mitigating health inequities. The process is to be data-driven, geographically diverse, and transparent. The DSHS document goes on to describe in greater detail who the First and Second Tier health care workers are in Phase 1A. 

It is difficult to argue against prioritizing healthcare workers, first responders, and even residents of long-term care facilities, who have been devastated by COVID-19. Some have expressed concern about nursing home patients being in the first group because they are elderly and may not tolerate the vaccine as well. However, vaccine trial participants have come from all age groups. And though each vaccine is different, the general consensus is that vaccinating older adults against COVID-19 is safe and effective. I was heartened to read recently that the three living former presidents – Bill Clinton (age 74), George W. Bush (age 74), and Barack Obama (age 59) – have said they would be happy to get vaccinated on camera to show that it is safe and to encourage others to get it. As I called for months ago, I hope President Trump (also age 74) is first in line. We need the unified endorsement of politicians across the political divide to encourage a significant majority of people to get vaccinated.

One particular group that should be vaccinated sooner rather than later is our prison population. Texas inmates and staff tested positive for coronavirus at a 490% higher rate than the state’s general population. Eighty percent of people who died in jails from COVID-19 were not convicted of any crime. Tragically, almost 6% of the prison population at Angelina County’s Duncan Unit, a geriatric prison, has died of COVID-19. That’s one out of every 18 inmates dying in the span of five months. If we are truly concerned about vaccine distribution being equitable and just, our prison populations must not be forgotten or ignored.

As a Texas local public health district, the Angelina County & Cities Health District (ACCHD) under the leadership of Sharon Shaw actively participates in all state and federal COVID-19 vaccine calls. They have a task force represented by hospitals, pharmacies, physician clinics, and long-term care facilities to coordinate local logistics and planning efforts for vaccine delivery. The Coronavirus Call Center at (936) 633-6500 continues to take calls regarding COVID-19 testing, quarantine guidance, and, when available, vaccine information.

Despite the catchy Christmas tune, I long ago stopped wishing for two front teeth. But my Christmas wish for a coronavirus vaccine is about to be granted. I just have to wait a little bit longer. Who knows? It may be the best Christmas present ever!

2020 and Coronavirus Fatigue

I’m tired. I’m tired of 2020 and COVID-19. 2020 has certainly been full of meme-worthy events, but the pandemic has loomed over them all. I vacillate between exasperation and calling people out for not wearing masks, on the one hand, and resignation on the other. Anger? Depression? Mostly, I’m just tired. 

I worry about friends who have had or will catch COVID-19. I grieve for those who have lost friends or relatives to the disease. I wonder if – no, when – I (or a family member) will catch it, and how severe the illness will be. I think we all suffer from a sense of impending doom.

I’m tired of trying to figure out why some people think they have a right to endanger others by not wearing a mask or social distancing. Would they also get drunk and drive? This selfish hubris is bald hypocrisy when practiced by those who conflate Christianity and partisan politics, whose insistence on personal rights and worship of Trump evidently are more important than loving their neighbor. (See there? I am getting angry again.)

And now that Trump has COVID-19, the politicization of mask wearing by some on the right has been countered with a celebratory “I-told-you-so” attitude by some on the left. As one observer said, referring to all the warnings about how cavalier the Trump White House has been about masks and social distancing, “There is no joy in being right.” My private prediction that Trump – if he got out of the hospital fairly quickly – would turn around and say, ‘See? This coronavirus isn’t that bad!’ came true. I do hope and pray he continues to a full recovery. But I am so very tired of the scientific community having to clean up after Trump’s ignorant and dangerous medical beliefs and statements.

Elisabeth Kübler-Ross famously described five stages of grief that terminally ill patients experience when faced with their impending death. These stages – denial, anger, bargaining, depression, and acceptance – have since been used to describe our emotional processing of any loss or tragedy. Or, in the case of 2020, an entire year. Kübler-Ross’s stages do not have to be experienced in the commonly stated order. And those stages, it seems to me, can be seen in our national narrative and psyche as well, not just our individual lives. The United States is reeling from successive, seemingly unrelenting blows (hurricanes, wildfires, protests, murder hornets, the pandemic, etc.), staggering between anger and depression – as I have been personally – or grasping at national denial and bargaining, depending on the day. 

My wife tells me how homesick she is for the life pre-pandemic. I find myself overeating as an escape from the relentless bad news cycle. I can tell I’m not sleeping as well, either. Are you tired as well? How are you handling 2020? We all need to be mindful of how we handle stress and depression. Relying on alcohol, marijuana, or other drugs is not appropriate coping, yet drug and alcohol use are on the rise. Mental health and alcohol and drug abuse organizations – Burke and the Alcohol and Drug Abuse Council of Deep East Texas (ADAC), for example – are here to help. Don’t let yourself spiral out of control. If you are having a mental health emergency, call Burke’s 24-hour crisis line at 1 (800) 392-8343. For ADAC services, call 1 (800) 445-8562 or (936) 634-5753 to schedule an appointment.

Regardless of the sequence or magnitude of the stages of grief, the goal for resolution and healing – individually as well as nationally – must be some movement toward acceptance. In the case of the pandemic, that acceptance ideally should include an acknowledgement of the reality and severity of the illness and the need for at least a basic individual and communal response (hand washing, masks, social distancing), even if we don’t always agree on broader, more complex issues, like how and when the economy or the schools should open up. We must accept that the scientific community is not out to derail the presidency; rather, to save lives.

2020 will come to an end. On December 31 at midnight, we will sing Auld Lang Syne and gratefully close the book on the year. Not so fast with the pandemic. A safe and effective vaccine may still be a ways off. Though we are all tired (and occasionally angry or depressed), we cannot let down our guard as individuals or as a society. Let’s move beyond denial, anger, bargaining and depression and toward acceptance, including acceptance of and care for each other. We have so many strengths as community, and we need each other now more than ever. Together, we can do this. The ancient prophet Isaiah could have written for today: we must renew our strength, to run and not grow weary, to walk and not be faint. And while we are at it, let’s not forget to love our neighbor as ourselves.

Will a Coronavirus Vaccine Be the Answer?

The novel coronavirus has changed our lives. Just about everything we do is affected by mask-wearing and social distancing. The economy has been reeling, although you wouldn’t know it by looking at the stock market. There have been more than 6 million cases in the US and closing in on 200,000 deaths so far. Thankfully, scientific knowledge around coronavirus is expanding at an unprecedented pace. Everyone is looking for a silver bullet against coronavirus. Many hope a vaccine will be that bullet.

Development of a coronavirus vaccine is an urgent priority of the federal government. Since its inception in May, Operation Warp Speed – the collaborative effort between the U.S. Department of Health and Human Services (HHS) and pharmaceutical companies to develop and produce hundreds of millions of doses of coronavirus vaccines – has helped identify well over one hundred vaccine candidates and implement dozens of trials. Nine vaccines are in large scale phase 3 trials. Projections of when a vaccine will be available have ranged from October (per President Trump in the early days of the vaccine development) to the end of 2020 or, more likely, early 2021, according to recent comments by Dr. Anthony Fauci, Director of the National Institutes of Health’s National Institute of Allergy and Infectious Disease. Dr. Fauci seriously doubts we will have to rely on an international vaccine (think Russia or China), having openly criticized the Russian President Vladimir Putin-promoted effort as “bogus”.

Obviously, the sooner we have a vaccine, the better. The Centers for Disease Control and Prevention (CDC) is calling on states to have vaccine distribution sites fully operational by November 1, a gargantuan task. That does not mean a vaccine will be delivered on November 1. We need to temper our expectations of what will happen – and how quickly – once a vaccine becomes available.

The goal of any vaccination campaign is “herd” (community) immunity, where a sufficient proportion of a population is immune to make disease spread from person to person unlikely. In general, 60% or more of a community or population needs to have either had a particular infectious disease or be vaccinated against it in order to provide sufficient community immunity. Sounds easy enough.

According to the Centers for Disease Control and Prevention (CDC), only 45.3% of adults got a flu vaccination for the 2018-2019 season, ranging from a low of 33.9% in Nevada to only 56.3% in Rhode Island. Twenty percent of Americans already say they will refuse to get a COVID-19 vaccine, and with another 31 percent unsure, reaching herd immunity could be that much more difficult. On a cautiously optimistic note, there is some speculation that the herd immunity level with the COVID-19 coronavirus might be as low as 43%. That shouldn’t make us think twice about getting vaccinated, however, especially when that vaccine will be effectively free and, if all goes as promised, readily available. The more the merrier, when it comes to people getting vaccinated.

I do worry how long it will take to get 300 million doses of a vaccine delivered and administered in our communities. In the 2009 H1N1 pandemic (caused by a more seasonal flu virus than the novel coronavirus), vaccine doses were first distributed to state and local health departments and then further out to mass clinics, employers, schools, hospitals, pharmacies, and doctor’s offices. Even so, only about a quarter of all Americans got vaccinated before the pandemic played out. The coronavirus vaccination effort will have to be larger and faster, and this pandemic is not expected to fizzle like a flu season does. (We already know that optimistic predictions of a summer lull did not happen.) All that is to say, it may be awhile before we reach herd immunity.

There are other logistical uncertainties as well. Will the vaccine require cold storage? (Probably.) Will a single dose be effective? (Probably not.) How will distribution and dosing be prioritized? (Health care workers? Elderly? Racial disparities?) With so many vaccines in development, “the first” vaccine may not be “the best” vaccine for the long run. I would still take it… and whatever follows as well, if that is what is recommended by the medical experts.

Politics continues to tussle with Science, most recently in the “breakthrough” announced from the White House regarding convalescent plasma as a COVID-19 treatment. FDA Commissioner Stephen Hahn sheepishly had to backtrack misleading comments made about convalescent plasma therapy while defending against Trump’s accusations that the “deep state” at the FDA was making it hard for drug companies to test coronavirus treatments. Thankfully, Politics is funding Science to an incredible extent during this pandemic. I suppose in any dance one partner may step on the other’s toes on occasion. As long as the dance continues, we have hope.

While we wait on a coronavirus vaccine, we should stay current with other vaccinations and definitely get the flu shot this fall. There is some speculation that vaccinations might help “train” or boost our overall immune system. Who knows? And we need to continue to slow the spread of coronavirus by wearing masks (mouth AND nose, please), washing our hands, and social distancing. Remember, this is a community effort.

One final thought. When a coronavirus vaccine does become available – one that is determined to be safe and effective – I would like to see President Trump, Speaker of the House Nancy Pelosi, and other major political and scientific leaders hold a news conference and all get vaccinated together on live television. Lead by bipartisan example! What better way to reassure the public and encourage all of us to follow suit. A vaccine may or may not be a silver bullet, but I am hopeful one (or more) will be a great tool in the fight. 

Coronavirus Information and Misinformation

As a physician, I have been fascinated by the rapid acquisition of knowledge about the novel coronavirus and the deadly disease it causes, COVID-19. True, that knowledge may not be coming as fast as we like. But the pace of vaccine development, for example, is remarkable. But along with knowledge come ignorance, misinformation, and deception.

First, a bit of ignorance. At a rally in Phoenix, in June, President Trump fired up his audience with anti-China rhetoric. In doing so, he displayed his lack of understanding of how COVID-19 got its name. “I said, ‘What’s the 19?’” Trump said. “COVID-19, some people can’t explain what the 19, give me, COVID-19, I said, ‘That’s an odd name.’” Trump apparently thought names like kung flu, Wuhan virus, and Chinese flu were more appropriate.

We can all be forgiven for not knowing something like how COVID-19 got its technical (and not intuitively obvious) name. First, the virus that causes COVID-19 is the novel (meaning new) coronavirus SARS-CoV-2, which stands for severe acute respiratory syndrome coronavirus 2. The first coronavirus caused an outbreak of SARS in the early 2000s. This new coronavirus appeared in 2019; hence, the disease it causes, COVID-19 – CO for corona, VI for virus, D for disease – carries the number 19 for the year it started (2019), not because it is the nineteenth disease (it is not). There’s your – and Trump’s – science lesson for the day.

On to misinformation and deception. Some misinformation is due to inaccurate information. For example, this paper published that while the number of COVID-19 cases has exploded in Texas nursing homes last month, Angelina County is bucking that trend. That turned out to be based on either inaccurate or delayed information, as local physicians are aware of many local nursing home cases. The paper has updated the story as more information has come available. What is certain, however, is that our case count continues to rise.

Lack of information or incomplete information is different from deception. I have written previously about the importance of wearing masks. But mask wearing took another hit recently when our own Congressman Louie Gohmert (TX-01) not only caught coronavirus, he released a video suggesting it was the mask that gave it to him. In his own self-deception, he believes he wears a mask often, but many eyewitnesses (not to mention ever-present news media) suggest otherwise. Gohmert loves history, but history will not be on his side on this one. Deception to support a false narrative is no different than writing history to support a political agenda. Our country has seen too much of that.

When it comes to treatment, President Trump famously has advocated for unproven therapies, from bleach to the anti-malaria hydroxychloroquine. Regarding hydroxychloroquine, the results are in. With strong data that hydroxychloroquine is not effective either as therapy or as postexposure prophylaxis, the Food and Drug Administration (FDA) recently revoked its Emergency Use Authorization, saying it is “unlikely to be effective in treating COVID-19” and that “in light of ongoing serious cardiac adverse events and other serious side effects, the known and potential benefits … no longer outweigh the known and potential risks” for authorized use. Our national coronavirus guru, Dr. Anthony Fauci, minced no words in saying, "The overwhelming prevailing clinical trials that have looked at the efficacy of hydroxychloroquine have indicated that it is not effective in coronavirus disease.” 

This has not stopped President Trump from practically practicing medicine without a license. 

Trump literally is the most famous and influential person in the world. He is not alone in equating personal or anecdotal experience (I did X and Y didn’t happen; therefore, X prevented Y) with rigorous scientific study. My patients do it all the time. However, they do not have an international bully pulpit. His hubris throughout the pandemic in suggesting treatments (like bleach) is jaw-droppingly astounding. (Bleach works on your countertop, right? Why wouldn’t it work inside your body?) Not only is his medical advice suspect at a minimum, it has been dangerous. And just this last week, Trump had his election campaign Twitter account temporarily blocked and a Facebook post deleted when he posted that children are “almost immune from this disease.” When it comes to your health, listen to the doctors.

But don’t listen to quacks, especially those with pseudo-religious and anti-scientific claims. The bleach treatment claim (touted by a family of swindlers who formed a “church” in Florida) falls into that category. But the icing on the cake – so far – has to go to a true charlatan, Dr. Stella Immanuel, a Houston physician of questionable medical training and even more dubious religious authority. She famously believes in alien DNA, demon sperm and that the government is run in part not by humans but by “reptilians” and other aliens. That didn’t stop Donald Trump Jr. declared a video of hers a “must watch,” while President Trump himself retweeted the video.

Unfortunately, attempts to set the record straight regarding coronavirus misinformation by referencing scientific data are considered by far too many to be “fake news” or viewed as a conspiracy theory. Just look at Facebook for examples. I implore you to use this information for how it is intended. Educate yourself on the facts of coronavirus. There is much we don’t yet know, of course. And the vast majority of us – anti-vaxxers excepted – eagerly await a vaccine. In the meantime, please DO wear your mask – over both your mouth AND nose, please! – and DO social distance. DO use hand sanitizer or soap and water often. Together – caring for each other – we can get through this. 

Pandemics and Personal Responsibility

We have been dealing with the COVID-19 pandemic for many months now. What an emotional roller coaster ride it has been. Early thoughts of “flattening the curve” have not panned out in Texas. In Angelina County, there has been a steady rise in cases since early April.  From a healthcare standpoint, much has been written of the way the virus – as if it had a mind of its own – discriminates against minority populations. Of course, the virus itself is colorblind. However, many of the social and economic factors that affect health are not.

The Economist, in a column titled Black America in peril , quotes WEB DuBois, an African American sociologist, who said that the “most difficult social problem in the matter of Negro health” was that so few white Americans were bothered by it. He wrote that in 1899. This “indifference” to human suffering continues today and is perpetuated by a broken procedure-oriented, insurance-driven system of healthcare that is vastly too expensive for everyone, not just those without insurance. The answer is not so simplistic as providing insurance coverage for everyone (although expanding Medicaid coverage is Texas would have significant positive health and economic benefits for the state).

In the United States, these health inequities extend beyond racial classification. The attainment and maintenance of health is a multifactorial and heavily socioeconomic phenomenon.  Enter COVID-19, the illness caused by the novel coronavirus. Once again, we see higher death rates in vulnerable populations. In the middle of a pandemic, we are not going to solve systemic inequities in healthcare.

But that does not mean we are helpless.

Ironically, the most effective prevention intervention – wearing masks – has become one of the most political, with some rights-obsessed conservatives (who presumably wear seatbelts in their cars) selfishly preferring to risk harming others rather than donning a minimally irritating face covering. Why is it that those shouting “personal rights and responsibility” from the rooftops are the ones rejecting the singularly individual action that can save lives?

In a recent interview, Dr. Francis Collins, director of the National Institutes of Health and former head of the Human Genome Project (and, incidentally, a committed Christian, which should be of some comfort to those who are inclined to conflate religious and political viewpoints), was asked, “As someone who is both an acclaimed scientist and a public Christian, what’s your perspective on the pandemic as a cultural issue?” His reply is both compassionate and pragmatic. “Your chance of spreading the coronavirus to a vulnerable person has nothing to do with what culture you come from or what political party you belong to. Your responsibility is to try to prevent that from happening to vulnerable people around you. But our country’s polarization is so extreme that it even seems to extend into a place like this — where it absolutely doesn’t belong. That is really troubling because it’s putting people at risk who shouldn’t be.” 

In times of great social and political upheaval, we can become despondent and feel there is nothing we as individuals can do to fix anything. (Frankly, we put too much hope in elections.) It just so happens that in the middle of this coronavirus pandemic it is exactly individual action that is going to make all the difference. Whatever your personal ethical or religious motivation, we can all follow the Golden Rule. We can follow the command of Jesus – “Love your neighbor as yourself.”  – who undoubtedly would be wearing a mask right now. Go and do likewise. Do it for the least of these. Wear your masks. Save lives.

Finding a New Normal with Coronavirus

We have been self-distancing through the COVID-19 pandemic for a few months now. What a wild ride it has been! Despite the number infected – over 1.25 million – and more than 75,000 deaths, many still question the legitimacy of the extraordinary measures that shut down our economy. Uninformed proclamations comparing COVID-19 to the seasonal flu are an affront to anyone who has been sickened or died from this disease. The average length of stay of those hospitalized (especially those requiring ICU care and ventilator support), not to mention the number of deaths, is far greater than with the flu.

Still, should we have shut down the economy? Professors at the Kellogg School of Management at Northwestern University called it a “brutal trade-off: inducing massive economic suffering in order to save human lives.”  Their research concludes that not closing the economy ultimately would be much costlier to society, potentially tens of trillions of dollars in addition to major loss of life. Consider it a “damned if you do; damned if you don’t” choice. I am grateful we chose to flatten the curve and save lives.

How do we recover from this mess? Many states are starting to loosen restrictive measures to reopen our economy. Trillions of dollars have been designated for businesses and individual taxpayers. That will help ease some of the financial suffering. But, we have paid a collective price psychologically as well.

The unpredictable factor in this recovery is going to be people. What are we willing to do when we emerge from isolation? Some never really changed their behavior to begin with. For those who did take the pandemic seriously – and still do – it is not as easy as flipping a switch and going back to a pre-coronavirus routine. Predictions for a rapid economic boom assume we will all be hitting the malls and restaurants as if nothing ever happened.

Me? I think I have PCSD – Post Coronavirus Stress Disorder. My habits have changed. My sense of personal space and need for barriers is heightened. I avoid people. It will take me months or longer before I go back into a store and don’t wonder whose germy fingers have been on everything. Interacting with strangers – or even friends I haven’t seen in a while – has a more dangerous feel to it. Consciously or not, we are figuring out what our personal risk tolerance is. Are there too many people in that store? Are the employees at that restaurant being careful enough? We decide with our feet and our pocketbooks.

Some will emerge sooner and more confidently than others. Peggy Noonan, columnist for the Wall Street Journal, called for patience and grace when other people are moving faster or slower in the recovery process than perhaps we think they should. “What will hurt us is secretly rooting for disaster for those who don’t share our priors.”  In the church, we refer in jest to some theological differences as “non-salvation issues” over which we can agree to disagree. As we emerge from our coronavirus self-isolation, we should respect that not everyone will be either as cautious or as cavalier as we may be. Extend grace.

The ideal conditions for me personally to feel truly comfortable again would be a) I have been infected (and recovered), and am proven immune, or b) I have been vaccinated. Only then will I regain my more nonchalant attitude toward life. Either of these conditions is imperfect assurance; only time and testing – and good science – will provide clarity on the true COVID-19 status of any of us.

In the meantime, I will continue my new habits (obsessions, really): self-distancing and cleanliness. I will avoid crowds for the foreseeable future. When I attend church services – at least in the beginning – I am at a minimum going to mask myself on entering and exiting, if not the entire service. The last thing I want is to be an undiagnosed carrier who infects an elderly or at-risk fellow church member. In public, I carry disinfectant wipes for use in the grocery store, at the gas pump, etc. Finally, I wash my hands. No, I really scrub them. Lots of bubbles all around. Often. (Admittedly, I still have trouble not touching my face.)

One more thing. Once we have a vaccine, we cannot let the anti-vaxxers and conspiracy theorists have their way. Legislators must remove conscientious and religious exemptions from vaccination requirements.

Eventually – hopefully next year sometime – enough of us will have recovered or been immunized and life truly can return to the pre-coronavirus routine… at least until the next pandemic comes along. Please, can we wait another century for that?

What If We Don’t Flatten the COVID-19 Curve?

On April 5, 2020, US Surgeon General Jerome Adams said, “The next week is going to be our Pearl Harbor moment. It’s going to be our 9/11 moment.” The same day Dr. Anthony Fauci, arguably our most trusted spokesperson during this coronavirus crisis, said, “We’ve got to get through this week that is coming up because it is going to be a bad week.” One oft-cited set of projections showed deaths from COVID-19, the illness caused by the novel coronavirus, and resource use (including ICU beds and ventilators) were expected to peak this weekend. That all of this is happening during Easter and Passover only adds to the sorrow.

For those of us in Texas, the wait to peak is a bit longer. Estimates a week ago were for peak resource use on May 6, 2020, but that prediction has now moved up to April 22, with peak in daily deaths on April 24. Texas appears to be flattening the curve. In Angelina County, we have 16 confirmed cases of COVID-19 as of April 9, but only 283 people have been tested so far. We can only hope that the wise and early decisions by our local elected officials, including the Stay Home – Stay Safe order, will have flattened our curve enough to avoid the healthcare crisis experienced in New York, New Orleans, and other cities.

But what if our hopes are unfounded? What if we get a surge of COVID-19 cases beyond what our healthcare system can handle? In New York City, some COVID-19 victims could be temporarily buried in mass graves in a park, as morgues don’t have the capacity to handle the mounting casualties.

Thankfully, doctors across the nation have been giving much thought to this grim prospect. After the 2003 SARS outbreak, North Texas physicians came together to answer that very question: What would they do if a really big pandemic hits and hospitals are overwhelmed? The result was the formation of the North Texas Mass Critical Care Council. The council established that during a time of crisis, the ethical, moral, and medical approach should be that “access to treatment would be based upon the patient’s ability to benefit from it, using objective physiologic criteria.” In other words, medical evidence – rather than insurance status, social standing, what have you – would guide decision-making about which patients are most likely to benefit from ICU interventions when there are not enough ICU beds or ventilators for every patient. The goal – as it should be in any medical crisis – is to save “as many lives as possible.”

In a similar fashion, CommonSpirit Health, the Catholic health system that is the second-largest nonprofit hospital chain in the US (and the parent of CHI St. Luke’s Health Memorial Lufkin), developed Crisis Response Guidelines for Hospital and ICU Triage Allocation. These guidelines are not based on opinion or guesswork. The many criteria used to prioritize who would benefit from ICU and ventilator support are validated in the medical literature and have been compiled to arrive at a robust sequential organ failure assessment (SOFA) score, based on the degree of dysfunction or failure of the heart, lungs, liver, kidneys, brain, and blood system. This SOFA assessment, well known to emergency and intensive care specialists, is used routinely to predict mortality in any critically ill patient.

Based on SOFA scores and other medical criteria, doctors might determine that an elderly patient with COVID-19 whose organs are functioning well is more likely to recover using a hospital ventilator than a young patient with multiple organs shutting down from the virus, but the decision would be based entirely on whether the treatment is likely to help the patient recover. Doctors are expressly prohibited from considering social status, money or other nonmedical criteria when making these decisions. The last thing doctors want to be accused of is indiscriminately playing God.

A recent Wall Street Journal opinion implied that merely considering apocalyptic scenarios would lead to legalizing euthanasia, and that not having guidelines (and thereby wasting resources on those that would not benefit) was morally superior to sound medical decision making. Texas Health and Safety Code §166.009 acknowledges that sometimes difficult choices have to be made and states that provision of life-sustaining treatment is not required if it “cannot be provided to a patient without denying the same treatment to another patient.” There is a larger problem of futile care in this country that did not start with the coronavirus pandemic and it won’t end once this virus is under control.

Crisis guidelines are not written to decide who lives and who dies; they help direct the most aggressive care to those who are most likely to benefit so that the most lives can be saved. Regardless, all patients are to be treated with dignity and receive appropriate and compassionate care. If I, as a physician and community leader, have little to no chance of survival if placed on a ventilator – based on solid medical criteria – but an illegal immigrant (for example) has a good chance of survival, guess who gets the ventilator? Not me. And that is the way it should be.

We must continue to follow the social distancing recommendations of our city, county, and health district leaders in order to minimize the impact of the coronavirus locally. We can do this – we ARE doing this. As the Lufkin/Angelina County Chamber of Commerce is encouraging us, we are #BetterTogether and #AngelinaStrong.

End-of-Life Implications of the Coronavirus Pandemic

We are early in this coronavirus game of social distancing and hand washing. We haven’t quite become weary of it. We joke about it. And yet, I am starting to see – among my friends – some very real concern about our elder parents and grandparents. But we don’t allow ourselves to linger on those thoughts much. We should.

The United States has been accused of being late to respond to the coronavirus pandemic, late to test our US population compared to other countries (South Korea, for example), and “doomed” in our response. Even so, we are just beginning the initial rise of the now well-known bell curve of the Coronavirus Disease 2019 (COVID-19) pandemic. Known cases are doubling every day, it seems. Deaths are increasing as well.

As a cancer physician with additional hospice and palliative medicine (end-of-life care) certification, I view the coronavirus pandemic with increasingly darkened lenses. Coronavirus is a new and immediate threat to life, and we are not ready for what that means. If we don’t succeed in slowing the spread of coronavirus and suppressing new cases – now widely known as flattening the curve – 2.2 million people in the US could die. We are not talking openly – publicly –about how we are going to handle this massive number of deaths with COVID-19.

If the coronavirus epidemic is as bad as some predict it will be, discussions about end-of-life care with this disease will soon become front and center. There may not be enough ventilators for everyone who “needs” ventilator support. Italy has been forced to triage sick coronavirus patients based on age, given that the death rate among the elderly is so high. Italian doctors have admitted that there were simply too many patients for each one of them to receive adequate care. They describe a “tsunami” of patients and a more than 7% death rate (though researchers have lowered the calculated death rate in Wuhan, where the pandemic started, to 1.4%). Preliminary outcomes of patients with COVID-19 in the US show death is highest in persons aged ≥85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65–84 years.

The Italian society of anesthesiologists issued fifteen recommendations of ethical and medical criteria to consider if ICU beds are exhausted, saying doctors may have to adopt more wartime triage criteria of gauging who has the best chance of survival versus “first come, first served.” Those who are chronically ill with pre-existing lung disease, even if they survive a serious coronavirus infection, are likely to be left with even further reduced lung function and poorer quality of life.

Unlike a localized disaster – most memorably Hurricane Katrina, in New Orleans in 2005, where healthcare decision-making received intense scrutiny and prompted legal action – we are experiencing a global, acute healthcare emergency that may require historic moral and ethical decisions that impact who lives and who dies. We will be rationing healthcare on the fly. Are we ready for that? As family members? As a community? As a nation? Are our hospices ready for the number of patients needing immediate, short-duration, and contagion-related end-of-life care?
Perhaps the most terrifying aspect of the coronavirus epidemic in countries where death has become frighteningly common is the loneliness of the death. Hospitals in the US are already limiting or even forbidding visitors. In Italy, seriously ill coronavirus patients are isolated from family and often die alone. Families are not allowed to have a proper burial, and not just due to restrictions on gathering – morgues have an enormous backlog to work through. That is certainly not what we would call a “good death” and not what those of us in the hospice care field want for any patient.

Trump has labeled himself a wartime president, declaring we are at war with an invisible enemy. "Now it's our time. We must sacrifice together, because we are all in this together, and we will come through together," he said. What is not stated – and what I am afraid will happen – is the wartime sacrifice analogy will extend to real lives lost. In an ironic twist of fate, it very well may be that the remnants of the Greatest Generation are once again on the front lines. Even down to the Baby Boomers, our nation’s elders will bear the brunt of the coronavirus disease, certainly, but likely the financial catastrophe surrounding the pandemic as well. (I wonder if the economic collapse will kill as many or more people than coronavirus does.)

The time is now to have discussions with our older/elderly parents and grandparents about the very real risk of serious illness and death from COVID-19. Wills need to be written and advance directives and durable powers of attorney completed now – before our loved ones hit the hospitals. This is not morbid; it is both pragmatic and necessary. If we emerge from this battle relatively unscathed, we are no worse off for having had the discussions and done the planning. Patients and families should be driving end-of-life care decisions. We owe it to our hospitals and healthcare workers not to overburden the system with trying to care for those who neither want nor would benefit from aggressive measures.