This article, edited, appeared in The American Thinker on May 16th, 2023

Several weeks ago, on my way to lunch, I stopped at the testing facility in our hospital for my weekly COVID test. This has been a requirement of my employment for at least the last year and a half after I refused vaccination.  The pretty young woman that has been assisting me, collected my sample. She then informed me that the testing facility was closing for good later today.  Subsequently, the hospital administration minimized the requirements for masking within the facility. With these developments, it felt as though the COVID debacle had finally ended.

Reflecting on this, I think back over the 3+ years and cannot escape the profound effect it has had on my life both during the pandemic and now afterward. I have seen death, certainly particularly in older patients and those with comorbid problems. But I have also seen fear and anxiety as a catalyst of social change, and generally not for the good. I have seen factionalism develop over differences in one’s level of vigilance and concern over the disease burden, and later about attitudes towards treatment and vaccination.

I lost friendships. In the beginning it was over the fear of being in contact with me as a caregiver for these patients. Later it was because I invoked natural immunity, and avoided vaccination. I endured their ridicule and even anger about my quaint notions of viral immunity, ideas that would have seemed completely rational, 2 years before.

Now things are changing. Very quietly I think people have grown to accept the notion that this virus was born in the Wuhan lab. It became clear that the draconian lockdowns were of little help, and left a lot of economic, social, and educational damage. They are finally beginning to understand that natural immunity, though not perfect, is likely to be more durable than that provoked by “boosters”.

It is also beginning to sink in, that the vaccines, were untested, minimally helpful and are likely to an extent unsafe, especially for the young. The lack of acceptance of the new bivalent injection I think confirms a new public wariness. Likewise, there has been a pronounced lack of enthusiasm for pediatric inoculation.

But for me, there have been much broader revelations.

As a physician in my 40th year of practice, the events of the past several years have had a profound effect on the way I think of the care I have been rendering.

The CDC, and NIH, manipulated the government, and the willing press, into supporting incredibly corrupt behavior. Prestigious medical journals, such as the Lancet, suspended their usual stringent review processes to publish fraudulent data. The regulatory agencies, and Pharma, acting in concert, punished non-doctrinaire opinions. They manipulated our academic institutions by the issuance and withholding of grant money. Leaders such as the beloved Dr. Fauci promoted phony letters to the editor decrying the lab leak origin story. This was done to protect the NIH and its likely illegal contributions to the Wuhan Institute of Virology for gain-of-function research.

Because of all of this, I looked back and wondered about my entire career. Was everything a lie? Were there medications, perfectly adequate, that I was convinced to discontinue in favor of new patented and expensive medications, with less well-understood safety profiles? How many of the other articles that I had read over the years were corrupt documents, meant to bolster the profits of the pharmaceutical industry? Just how badly have I been manipulated?

As a physician, particularly at my age, I have tried hard to remain current with my specialty. But how much of the latest information I absorbed served only to support the lucrative relationship between academic medicine and their sponsors at the pharmaceutical companies.

I never meant to bring too much drama to this pandemic, which I was fairly sure, even early on, would not be as severe as the doomsayers predicted. But I failed to anticipate the more profound interpersonal, economic, and professional impacts it would have on my life and that of others.

There is a punch line here. Despite being completely asymptomatic, and despite the fact, that months ago, the CDC declared random testing to be useless my last test was… positive.

Feels like a fitting end for this nonsense…at least for now.

I would be honored if you shared this.

Header image: After the Fire (Fujifilm X100V)

This was originally published in The American Thinker on January 12th,2022. It has been slightly edited from that article

We are now officially entering the third year of the Wuhan surprise. We are experiencing a brand-new SARS co-V2 variant, Omicron, which is sweeping through the population like a lot of nasty winter respiratory infections. Except that we test for it. And we know its name. 

As of early January, the Omicron makes up roughly 95% of cases in the Northeast (CDC data). In my state of Pennsylvania, for instance, our peak case numbers were triple what they were last December. Our hospital, and ICU occupancy so far however is slightly lower than last year, attesting to the more benign nature of this particular bug. 

I was looking through the hospitalization data, on the Johns Hopkins site.  As a former critical care specialist, two things are curious to me. Number one is that the total number of ICU beds in the country has fallen from 91,000 in January 2021 to 80,000 now. I’m sure that a portion of that decrease is due to acute illness of ICU personnel, given Omicron’s infectivity, and vaccine avoidance. I do wonder however how many of those beds were lost due to the firing of ICU staff due to their vaccines status. 

The second strange data point is that in the US as a whole or Pennsylvania in particular, there are said to be roughly 20% of ICU beds unoccupied. In my experience over the years, intensive care units tend to be full, and we accept new admissions only by transferring out the least ill. If I was running a 20 bed ICU and had 4 open beds, I’d be feeling pretty comfortable. Maybe this data is wrong, but if it’s not, this is hardly a crisis. 

As of January 2022, a majority of the population has been coerced into multiple inoculations, with spike protein-producing mRNA. Despite this, we are seeing record numbers. How could this be? 

Data from Britain suggest that roughly 50% of coronavirus patients in the hospital, were admitted for something else. In the United States, those numbers fall between 30% and 60% depending on the locale. In our hospital, there has been an obvious reduction in acuity for patients that carry the Covid diagnosis, given the benign characteristics of Omicron. 

It has become rather clear that natural immunity and/or vaccination/booster status are irrelevant in the current surge. In fact, in the case of vaccination, there is data from Iceland and Denmark suggesting that the population most prone to Omicron are those who have had the full original course of the vaccine. Here’s the data from Iceland, where the population is 91% fully vaccinated. If you look at infections per 100,000 people based on vaccine status, the fully vaccinated, have the highest prevalence of infection. Now in the same data set, it’s clear that the vaccinated have less severe disease, which we have been saying for some time, In the case of Omicron, for most people, that point is moot, given the mild nature of the syndrome. 

Again I say, if you’re interested in being vaccinated or boosted, that’s your choice. But given Omicron’s obvious vaccine resistance ( which is likely to persist in future variants), the strategy of forcing a monovalent vaccine on the population during a pandemic has clearly failed. 

Data out of Israel suggests efforts there with a fourth Pfizer booster have been ineffective in preventing the spread of Omicron.

In my circles over the last month, I’ve had a fairly large group of friends and acquaintances, who have been infected. These include the vaxed and boosted, the group formerly known as fully vaccinated, the unvaccinated, and those like me with natural immunity. All of us, at a variety of ages, have had a roughly 3 to 4 day viral upper respiratory syndrome, of little consequence. I know from my practice, that this is also being seen more broadly in the community. 

Another thing I have noticed is that given their cold-like illness, people that suspect they have omicron are reluctant to be tested, so as not to be inconvenienced by having to isolate. This may be contributing to spread, but also signals a change in attitude towards this illness among many people. 

In a sensible world, given this data, public health officials would quietly back away from the insistence on mass inoculation, and begin to feature therapeutics in their approach to Covid. I wouldn’t actually expect them to admit failure, but perhaps only to change their emphasis. Instead, they are doubling down. 

In my former life as a doctrinaire practitioner, I would’ve been loath to consider the wild claims of medical conspiracy theorists. Some talk about the vaccine containing graphene, and other nanoparticles meant to monitor and control. I certainly don’t believe in these theories. But the escalating efforts to penalize the unvaccinated by their governments seem so irrational, that it is not unreasonable to wonder: what the hell is going on? 

Why insist, that an increasingly ineffective immunization be given again and again, at shorter intervals, to the entire human population, including children who tend not to be severely affected? And how can we force injections with products that are still officially investigational, and not FDA approved? And why, as these vaccines have the highest rate of adverse effects by far, according to the CDC’s VAERS data, do we insist? And by firing reluctant healthcare workers, who have a fairly high rate of vaccine hesitancy (I wonder why?), we are stripping the healthcare system of talent we now claim to desperately need. 

None of this passes any test of common sense. More and more I think people are beginning to realize this, and are growing skeptical. Even elements of the press are starting to ask questions like: “how many more boosters will we be expected to take?”  

There is an alternate way, as shown by countries as diverse as India, Mexico, and Japan. We need to encourage early treatment, with cheap safe, and proven antiviral therapy such as hydroxychloroquine and Ivermectin, in protocols that have already been developed. Pfizers new drug Paxlovid may be useful if further studies confirm safety and efficacy. If people wish to be vaccinated, fine, but only with products approved for use by the FDA (Pfizer’s Comirnaty). This would mean patients would have legal recourse if they were to suffer a devastating side effect. 

We have a right to expect competency, not corruption from our public health officials. 

Seems to me, they have been a big disappointment.  

As always, I’d be honored if you’d share

It is been a year and 11 months since the happy little packet of spike proteins and mRNA arrived in our country courtesy of Dr. Fauci and the Chinese Communist Party.

So here’s a little schadenfreude for my naysayers: yesterday, I was diagnosed with what I suspect is Omicron. In my case, it started with very subtle bronchitic symptoms at the end of the day on Tuesday. Walking out to my car from work, I suddenly felt an unexpected sense of fatigue for that time of day. Suspicious, I went straight home, and grabbed a home test kit. That first test was negative.

Overnight I felt chilled and achy but took some Naprosyn which improved my symptoms. The next morning I retested and was unequivocally positive.

Since then, my main symptoms have been that of a rather annoying viral respiratory infection. There is some fatigue, a modest cough, but a lot of upper respiratory congestion and sneezing. Yesterday, at least in the morning, the symptoms might have prompted me to call off work (as if I weren’t busy) even without the quarantine requirements of Covid-19. Today I feel better. Symptomatically I would’ve gone back to work, albeit with a little self-pity.

Unfortunately, this is SARS CO-V2. The 10 day period of isolation will encompass Christmas, and disrupt plans to gather with family, and otherwise socialize. This arbitrary number is annoying given that I can easily retest when I become asymptomatic and prove I’m not shedding virus.

In my case, I can see why this variant spreads so efficiently. Omicron infects preferentially the tracheobronchial tree, versus the alveoli (lung tissue) in earlier viruses. It thus causes more cough and sneezing symptoms which help to aerosolize and spread the viral particles. Given this, however, it is much less likely to cause issues with “gas exchange” and thus hypoxia and respiratory failure. This seems to have so far borne out both in South Africa and now Great Britain.

I have been taking again the cocktail of hydroxychloroquine, and azithromycin, given the unavailability of Ivermectin. I’m also taking zinc, vitamin D, and a B complex supplement in addition to my usual medications.

Obviously, my situation will not be universal, and some people, particularly people with lung disease, will have more problems. But in reading reports in countries where omicron has become dominant, this is a fairly typical presentation. From my point of view my experience is nothing to get excited about. We’ll see what happens but, three years ago, if such an illness were spread in the community, I would probably notice an increase in exacerbations in my asthma and COPD patients. I have seen this kind of outbreak many times before Covid. The general public is typically unaware.

Omicron has definitely changed the game. There is an international study in preprint, detailing the mutational change in the virus, and its ability to escape immunity, both natural, and vaccine-induced. Here is an article in Forbes that nicely summarizes the study’s findings. In short, the spike proteins have mutated to cling more tightly to the ACE-2 receptors in the respiratory tree, which may explain the preference for the upper airways. Natural immunity also has been thwarted by these new mutations. This was studied by using convalescent serum.

It is interesting to look at the vaccines in detail. Pretty much all of the vaccines lost efficacy against the virus two weeks after the last injection. By three months post the third injection, the vaccinated were susceptible to Omicron. It is interesting to me that the most durable vaccine appears to of been the one offered in China by Sinopharm, which, by the way, is a traditional attenuated live viral vaccine. This means people are vaccinated against the whole virus, rather than just the spike protein.

Parenthetically, according to Robert Malone, the inventor of the mRNA vaccine technique, traditional vaccines take much longer to produce. China appears to have gotten it done in record time. I wonder whether they had a “head start”

To me, all of this suggests several conclusions:

#1. With Omicron we are essentially back to square one in terms of immunity. Thank God it isn’t particularly virulent. Hopefully, this will be a trend.

#2. As with multiple efforts with coronaviruses in the past, vaccination is not a practical solution, and ought to be deemphasized.

#3. It’s time to turn to therapeutics, which are less likely to be affected by mutations.  We need Ivermectin to be freed up for use. The promising new antiviral from Pfizer, Paxlovid, has just been granted an Emergency Use Authorization but is unlikely to be widely available for some time. Unfortunately, from their own data, Merck’s drug Molnupivinir, may not be particularly useful.

As I have said before, this virus and its variants are becoming endemic in the population. Any expectation that you will not be infected, or re-infected, is likely unrealistic.

And for my vaccine-devoted, Fauci-worshiping critics, enjoy your opportunity to revel in my illness.

Your turn is coming.

As always, I’d be honored if you’d share.

Header Image: Tracks on the Back Pond (Fujifilm X Pro 1, XF 18-55mm f2.8-4)

Well, here we are at Christmas, 2020. Like everything else in this godforsaken year, it trends toward joyless. My wife and I are spending it alone as our children are essentially trapped in the Pacific Northwest by current circumstances. We will have a small dinner at the family homestead, but attendance is limited. Those of us who work in healthcare, (and have not, like me, recovered from Covid) have chosen not to attend given my father’s advanced age. All agree that this is prudent.

We had hoped for a white Christmas given the roughly 13 inches of snow that fell last week. My little Victorian hamlet looked like the background of a Norman Rockwell Christmas painting. But it’s 2020. Yesterday temperatures warmed into the 50s, and we had roughly 3 inches of rain. The high winds that accompanied this trough were sufficient to knock down a strategically placed tree, wiping out power for our little village about 8 PM. Power did eventually return overnight. I awakened this morning to green lawns, and with temperatures plummeting, freezing rain. Down in the Susquehanna River Valley, given the rain and the snowmelt, they’re making preparations for the river to crest above flood stage in a day or so.

Merry Christmas.

Still, I don’t want my seasonal affective disorder to completely overwhelm this Christmas posting. My family has much for which to be grateful. Despite several of us working in healthcare, my case of Covid 19 made me the only one affected. Despite misery of the lockdowns, we remain gainfully employed which cannot be said for many of our friends. My father, at 94 years old, still fully functional. I love having a beer with him at the end of the day.

For my Christmas gift to you, I offer a pleasant discovery I made this year. From Branson Missouri, I give you The Petersons, a wonderful bluegrass band that I found in my YouTube lineup. They are a very traditional family with a wonderful back story well worth reading. They are also, as a clan I think, an almost freakishly musical.

And here in the east… try to ignore the weather.

So Merry Christmas to one and all. Indulge yourself in the joy of friends and family. Stay safe. Eat a little, drink a little more.

As always, I would be honored to share this post.

Header Image: Christmas Bench (Fujifilm XE3, XF 18-55 f2.8-4)

We have officially hit week 31 of curve flattening, infection prevention, disease curing, bizarro world. With the weather growing colder here in Pennsylvania there has been an uptick in positive coronavirus “cases”, meaning positive PCR tests. There has been a small increase in hospitalizations, but the death curve is so far flat.

Remember that the New York Times reported that by the current method of PCR testing, up to 90% of people who are PCR positive may be noninfectious. My fear about the rising case numbers is that our governor and health secretary will use the occasion to increase the restrictions upon us. Remember the severe “red phase” lockdowns in spring. All that misery and lots of people still got sick.

Of course, the big news in the last week was the fact that President Trump and a significant number of White House staff have tested positive for coronavirus. Although there have been allegations, that the president was cavalier about masking, the bottom line was that he has been tested frequently if not every day, along with apparently anyone who was in contact with him in the White House. This clearly was an extraordinary effort to protect him from the virus. Yet it failed. It did so for one reason: this virus is ubiquitous in the environment.

He was admitted to Walter Reed Hospital, not so much because he met the criteria for admission, but because he is the president. Though apparently never requiring oxygen, or getting particularly sick, he was treated with a very aggressive regimen of medications including the antibody preparation from Regeneron which is clearly experimental. After a 2 day admission, he was discharged.

Apparently, he is testing negative for coronavirus now and has been deemed “noncontagious”. The other “infected” staffers, including the first lady, have all done well. As I understand it, no one else was hospitalized.

The Pennsylvania new “case“ numbers are impressive. On October 7 there were roughly 1400 cases reported, roughly the same number, as were reported on April 23 for instance. The difference is that on October 7 there were roughly 700 patients admitted to the hospital with COVID, versus 2700 in April. Whether these patients are actually sick from the virus, or merely PCR positive is anyone’s guess.

It’s also was noting there was far less testing being done in the spring. Clearly, either the tests are oversensitive, or the virus has changed. Maybe it’s a little bit of both.

The search for a vaccine apparently is continuing at a rapid pace. Apparently, the Johnson & Johnson candidate may have provoked some unusual symptoms in one of its test subjects and for now hold has been placed on their efforts.

So now we have increasing cases and so far, God willing, little morbidity. Given the availability of more sophisticated care for those to become ill, I continue to believe that continued numbers of asymptomatic and mildly symptomatic COVID infections is actually good news about our journey to a helpful degree of herd immunity.

Remdesivir is also in the news. On October 8 a study comparing the drug to placebo in ICU patient’s revealed that the median time to recovery, defined by the study as either discharged from the hospital or to a custodial situation was 10 days in the treatment arm and 15 days in the placebo arm. This is a fairly significant result suggesting the drug is a useful part of our growing options for the treatment of COVID 19.

I continue to believe that given the persistence of the virus, it’s declining virulence, the improvements in treatment, that we should relax the regulations killing specific industries and small businesses. We need to react, not to PCR tests, but to actual illness, hospitalizations, and death from COVID, not PCR positives with other acute medical problems.

Finally this week, the World Health Organization seems to change its mind on the advisability of lockdowns. In an interview, Dr. David Nabarro, the WHO’s Special Envoy on Covid-19, warned against using lockdowns as the primary control method for the coronavirus, for fears that global poverty and malnutrition may ultimately result. He expressed concern that for instance, the suppression of the tourist industry has impacted many destination countries severely.

In other words… after eight months of masks and misery, people continue to be exposed to this virus. Time for plan “B”.

Hopefully, Governor Wolf is listening.

As always, I’d be delighted if you’d share this with your friends.

Header image: Maple in the Glen (Fujifilm X100V, TCL X100 II)

It is week 20 of the coronavirus lockdown. For a man of my age, between the pandemic, the sometimes illogical/irrational Government response, and the everlasting urban mayhem, this is clearly the most bizarre time period of my entire life.

Here in Pennsylvania, presumably due to a rise in cases in western Pennsylvania, our governor has re-imposed restrictions on bars and restaurants. The first version of this specified that there could be no bar seating, and customers had to buy food if they wanted a drink.

Understandably, many already struggling taverns created inexpensive food items for patrons who wish to have a libation while sitting at a table. Curiously, Governor Cuomo in New York, imposed the same rules on his state. This occurred despite the fact that the number of new cases in that state were minimal.

Apparently, New York bars and restaurants followed the Pennsylvania practice, and soon there were “Cuomo chips” made available to patrons.

For absolutely no discernible reason, other than perhaps pique, both Governors imposed additional rules requiring that A “substantial meal” be served. Andrew Cuomo made it clear that for instance “chicken wings” don’t qualify, undoubtedly endearing him to western New York voters.

All of this is ridiculous. I think of restaurants that I frequent in places like Sullivan County, Pennsylvania (5 confirmed cases), or Hamilton County New York (same statistics) which were forced to stay closed from March to June, only to have restrictions re-imposed once again for no good reason. No wonder that a recent Yelp survey reported that 53% of their member restaurants were closing for good.

I recently visited an establishment where I sometimes go for lunch on my day off. I usually sit at the bar, talk to friends, have a beer, and a single slice of sausage pizza (I love the crispy texture of re-baked crust). The slices are large and it’s more than enough food for me.

My waitress on that day was unfamiliar. I dutifully sat alone at a table, no friends around. I ordered my usual slice of pizza with a beverage and waited.

She came to the table with the pizza and beer and then informed me that although they would honor my order today, the slice of pizza was inadequate to be considered a meal, and they would not do this again. I was also told that I could not have another beer regardless of whether the pizza was finished. The restaurant, often quite busy on a Thursday, was minimally occupied. I can’t imagine why.

What kind of madness is this? Is the state now determining what I eat for lunch? And how does this protect anybody from COVID? Or is it just meant to add to the general misery? You decide.

I would be remiss if I didn’t discuss the surge in cases throughout the southern US. There are likely multiple reasons for this from the parallel surge in Mexico, to the loosening of COVID restrictions. Spring break activities may well have played a role.

The climate may also have something to do with this. While the Northeast in March April and May were “hotspots”, the South had minimal problems with really no “peak” like we experienced in April. It was a cold spring in the North and for most of us, we were trapped indoors, while people in the South presumably spent more time outside.

Now in summer things have reversed themselves, with those in the South, escaping the summer heat indoors with air conditioning, and those of us in the North are enjoying the outdoors. I do wonder whether HVAC systems are helping to spread the virus. There is some emerging interest in this possibility.

So, let’s talk about hydroxychloroquine. I’ve been writing about the pandemic since March 21st. In that first article, I already noted that there was some evidence that hydroxychloroquine, along with azithromycin might have some efficacy. I also noted that a research-based physician such as Dr. Fauci would culturally be uncomfortable recommending a medication without multiple double-blind studies. This is entirely understandable. But Dr. Fauci doesn’t treat anybody. Practicing caregivers in the middle of a pandemic are sometimes forced to innovate for the benefit of the patients.

Even in March, there was in vitro data suggesting that HCQ inhibited coronavirus replication, and since then, we have come to understand that there perhaps for other mechanisms on a cellular level where the drug may prevent viral contents from entering human cells. There were also non-blinded trials strongly suggesting that the drug was useful. In later articles, I discussed other papers that had been published with similar views. Finally, there was the controlled study from Detroit where HCQ halved the mortality rate of hospitalized COVID patients.

Unfortunately, when Donald Trump mentioned the drug in one of his briefings, all hell broke loose. I think I understood what he was trying to do, namely offer some optimism during frightening times. I honestly believe that another president, at another time might have been given the benefit of the doubt. Not in this case. Hydroxychloroquine became “Trump’s drug” and its use must not be allowed.

On Monday, a group of physicians calling themselves America’s Frontline Doctors held a press event in front of the Supreme Court. There they discussed their experiences using hydroxychloroquine in the treatment of COVID. The most prominent and controversial speaker was Dr. Stella Immanuel, who was apparently a pediatrician, born in Cameroon. She also claims to be a minister. She is convinced that hydroxychloroquine is effective having by her account treated 350 patients with it with minimal morbidity and no mortality.

What she seems to believe is that “Big Pharma” is suppressing information on the drug’s efficacy in order to boost profits from drugs such as remdesivir, as well as from vaccines to be developed. Having dealt with pharmaceutical companies for much of my career, I do not find this idea completely fantastic.

It was her opinion, that if hydroxychloroquine was used more often for prophylaxis and treatment, that no masks or other restrictions would be necessary. She was, to say the least, very fervent in her beliefs.

I saw this video on Monday night. It was interesting, but I’d never heard of the physician group and thus wasn’t sure what to make of it. Nonetheless, if her treatment claims are truthful, it is another data point. I couldn’t really figure an ulterior motive when the drug is off-patent for 40 years.

Tuesday morning, I was perusing Facebook when I noticed that multiple friends of mine had posted the video. They also were reporting that Facebook and YouTube were deleting it. I despise “Big Data” censorship, and thus I shared the video with the comment that I was posting this because it was being removed, but I found the video “interesting”.

I was then beset upon by a young lady of my acquaintance, who works in health sciences who was extremely offended that I would post what she considers to be essentially anti-science. She informed me that either I should take down the post, or undoubtedly Facebook would, as she had already reported the post to their “editors”.

Dr. Immanuel, as it turns out as a somewhat “colorful” online presence and holds some controversial opinions as part of her ministry. Websites like the Daily Beast, eschewing their usual love of diversity, quickly did a “deep dive” in order to debunk her. They claimed that Dr. Immanuel claimed that masks are not necessary, without the qualifier she provided.

Nonetheless, if her claims about her medical practice and her treatment of coronavirus are true, then the information may be useful. Again, it’s information to be processed and then believed or discarded. Information is generally helpful.

Given the significant number of articles that I have quoted in the past, some controlled, some anecdotal, but all supporting hydroxychloroquine as a COVID antiviral (here is a recent one from Newsweek), the virulence of opposition to this video would suggest that there are people who just don’t want to know if the drug works. Logically, it suggests that they may not wish for any chance to see the pandemic brought under control so that the economy can fully reopen. And why would they feel that way? Maybe it has something to do with the presidential election in 3 months or so?

I for one cannot imagine being such a nihilist- so politically driven that I would be willing to discard a potential treatment and prolong people’s physical and economic distress. I do not understand on an interactive forum like Facebook, why people who disagree with a viewpoint, would want to erase it, rather than just to make their case in opposition.

I just want to know what works so I can treat my patients.

And perhaps selfishly… sit at a bar with a beer and eat a piece of pizza.

It’s late June here in Northeastern Pennsylvania. Up here in the highlands, the mountain laurels in my yard are in bloom. I know from experience that the vast expanses of laurel in places like Hickory Run State Park, and in Sullivan County, on the Loyalsock Trail, will also have erupted. It’s time for some hiking and photography.

Here in Luzerne County, we are finally in the “green” phase of our coronavirus lockdown. Our benevolent overlords will finally let us live life in a quasi-normal state. Businesses can reopen, providing they attend to mask-wearing, and social distancing.

We can now sit at a bar, even one indoors, and enjoy eating in a restaurant so long as the capacity is properly limited, and the tables appropriately spaced. There are some quirky rules, like the requirement to wear a mask on entering a restaurant, but not after you are seated. People, I think, sense the illogic of this, which will ultimately erode compliance.

Of course, while we all politely comply with the state edicts, all sorts of people are out on the streets of our larger cities rearranging the statuary. I suspect their mask usage has less to do with protecting others and more to do with protecting their identities.

We are seeing additional cases of COVID reported. In our county, the numbers of new cases per day are generally in the low single digits. Hospitalizations and deaths also continue to decline statewide. There have been no changes in this with the phase changes, suggesting that perhaps a seasonal effect is indeed happening.

In reviewing the numbers from the various states, there are certainly curiosities. First, while it is true that daily numbers of cases in Florida and Texas are increasing, when you review the overall curve, you get the impression that they actually never peaked. This is true also of some of the Western states like California. There the curve has been slowly rising since March. Interestingly though deaths per day are flat or decreasing perhaps again suggesting a decrease in virulence of the virus.

Florida had a very minimal early peaking in early April, began to gently decline, and now has had a precipitous rise starting perhaps a week ago. Mortality, however, remains flat to decreasing. Deaths are obviously a late effect however so there still may be a bump there.

Georgia is also seeing an uptick in cases. They originally peaked in early April and were having a slow noisy decline in activity. Within the last couple of days, they had a second higher peak. Georgia as you may recall lifted its lockdown in late April, but still declined for weeks afterward. Another state with this profile is Washington which also peaked in April and now has had a higher second peak again within the last several days.

Given that Atlanta and Seattle have been the sites of some significant mayhem starting perhaps 3-4 weeks ago, I do wonder whether there is a relationship.

Another interesting detail is that the new cases are shifting to the young, which is probably explainable by the fact that they tend to be the ones most eager to take advantage of reopened social venues (not to mention the protests, etc…). It may also be why the death rates have so far not increased.

Perhaps I’m suffering from fear fatigue, but I’m at least personally not as frightened at the possibility of acquiring this infection. Other people still are though, and particularly of contact with me. This is hopefully because of my status as a healthcare worker. It is kind of ironic, because as the cases dwindle, I am largely confined to my office, and have not had any known COVID exposures in more than a month. I suspect there is more risk of exposure out in public than here at the VA, where we screen everyone who enters the building and test everyone we treat.

Anyway, it’s nice to be out and about, to catch up with friends and acquaintances, and to sip a draft beer (albeit from a plastic cup). And is nice to see my 94-year-old father be able to emerge from his quarantine and enjoy a restaurant (on an outdoor deck). Conversely, it sad to see those businesses could not tolerate the lockdown and will never reopen. I hope the owners and workers find other opportunities.

Still, it’s still worth being careful. The virus is still in the population, hopefully, weakened and decreasing in prevalence. I sincerely hope it fades away over summer, not to return.

In the meantime, I’ll be out with my camera and my tripod surrounded by the white blossoms of a Pennsylvania June (and probably the damn blackflies).

Enjoy your new freedom. I hope it lasts.

We have reached week 11 of the suspension, by decree, of religion and commerce in the Commonwealth of Pennsylvania. Here in Luzerne County, we are scheduled on 5 June (Friday) to move into the “yellow phase” which means that the Wolf and Levine team will allow a tepid amount of additional business activity.

Whoopee.

This is occurring in the middle of a new crisis, namely the protests/riots in our cities caused by the universal outrage over the apparent murder of George Floyd, a black man, by a Minneapolis policeman who has been subsequently fired, charged, and imprisoned.

Scenes of large crowds of masked and unmasked protesters, provocateurs, and criminals, freely associating in our urban centers, to say the least, has been destructive to the culture of social distancing we have come to know over the past weeks.

Suddenly, coronavirus feels like yesterday’s news. With this new crisis, I suspect the caution and fear people felt about the pandemic will begin to dissipate.

There may be other reasons for this. Certainly, in most areas of the US, the number of new infections and deaths is clearly decreasing. No longer do we wait breathlessly for the state and federal coronavirus broadcasts for the most recent bad news. Drs Birx and Fauci seemed to have faded from the public view.

There was a report this week out of Italy (which appears to be the proximate source of our eastern viral strains) to suggest that the coronavirus there has become significantly less virulent in recent weeks. Based on basic virology, this would make sense.

First, it’s important to remember that this virus comes from a specific species of bat, where it infected large colonies with minimal deleterious effects. This is likely because the bats had a degree of “herd immunity” and the virus had evolved to maximize its spread by minimizing virulence. A virus receives no advantage by killing its host.

Then it spread to humans, whether from freshly slaughtered animals in a Wuhan market or more likely released by accident from the neighborhood virology lab. Humans had little or no immune defenses to this novel agent, and the virus had not yet evolved to avoid excessively sickening the new hosts.

Add in a little globalization and voila… a worldwide pandemic.

Now, if over time, there are multiple mutations of this virus (which there are), it makes sense that some of them will be more aggressive and some less. The strains that make people obviously sick, and/or dead, will tend to be more quickly diagnosed, and the patient isolated, impeding further spread.

Less symptomatic strains will be less likely to attract the attention of the public health system and thus have more opportunity to spread to and replicate in a new host.

At some level, the most successful viruses will be among the mildest ones. The virus has to be aggressive enough to infect the right tissues (respiratory ) to facilitate transmission by coughing and sneezing, but mild enough that the illness will provoke little concern from others and can spread freely.

Now consider a virus such as Ebola, with a horrifying presentation. In modern times an infected patient is quickly recognized and carefully isolated, reducing or hopefully eliminating spread.

In one of Dr. Fauci’s last publicized statements, he feels there is now hope that there will be no recurrence of the virus in the fall. I don’t entirely understand the data that this is based on, but it is undoubtedly good news.

With the good weather, and now obviously with the mayhem, the enthusiasm for social distancing is fading, and I think will eventually become extinct, rules or not. If there is no meaningful bump in cases around the country after all of the mass gatherings that have been occurring, then I suspect the sense of the coronavirus as a threat will reasonably ebb. The practice of masking, and spacing ourselves out, will likely then feel dated and unnecessary.

We are obviously living through extraordinary times. More than anytime in my life, I find myself praying for the welfare of our country and its citizens. I do believe that in God’s good time, there will be recovery and a return to a slightly different, but acceptable baseline.

I just hope this happens before there is more damage to our economy, our infrastructure, and our psyche.

We have now reached week 10 of the Wolf/ Levine “2-week lockdown to flatten the curve”.

For my county, Luzerne, and other counties in eastern Pennsylvania, there is a tiny light at the end of the tunnel. On Friday, we are going to be allowed to exercise a slightly larger sliver of our former civil rights. We are moving into the “yellow” phase.

For many people, this will seem like thin gruel. Though the governor will allow us to open more of our businesses, which will undoubtedly help some to survive, he still refuses to allow restaurants, hair care professionals, athletic facilities, and shockingly, the almighty casinos to reopen. Schools also remained closed, even though children are minimally affected by this virus. Church services are still functionally forbidden.

He is finally allowing much of the Northwest of the state to move into the so-called “green” phase. Even this however is rather restricted with some businesses limited to 75% of capacity, and bars/restaurants limited to 50%. The governor likes to refer to this as “the new normal”.

He now apparently believes, that we cannot return to baseline until there is a vaccine (presumably one that is widely available). Perhaps conveniently for him, this is unlikely to occur before early November.

If I lived for instance in Tioga, Cameron, or Sullivan County each of which has low single-digit numbers of cases, and no deaths, I would be furious. These counties have likely had more influenza cases than COVID cases, yet they are only now being allowed into the “green” phase. Imagine owning a small business in say, Coudersport, and watching it fail, arguably for no good reason.

Germane to this, is new data out of the CDC suggesting that the death rate of this virus, based on the ever-growing number of documented asymptomatic cases, is down to about 0.25%. This is roughly what is seen during a bad influenza year.

,Another fascinating study has found that 40% of random blood samples collected from patients prior to the pandemic have immunologic cross-reactivity with COVID 19. In other words: some of us may have had full or partial immunity to this coronavirus all along. This helps to explain so many infected ended up asymptomatic or with very mild cases.

As I reflect on this, I think most everyone supported a short period of lockdown, especially given circumstances such as those in Italy, and of course in New York City. It was not unreasonable to think that such a dire situation could’ve happened here. It clearly did not, but despite this, the lockdown continues.

In fact, most of the severity of COVID 19 in Pennsylvania occurred because of the Wolf/ Levine decision to insist that infected patients be admitted to nursing care facilities. This of course occurred at the same time Dr. Levine insisted her elderly mother be moved from just such a facility, to a hotel. I don’t really want to fault a decision to protect an aging parent, but the sense of risk to the mother should have absolutely informed the decisions affecting other elders at risk.

If one looks at deaths per 100,000 of the population, Pennsylvania’s number is 40. Florida, early on did the opposite and prohibited COVID patients from admission to nursing facilities. Their death rate that is one quarter as large. As more than 2/3 of deaths in Pennsylvania involved nursing facilities or personal care homes, the numbers make sense. And remember, Florida locked down less severely, and opened earlier, than Pa.

Now to be fair, there was a concern at the beginning of the pandemic that hospital beds would quickly fill, and nursing homes would have to be utilized for convalescing patients. On the other hand, the first outbreaks in the country, occurred in Washington state where it swept in deadly fashion through nursing homes in the Seattle area. This might have been a clue as to what not to do.

At any rate, the disease statistics being used to justify our imprisonment were mostly the result of faulty decisions made at the beginning of this pandemic. And so far as I can tell the governor’s emergency powers have no time limit.

I was curious about what limitations different states place on their executive branch during times of emergency. It turns out that 35 states are like Pennsylvania, in that they allow the governor to change both statutes and regulations under emergency powers. Seven states allow Governors to only change regulations, and 8 states give the governor no explicit power under these circumstances.

While we need to our governors, to have flexibility during times of emergency, this should have limits.

We need to revamp the system. I imagine the law modified so that at some point, perhaps a month, any emergency authority should expire, which would relax all the restrictions that have been imposed. This would occur unless the state legislature voted to extend the time limits. Any extension by statute ought to itself be limited, requiring additional votes. This would force the governor to work with the legislative branch, rather than reject their input as Governor Wolf has done.

I have no wish to disparage fellow public servants who in the beginning, worked very hard to contain this pandemic. Happily they succeeded. As this drags on, it is not hard to believe that other factors are at play.

And they’re likely no longer about us.

It is now roughly 5 weeks since the spread of the novel coronavirus forced us to shut down the vast majority of our commerce and personal interaction. It’s been a long period with a very unnatural but necessary restriction of our freedoms. At this point, enough time has passed that we are starting to see the trajectory of this pandemic.

In most places, even in New York, the number of new diagnoses, as well as deaths, have either plateaued or are on the downslope. This is not to say that the numbers are small. As I write this, it appears that another 20 people died in my county in the last 24 hours (50 deaths of 1800 total cases).

By all accounts, outside of New York City, hospital systems have not been overwhelmed. Our facility continues to see sporadic cases, none of them particularly severe. Many of these people come from nursing facilities. An emerging problem is the understandable reluctance of those facilities to receive these residents back once they no longer require hospitalization.

I want to discuss several topics related to COVID 19. The first is the topic of ventilators. When the pandemic started there was enough hype to suggest that these devices were going to be essential for the survival of the species. We all watched the great efforts that were made to procure large numbers in anticipation of a respiratory disaster.

There was also talk in the popular press that severely compromised patients should be kept on a ventilator for at least 14 days prior to “weaning” them. I looked around the pulmonary literature but could find no support for this. Still, I kept seeing this in medical chat rooms and the like. My partner, who is also very experienced in critical care, was equally befuddled.

Roughly a week ago I began to hear a different theme. Suddenly, there arose the theory that ventilators are actually the problem, and that mechanical ventilation is causing damage to the patient’s lungs. Therefore, only oxygen should be given.

Given my career in critical care, none of this has any bearing on reality. Ventilators are used in situations where either the patient’s oxygenation cannot be maintained by the lesser means, and/or when the patient’s own respiratory system can no longer maintain ventilation without fatigue and ultimately respiratory arrest. Beyond this, there is no therapeutic benefit. Actual harm to the lungs can result if ventilator settings are inappropriate. We do think we have learned over the years how to minimize this problem.

We also have intermediate modalities, including oxygen supplementation, “high flow oxygen” and “noninvasive ventilation as “that are delivered by mask, and generally offered long before intubation is considered.

The problem is, these less invasive respiratory modalities have a bad tendency to create aerosols of the patient’s secretions, which, in a small ICU room, puts the staff at risk.  

Also, the actual act of intubation (placing the breathing tube in the trachea) exposes the operator to a high risk of infection. This is even more true when done emergently. Thus, I think there has been a general sense that when the patient is deteriorating, that “securing the airway” in a deliberate fashion, before the crisis, is safer for all concerned than intubating a “crashing” patient.

In ventilated patients, once there is no other factor to prevent it, patients are tested daily to see whether they can breathe on their own once again. If so they are extubated. This is important as endotracheal tubes provide a significant risk of secondary infection, and the enforced inactivity in ventilated patients creates other complications.

The sooner you can get them extubated, out of bed and ambulatory, the better they do. So far as I can tell, other than some interesting nuances about the patient’s lung physiology, there is nothing really truly different about ventilating these patients versus those with other similar critical illnesses.

On other fronts, as antibody testing proceeds, we are started to get a sense that many more in the population have been infected then we ever expected. In some ways, this is good news as it suggests there may be many more recovered people about, and we are closer to herd immunity. it also drops the case fatality rate, perhaps significantly.

Unfortunately, this is a little comfort to the roughly 47,000 people have died. Even if the death rate approaches that of the flu, the denominator for the flu is always based on symptomatic patients, who are the only people we test. There is little sense in the literature that influenza, unlike coronavirus, can be asymptomatic.

There is evidence that in the first quarter of 2020 the overall death rate in the United States is not particularly high. This is curious. Some of this may be due to the “cause of death substitution”. It may also be due to decreased opportunities for auto accidents and other trauma, given the social isolation.

I don’t think however it diminishes the extraordinary number of deaths in unique situations like New York City where reliance on public transportation and population density seems to have affected them exponentially. I have no desire to downplay the severity of this pandemic.

Nonetheless, I continue to believe if we are to prevent a severe economic recession if not depression, we need to adapt to current reality, and reopen commerce in a thoughtful way. I look at vast states like Wyoming and Montana where there are less than a quarter of the cases than in my little county. Is it fair to ask them to remain “locked down”?

 There is probably no way to do this without some risk, and we have to know that some degree of increased spread will occur. We need to steel ourselves for this and not panic when it happens.

This can only occur if the political factions in this country stop attacking each other for political gain, every time there is bad news. That must stop. This is too serious now.

I hope you and your loved ones, are safe and well.

Let’s see what this next week brings