Knowin' what to throw away, and knowin' what to keep....
I had an entire, rather pissed-off paragraph right here before I remembered to take a deep breath (yep. Breathing: Still important), remembered to hydrate a little bit more, remembered to get up and take a little walk in the early morning cold, and, most importantly, remembered that we’re all dealing with Fear, and that fear responses show up differently in different people.
Some of you are going to argue that I’m giving too much grace around this issue (I actually had THAT argument with myself, too, so knock yourself out – I promise I’m far less charitable with me than you will ever be) but this is actually how I’m choosing to reframe the issue. Because the alternative – that people are shallow, callous, uneducated, hateful lemmings – is a poison that leads me to a dark, unkind place. And these are times when we’re called to dig deep for MORE: more kindness, more genuine understanding, more empathy, more compassion and, most of all, more willingness to lean into the liminal space and embrace the yes/and of it all.
Reframing, by the way, is one of the most powerful mental resiliency builders we have at our disposal. I’ll try to come back to that, specifically, in another post. But rumble with it in the meantime if you will…
So. Where are we? (I am going to take time to post several vetted links in the comments section to support understanding and discussion – please share those, too, if you choose to share the post).
The #Covid19 death toll this week was very hard to watch. We knew it was coming, because we know that death lags cases and the curve by 8-14 days, but still, it hurt. Remember though, that when we talk about flattening we are talking about the *slope* of the curve (the first derivative) and that even though there is a steady climb in the total number of deaths, we are seeing an overall flattening in the rise.
While the peak is still coming in some communities, the country as a whole and most places that saw a steep, sharp, early peak are on the backside. Increasingly it seems we've managed to slow the spread to manageable levels.
We saw lots of talk this week about reopening America, and I have had many people reach out to ask what I think of the suggested federal plan and guidelines. Here’s the truth: it isn’t the worst plan I’ve ever seen…
Let me start with this: we do HAVE to make moves to reopening, particularly in parts of the country less hard hit and most particularly in restoring provision of “non-emergent” healthcare services. We are seeing an alarming increase in health issues that would have been routine or urgent that are becoming emergent because patients don’t have appropriate access to their physician, or because they are too afraid to seek care. This will get worse if we don't move quickly to risk-stratify the reopening of our clinics and hospitals, and to "return" to a new-normal patient care structure.
One of the challenges when converting public health strategies to public policy is that the health of a population is largely impacted by social determinants: Income. Housing. Access to food. Health insurance. The impact of these on long-term population health are extensively researched and uncontested. The longer and deeper the economic impact of this extends, the greater, more devastating and longer lasting will be the negative health outcomes on the very people we are trying to save.
In other words, as callous as it may sound to say, “we know that we will see an uptick in cases when we reopen, but we need to reopen nonetheless” there are excellent morbidity and mortality arguments to be made IN FAVOR of reopening.
As we get more and better data, we also are revising our estimates and modelling. I’ve mentioned before that the data out of China reflected clinically diagnosed cases – meaning case presentation (symptoms, chest x-ray, CT). In the U.S., Germany and elsewhere we are basing diagnosis solely on positive viral testing. As a result, we are increasingly able to recognize that the “denominator” of this disease is larger – possibly much larger – than originally posited. This is NOT TO SAY that physical distancing wasn’t absolutely – and continues to be – the right thing to do. It absolutely was and is, for now.
And this is where I’m going to get a bit salty: Remember, the whole purpose of this was NOT to prevent everyone from getting Covid *ever* but to decrease the R0 (R-naught) to the point that we #flattenthecurve, thus preventing our healthcare system from being utterly overwhelmed. The goal was to BUY TIME for our physicians to prepare and hospitals to ramp up, expand capacity, obtain materials, refine caregiving and to have enough of the 3S’s (Staff, Stuff, Space) to manage that 5ish percent of patients who become critically ill.
The #Suppression strategy HAS WORKED.
Frankly, folks, it wasn’t too much to ask that we just follow the damn rules in order to save a quarter of a million people. Yes – those were the original projections. And lets say they were off by half (they probably weren’t, if we’d let this run unchecked, but I’m all about giving some damn grace to people today, remember) so lets say they were off by HALF. That’s still 125,000 American lives we’ve collectively saved (well – not all of us helped. I SEE YOU, mom flipping off the clerks at the front door as you strut into the store with your kid in tow).
We did this. And yes, a heavy price has been paid – and paid (as per usual) disproportionately by small businesses, local restaurants and millions of Americans who could least afford to pay it.
But dammit, #MyFellowAmericans, stop behaving like spoiled, entitled, rebellious teenagers.
Yes, this is hard AND we can work together to find a way forward.
Stop it with these silly, obnoxious, paranoid, ridiculous, sophomoric protests. They’re foolish on a whole multitude of levels, and furthermore they’re damn disrespectful to the physicians and nurses who will have to treat you or someone you love on the backside of it all. They’re a sign of DEEP disrespect to those serving, sacrificing and dying on the frontlines of this in WA, NY, MI, LA and elsewhere. Shame on you for being so selfish. #YoureGrounded
---- A plan forward has been proposed. It leaves a LOT to the state governments, which is, frankly, ok because they are best suited to know in what parts of their state things can be reopened and when. It’s a slow, multi-tier, risk-stratified approach that takes a great deal of what we know about this disease and its spread into consideration.
It also, rightly, hinges on the ability to do widespread testing as well as aggressive contact-tracing. But this, frankly, is where things will fall apart. Despite assurances from the federal government, states DO NOT HAVE “all they need” to do this. THIS needs to be fully funded, supplied and managed by the federal government.
I pay my taxes in part for national defense. All enemies, foreign and domestic – remember? Well here we are – an enemy on our soil, and the federal response (daily briefings notwithstanding) has been lukewarm.
You all want to know what you can do? Call your representatives, tell them you support the tiered reopening of America WHEN we have the resources we need to do aggressive contact tracing. This means 1) Antigen testing; 2) Antibody testing; 3) Trained public health teams in every community.
We WILL have flares of this disease when we relax social distancing – that is the only thing I can 100% guarantee. But if we have the ability to test everyone regularly and rapidly, and have trained healthcare teams to do surveillance, contact tracing and quarantining, we can prevent this curve from becoming a U.
Those who are tempted to chuck the federal plan because it is “republican” are as foolish as those who refuse to follow distancing guidance because it came from “democrats” (it didn’t). ----
One of the things almost no one knows about me is that I love country music. Now don’t @ me, any of you – my musical passion is eclectic and broad, and my playlist is, well, frankly weird. But when I walk, particularly when I’m walking out in the middle of nowhere, I put on country and go ahead and get teary or proud or whatever sappy emotion the current ballad is meant to wrench out of me.
Kenny Rogers died recently, and his passing hit my heart. He was one of my first “favorite” artists, dating back to when I was about 8 years old. As I was storming across the fields in a fit of pique yesterday afternoon, “The Gambler” came up, and I was particularly struck by the line, “the secret to surviving is knowing what to throw away and knowing what to keep. ‘Cause every hand’s a winner, and every hand’s a loser….”
I think we can hope for better than to die in our sleep on this one. We’ve been dealt a hand, America. We are learning more about it every day, and figuring out what to throw away and what to keep is important -- no idea should be reflexively rejected because it came from "the other side."
And please: rather than scream at scientists that they were wrong, or point fingers at governors who are doing their best to keep folks alive and digest information that is out of their wheelhouse (and is changing every day), please take a minute to understand that THIS IS HOW SCIENCE WORKS. We use the data we have, and when we have new or better data, we adjust our model. There’s no grand conspiracy at play, loves.
This hand can be a winner. Things that have been long broken but partially hidden from view have been dragged center stage. Let’s build something new, something stronger and more equitable. Let’s be better, my friends.
I really wanted to address mental health today, but honestly, I’m out of words and its gorgeous outside. I’m heading out and I hope you will, too.
Hydrate before you go. Breathe deeply. Reframe whatever thoughts are hurting you (I promise to return to that one). Find and stick to a sleep schedule. We have a lot of work to do, together, and we need you in top shape.
Keep being brave, generous and kind, always.